{"title":"Attention 2016 Health Policy Shoppers: Read the Fine Print.","authors":"J. Cohn","doi":"10.1111/1468-0009.12175","DOIUrl":"https://doi.org/10.1111/1468-0009.12175","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"171 2 1","pages":"27-9"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83443983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I n the decades since reproductive health rights emerged as an issue before the US Supreme Court, there never has been a term quite like the current one, which will conclude several months before the 2016 presidential election. The origins of the Court’s involvement with reproductive rights can be traced to Griswold v Connecticut (381 US 479 [1965]), which established a constitutional right to marital privacy in the use of contraceptives. Eight years later, in Roe v Wade (410 US 113 [1973]), in a 7 to 2 ruling, the Court held that women’s access to abortion was a protected constitutional right that could be strictly limited only once the third trimester of pregnancy was reached. Nearly 20 years later, in Planned Parenthood of Southeastern Pennsylvania v Casey (505 US 833 [1992]), the Court significantly altered Roe’s broad, trimester-based framework. Although technically upholding Roe, a more conservative majority redefined the constitutional standard, permitting states to enact laws restricting abortion before fetal viability but barring laws that imposed an “undue burden” on access to abortion, including “unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion.” The politics of abortion led to a barrage of increasingly intrusive laws. For decades federal law has barred virtually all public funding for abortion. Federal law now bars “partial birth” abortions, a specific type of pregnancy termination procedure, regardless of whether it is carried out before or after viability (Gonzales v Carhart, 550 US 124 [2007]). Since 2010, states have enacted 282 abortion restrictions that run the gamut from the targeted regulation of abortion providers distinct from other routine, outpatient surgical procedures (of which abortion is the most common) to laws requiring waiting periods, restricting medication abortions, and curtailing access to abortion after the first trimester.1 Opponents of abortion actively
自从生殖健康权利成为摆在美国最高法院面前的一个问题以来的几十年里，从未有过一个任期像现在这样，它将在2016年总统大选前几个月结束。最高法院涉及生殖权利的起源可以追溯到格里斯沃尔德诉康涅狄格州案(381 US 479[1965])，该案件确立了在使用避孕药具方面婚姻隐私的宪法权利。八年后，在罗伊诉韦德案(410 US 113[1973])中，最高法院以7比2的票数裁定，妇女获得堕胎是一项受保护的宪法权利，只有在怀孕到第三个月时才能受到严格限制。近20年后，在宾夕法尼亚州东南部计划生育诉凯西案(505 US 833[1992])中，最高法院显著改变了罗伊案中宽泛的、以妊娠期为基础的框架。虽然在技术上支持罗伊案，但更为保守的多数派重新定义了宪法标准，允许各州制定法律限制在胎儿存活之前堕胎，但禁止对堕胎施加“不当负担”的法律，包括“旨在或实际上对寻求堕胎的妇女构成实质性障碍的不必要的健康法规”。堕胎的政治导致了一系列越来越具有侵入性的法律。几十年来，联邦法律几乎禁止所有公共资金用于堕胎。联邦法律现在禁止“部分分娩”堕胎，这是一种特殊的终止妊娠程序，无论堕胎是在胎儿存活之前还是之后进行(Gonzales v Carhart, 550 US 124[2007])。自2010年以来，各州已经颁布了282项堕胎限制，范围从对堕胎提供者的针对性监管，区别于其他常规的门诊手术(堕胎是最常见的)，到要求等待期的法律，限制药物堕胎，以及减少妊娠早期堕胎的机会堕胎的反对者积极
{"title":"The US Supreme Court and the Future of Reproductive Health.","authors":"S. Rosenbaum","doi":"10.1111/1468-0009.12170","DOIUrl":"https://doi.org/10.1111/1468-0009.12170","url":null,"abstract":"I n the decades since reproductive health rights emerged as an issue before the US Supreme Court, there never has been a term quite like the current one, which will conclude several months before the 2016 presidential election. The origins of the Court’s involvement with reproductive rights can be traced to Griswold v Connecticut (381 US 479 [1965]), which established a constitutional right to marital privacy in the use of contraceptives. Eight years later, in Roe v Wade (410 US 113 [1973]), in a 7 to 2 ruling, the Court held that women’s access to abortion was a protected constitutional right that could be strictly limited only once the third trimester of pregnancy was reached. Nearly 20 years later, in Planned Parenthood of Southeastern Pennsylvania v Casey (505 US 833 [1992]), the Court significantly altered Roe’s broad, trimester-based framework. Although technically upholding Roe, a more conservative majority redefined the constitutional standard, permitting states to enact laws restricting abortion before fetal viability but barring laws that imposed an “undue burden” on access to abortion, including “unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion.” The politics of abortion led to a barrage of increasingly intrusive laws. For decades federal law has barred virtually all public funding for abortion. Federal law now bars “partial birth” abortions, a specific type of pregnancy termination procedure, regardless of whether it is carried out before or after viability (Gonzales v Carhart, 550 US 124 [2007]). Since 2010, states have enacted 282 abortion restrictions that run the gamut from the targeted regulation of abortion providers distinct from other routine, outpatient surgical procedures (of which abortion is the most common) to laws requiring waiting periods, restricting medication abortions, and curtailing access to abortion after the first trimester.1 Opponents of abortion actively","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"1 1","pages":"23-6"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88659473","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
POLICY POINTS In situations of scientific uncertainty, public health interventions, such as counseling for HIV infection, sometimes must be implemented before obtaining evidence of efficacy. The history of HIV counseling and testing, which served as the cornerstone of HIV prevention efforts at the US Centers for Disease Control and Prevention (CDC) for a quarter of a century, illustrates the influence of institutional resistance on public health decision making and the challenge of de-implementing well-established programs. CONTEXT In 1985, amid uncertainty about the accuracy of the new test for HIV, public health officials at the Centers for Disease Control and Prevention (CDC) and AIDS activists agreed that counseling should always be provided both before and after testing to ensure that patients were tested voluntarily and understood the meaning of their results. As the "exceptionalist" perspective that framed HIV in the early years began to recede, the purpose of HIV test counseling shifted over the next 30 years from emphasizing consent, to providing information, to encouraging behavioral change. With this increasing emphasis on prevention, HIV test counseling faced mounting doubts about whether it "worked." The CDC finally discontinued its preferred test counseling approach in October 2014. METHODS Drawing on key informant interviews with current and former CDC officials, behavioral scientists, AIDS activists, and others, along with archival material, news reports, and scientific and governmental publications, we examined the origins, development, and decline of the CDC's "counseling and testing" paradigm for HIV prevention. FINDINGS Disagreements within the CDC emerged by the 1990s over whether test counseling could be justified on the basis of efficacy and cost. Resistance to the prospect of policy change by supporters of test counseling in the CDC, gay activists for whom counseling carried important ethical and symbolic meanings, and community organizations dependent on federal funding made it difficult for the CDC to de-implement the practice. CONCLUSIONS Analyses of changes in public health policy that emphasize the impact of research evidence produced in experimental or epidemiological inquiries may overlook key social and political factors involving resistance to deimplementation that powerfully shape the relationship between science and policy.
{"title":"Evidence and the Politics of Deimplementation: The Rise and Decline of the \"Counseling and Testing\" Paradigm for HIV Prevention at the US Centers for Disease Control and Prevention.","authors":"D. Johns, R. Bayer, A. Fairchild","doi":"10.1111/1468-0009.12183","DOIUrl":"https://doi.org/10.1111/1468-0009.12183","url":null,"abstract":"POLICY POINTS\u0000In situations of scientific uncertainty, public health interventions, such as counseling for HIV infection, sometimes must be implemented before obtaining evidence of efficacy. The history of HIV counseling and testing, which served as the cornerstone of HIV prevention efforts at the US Centers for Disease Control and Prevention (CDC) for a quarter of a century, illustrates the influence of institutional resistance on public health decision making and the challenge of de-implementing well-established programs.\u0000\u0000\u0000CONTEXT\u0000In 1985, amid uncertainty about the accuracy of the new test for HIV, public health officials at the Centers for Disease Control and Prevention (CDC) and AIDS activists agreed that counseling should always be provided both before and after testing to ensure that patients were tested voluntarily and understood the meaning of their results. As the \"exceptionalist\" perspective that framed HIV in the early years began to recede, the purpose of HIV test counseling shifted over the next 30 years from emphasizing consent, to providing information, to encouraging behavioral change. With this increasing emphasis on prevention, HIV test counseling faced mounting doubts about whether it \"worked.\" The CDC finally discontinued its preferred test counseling approach in October 2014.\u0000\u0000\u0000METHODS\u0000Drawing on key informant interviews with current and former CDC officials, behavioral scientists, AIDS activists, and others, along with archival material, news reports, and scientific and governmental publications, we examined the origins, development, and decline of the CDC's \"counseling and testing\" paradigm for HIV prevention.\u0000\u0000\u0000FINDINGS\u0000Disagreements within the CDC emerged by the 1990s over whether test counseling could be justified on the basis of efficacy and cost. Resistance to the prospect of policy change by supporters of test counseling in the CDC, gay activists for whom counseling carried important ethical and symbolic meanings, and community organizations dependent on federal funding made it difficult for the CDC to de-implement the practice.\u0000\u0000\u0000CONCLUSIONS\u0000Analyses of changes in public health policy that emphasize the impact of research evidence produced in experimental or epidemiological inquiries may overlook key social and political factors involving resistance to deimplementation that powerfully shape the relationship between science and policy.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"82 1","pages":"126-62"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83997609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I n the December 2015 issue of THE MILBANK QUARTERLY, I discussed why it is important for the public’s health that physicians disclose their financial relationships with pharmaceutical companies, including payments made to physicians by these companies to help market their drugs.1 But that is only part of the story, a tale that has had a significant impact on the health of both the public and individual patients. Equally troubling are the enormous profits that pharmaceutical companies make on the sales of their drugs and how pharmaceutical executives determine the costs of those drugs, which must be paid by the public, either through their insurance companies or directly out of pocket. I have no problem with pharmaceutical companies making a reasonable profit from the drugs they develop. After all, these often are medications that contribute substantially to the public’s health, and these companies certainly deserve credit and financial remuneration for drugs that have saved much pain and suffering and many lives. The essential question is what a fair and legitimate profit for drugs should be. Let’s first look at a few numbers. In 2013 the profit margin for pharmaceutical companies ranged from 10% to 42%, with an average of 18%. Pfizer was at the top of the profit list, and 4 other companies (Hoffman-La Roche, AbbVie, GlaxoSmithKline, and Eli Lilly) had profit margins of more than 20%. As a point of reference, the profit margin of pharmaceutical companies was essentially the same as that of banks, but the banks’ range of profit was lower, from 5% to 29%.2 Although most of us might be able to survive without a bank, many of us who need life-saving, life-extending, and pain-relieving medicines do rely on pharmaceutical companies. If drug prices are too high, people stop filling prescriptions, leading to complications and sometimes even death. What has accounted for the pharmaceutical companies’ very large profit margins? For one thing, the United States, unlike other developed countries, allows pharmaceutical companies to charge whatever they
{"title":"Big Pharma Profits and the Public Loses.","authors":"C. Deangelis","doi":"10.1111/1468-0009.12171","DOIUrl":"https://doi.org/10.1111/1468-0009.12171","url":null,"abstract":"I n the December 2015 issue of THE MILBANK QUARTERLY, I discussed why it is important for the public’s health that physicians disclose their financial relationships with pharmaceutical companies, including payments made to physicians by these companies to help market their drugs.1 But that is only part of the story, a tale that has had a significant impact on the health of both the public and individual patients. Equally troubling are the enormous profits that pharmaceutical companies make on the sales of their drugs and how pharmaceutical executives determine the costs of those drugs, which must be paid by the public, either through their insurance companies or directly out of pocket. I have no problem with pharmaceutical companies making a reasonable profit from the drugs they develop. After all, these often are medications that contribute substantially to the public’s health, and these companies certainly deserve credit and financial remuneration for drugs that have saved much pain and suffering and many lives. The essential question is what a fair and legitimate profit for drugs should be. Let’s first look at a few numbers. In 2013 the profit margin for pharmaceutical companies ranged from 10% to 42%, with an average of 18%. Pfizer was at the top of the profit list, and 4 other companies (Hoffman-La Roche, AbbVie, GlaxoSmithKline, and Eli Lilly) had profit margins of more than 20%. As a point of reference, the profit margin of pharmaceutical companies was essentially the same as that of banks, but the banks’ range of profit was lower, from 5% to 29%.2 Although most of us might be able to survive without a bank, many of us who need life-saving, life-extending, and pain-relieving medicines do rely on pharmaceutical companies. If drug prices are too high, people stop filling prescriptions, leading to complications and sometimes even death. What has accounted for the pharmaceutical companies’ very large profit margins? For one thing, the United States, unlike other developed countries, allows pharmaceutical companies to charge whatever they","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"295 1","pages":"30-3"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77505002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C hild abuse, be it physical, sexual, or emotional, is one of the saddest, needless, and longest running stories in the history of public health. Even more outrageous has been our collectively poor track record in adequately recognizing, solving, or, at least, preventing this problem. Using data collected in 2008, the US Centers for Disease Control and Prevention (CDC) estimated that the total lifetime costs associated with confirmed child abuse and neglect cases for that year (1,740 deaths and 579,000 nonfatal cases) was about $124 billion, although other methods of measurement applied suggest that the cost may be as large as $585 billion. The CDC estimated that the average lifetime cost per victim of nonfatal abuse was $210,012 (broken down, that’s $32,648 in childhood health costs, $10,530 in adult health costs, $144,360 in productivity costs, $7,728 in child welfare costs, $6,747 in criminal justice costs, and $7,999 in special education costs). These lifetime sums put child abuse in the same economic ballpark as strokes ($159,846) or type 2 diabetes (between $181,000 and $253,000). The average lifetime costs associated with fatal child maltreatment are even higher: $1,272,900 (approximately $14,100 in medical costs and $1,258,800 in productivity losses).1 The bleak and tragic stories of abused children are all too familiar to those of us who work as pediatricians, nurses, social workers, teachers, and children’s health or well-being professionals. What appears below is one of the most poignant examples I have read:
{"title":"Neglected.","authors":"H. Markel","doi":"10.1111/1468-0009.12220","DOIUrl":"https://doi.org/10.1111/1468-0009.12220","url":null,"abstract":"C hild abuse, be it physical, sexual, or emotional, is one of the saddest, needless, and longest running stories in the history of public health. Even more outrageous has been our collectively poor track record in adequately recognizing, solving, or, at least, preventing this problem. Using data collected in 2008, the US Centers for Disease Control and Prevention (CDC) estimated that the total lifetime costs associated with confirmed child abuse and neglect cases for that year (1,740 deaths and 579,000 nonfatal cases) was about $124 billion, although other methods of measurement applied suggest that the cost may be as large as $585 billion. The CDC estimated that the average lifetime cost per victim of nonfatal abuse was $210,012 (broken down, that’s $32,648 in childhood health costs, $10,530 in adult health costs, $144,360 in productivity costs, $7,728 in child welfare costs, $6,747 in criminal justice costs, and $7,999 in special education costs). These lifetime sums put child abuse in the same economic ballpark as strokes ($159,846) or type 2 diabetes (between $181,000 and $253,000). The average lifetime costs associated with fatal child maltreatment are even higher: $1,272,900 (approximately $14,100 in medical costs and $1,258,800 in productivity losses).1 The bleak and tragic stories of abused children are all too familiar to those of us who work as pediatricians, nurses, social workers, teachers, and children’s health or well-being professionals. What appears below is one of the most poignant examples I have read:","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"6 1","pages":"699-703"},"PeriodicalIF":0.0,"publicationDate":"2016-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89349757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
During its term that begins in October 2015, the United States Supreme Court will hear Gobeille v Liberty Mutual Insurance Company, a case that will test whether self-insuring employers can refuse to comply with state all-payer claims reporting laws. Without a uniform, nationwide strategy to comprehensively address health care costs and quality—notably absent from the Affordable Care Act (ACA)—the stakes could not be greater for states that seek to take action.
在2015年10月开始的任期内，美国最高法院将审理戈贝尔诉利宝互助保险公司(Gobeille v Liberty Mutual Insurance Company)一案，该案将检验自行投保的雇主是否可以拒绝遵守州的全付款人索赔报告法。如果没有一个统一的、全国性的战略来全面解决医疗保健成本和质量问题——这一点在《平价医疗法案》(ACA)中是不存在的——那么寻求采取行动的各州所面临的风险就不会更大。
{"title":"Clash of the Titans: State All-Payer Claims Reporting Systems Meet ERISA Preemption.","authors":"S. Rosenbaum","doi":"10.1111/1468-0009.12160","DOIUrl":"https://doi.org/10.1111/1468-0009.12160","url":null,"abstract":"During its term that begins in October 2015, the United States Supreme Court will hear Gobeille v Liberty Mutual Insurance Company, a case that will test whether self-insuring employers can refuse to comply with state all-payer claims reporting laws. Without a uniform, nationwide strategy to comprehensively address health care costs and quality—notably absent from the Affordable Care Act (ACA)—the stakes could not be greater for states that seek to take action.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"11 1","pages":"683-6"},"PeriodicalIF":0.0,"publicationDate":"2015-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88377674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Meeting the ACA's Goals.","authors":"Gail R Wilensky","doi":"10.1111/1468-0009.12157","DOIUrl":"https://doi.org/10.1111/1468-0009.12157","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"84 1","pages":"671-4"},"PeriodicalIF":0.0,"publicationDate":"2015-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88243973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
After a terrific 2014 season in which he won 14 games for the Baltimore Orioles, pitcher Bud Norris struggled in 2015. He lost 9 games and won just 2. On August 8, 2015, in the middle of the season, the Orioles fired him.
{"title":"Accountability for Health.","authors":"J. Sharfstein","doi":"10.1111/1468-0009.12158","DOIUrl":"https://doi.org/10.1111/1468-0009.12158","url":null,"abstract":"After a terrific 2014 season in which he won 14 games for the Baltimore Orioles, pitcher Bud Norris struggled in 2015. He lost 9 games and won just 2. On August 8, 2015, in the middle of the season, the Orioles fired him.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"12 1","pages":"675-8"},"PeriodicalIF":0.0,"publicationDate":"2015-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86193491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A s a longtime health policy reformer, I have come to love Winston Churchill’s observation that American policymakers always get it right, but only after trying everything else. I am also beholden to my now deceased Alabama Democratic colleague Senator Howell Heflin’s explanation of Congressman Claude Pepper’s (D-FL) interview with God after Pepper’s death in 1989. In Heflin’s telling, Pepper asked God if we would ever get health reform right in America, to which God replied, “I have good news and bad news. The good news is, yes, Americans will eventually get it right. The bad news is, not in my lifetime.” Even though we have not “tried everything else” (including single-payer financing), and even though politics in America is about as discouraging as it’s been in my lifetime, nearly 50 years of involvement in health reform tells me that someday there will be an affordable American health system available to all. The foundation for such a policy reform was established with the passage in 2010 of the Affordable Care Act (ACA). At its heart, the ACA broadens coverage and changes financing policy from fee-for-service to value-based outcomes and population health improvement. American communities are building on this foundation and contributing their experiences to future policy improvements. The ACA represents nearly 4 decades of accumulated experiences with health care payment policy reform at the state and federal levels, bolstered by health services research that has translated these experiences into policy. It is this approach, not partisan politics, that has long been at the heart of health care policy improvement in America. As everyone knows, the ACA became law only because a Democratic president and Democratic members of Congress seized one of those “If not us, who, if not now, when?” moments in our history. Unfortunately, every single elected Republican congressman chose to oppose passage.
{"title":"Health Care Reform and the American Congress.","authors":"D. Durenberger","doi":"10.1111/1468-0009.12155","DOIUrl":"https://doi.org/10.1111/1468-0009.12155","url":null,"abstract":"A s a longtime health policy reformer, I have come to love Winston Churchill’s observation that American policymakers always get it right, but only after trying everything else. I am also beholden to my now deceased Alabama Democratic colleague Senator Howell Heflin’s explanation of Congressman Claude Pepper’s (D-FL) interview with God after Pepper’s death in 1989. In Heflin’s telling, Pepper asked God if we would ever get health reform right in America, to which God replied, “I have good news and bad news. The good news is, yes, Americans will eventually get it right. The bad news is, not in my lifetime.” Even though we have not “tried everything else” (including single-payer financing), and even though politics in America is about as discouraging as it’s been in my lifetime, nearly 50 years of involvement in health reform tells me that someday there will be an affordable American health system available to all. The foundation for such a policy reform was established with the passage in 2010 of the Affordable Care Act (ACA). At its heart, the ACA broadens coverage and changes financing policy from fee-for-service to value-based outcomes and population health improvement. American communities are building on this foundation and contributing their experiences to future policy improvements. The ACA represents nearly 4 decades of accumulated experiences with health care payment policy reform at the state and federal levels, bolstered by health services research that has translated these experiences into policy. It is this approach, not partisan politics, that has long been at the heart of health care policy improvement in America. As everyone knows, the ACA became law only because a Democratic president and Democratic members of Congress seized one of those “If not us, who, if not now, when?” moments in our history. Unfortunately, every single elected Republican congressman chose to oppose passage.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"43 1","pages":"663-6"},"PeriodicalIF":0.0,"publicationDate":"2015-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88144345","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
There have been dramatic advances in the treatment of HIV/AIDS. Whereas HIV was once a dire diagnosis, today it is treatable, and individuals who receive early and consistent treatment can expect to live a normal lifespan. Why has the scientific community made the same strides with mental illness? When I was the Legal Director of the National Association of Mental Health in the United Kingdom in the 1980s, major mental illnesses were primarily treated with powerful antipsychotics, such as haloperidol, that carried the debilitating side effects of tardive dyskinesia -- involuntary movements of the tongue, lips, face, trunk, and extremities. When I first saw mental patients shuffling, tongues protruding, and physically shaking, I thought they exhibited symptoms of mental illness, but soon realized it was the treatment itself. Newer second-generation medicines cause metabolic syndrome, obesity, and cardiovascular disease. In other words, the therapeutic science of mental health has not come nearly far enough.Another indicator of the lamentable failure to meet the needs of persons with mental disabilities is the large number of vulnerable individuals warehoused in large, inhumane institutions, often for decades. While the de-institutionalization movement (a strained alliance between civil libertarians and fiscal conservatives) tore down sterile hospitals, today many individuals with mental illness are in prisons, nursing homes, or are homeless. Inadequacies of science and failures in policy might be overlooked if mental illness were not so prevalent, with enormous individual, family, community, and economic costs.Mental illness accounts for about 13% of healthcare costs globally, but only 3% of healthcare funding; many countries have no dedicated mental health budget. Despite a higher death rate, mental illnesses receive a fraction of the charitable donations made to combat cancer or HIV/AIDS. Moreover, the trained mental health workforce is pitifully small given the need. Mental health professionals account for just 1% of the global health workforce. HIV/AIDS and mental illness have common features. Both are complex intractable diseases affecting marginalized communities throughout the lifespan and both are shrouded in stigma and discrimination. Certainly the human suffering and social alienation caused by HIV/AIDS remains an urgent global threat. Yet, AIDS has changed the world. How did all these technological advances come about, and why did a particular disease, AIDS, forge a pathway toward unprecedented scientific discoveries while mental illness remains largely ignored? So much scientific progress has been made since AIDS first emerged. But today, persons with serious mental illnesses -- particularly in lower socioeconomic classes -- are no better off than they would have been if they were born decades ago. Their treatment, if they have access to any treatment, will be nearly as debilitating as the disease. They are likely to be in a prison or
{"title":"A Tale of Two Diseases: Mental Illness and HIV/AIDS.","authors":"L. Gostin","doi":"10.1111/1468-0009.12161","DOIUrl":"https://doi.org/10.1111/1468-0009.12161","url":null,"abstract":"There have been dramatic advances in the treatment of HIV/AIDS. Whereas HIV was once a dire diagnosis, today it is treatable, and individuals who receive early and consistent treatment can expect to live a normal lifespan. Why has the scientific community made the same strides with mental illness? When I was the Legal Director of the National Association of Mental Health in the United Kingdom in the 1980s, major mental illnesses were primarily treated with powerful antipsychotics, such as haloperidol, that carried the debilitating side effects of tardive dyskinesia -- involuntary movements of the tongue, lips, face, trunk, and extremities. When I first saw mental patients shuffling, tongues protruding, and physically shaking, I thought they exhibited symptoms of mental illness, but soon realized it was the treatment itself. Newer second-generation medicines cause metabolic syndrome, obesity, and cardiovascular disease. In other words, the therapeutic science of mental health has not come nearly far enough.Another indicator of the lamentable failure to meet the needs of persons with mental disabilities is the large number of vulnerable individuals warehoused in large, inhumane institutions, often for decades. While the de-institutionalization movement (a strained alliance between civil libertarians and fiscal conservatives) tore down sterile hospitals, today many individuals with mental illness are in prisons, nursing homes, or are homeless. Inadequacies of science and failures in policy might be overlooked if mental illness were not so prevalent, with enormous individual, family, community, and economic costs.Mental illness accounts for about 13% of healthcare costs globally, but only 3% of healthcare funding; many countries have no dedicated mental health budget. Despite a higher death rate, mental illnesses receive a fraction of the charitable donations made to combat cancer or HIV/AIDS. Moreover, the trained mental health workforce is pitifully small given the need. Mental health professionals account for just 1% of the global health workforce. HIV/AIDS and mental illness have common features. Both are complex intractable diseases affecting marginalized communities throughout the lifespan and both are shrouded in stigma and discrimination. Certainly the human suffering and social alienation caused by HIV/AIDS remains an urgent global threat. Yet, AIDS has changed the world. How did all these technological advances come about, and why did a particular disease, AIDS, forge a pathway toward unprecedented scientific discoveries while mental illness remains largely ignored? So much scientific progress has been made since AIDS first emerged. But today, persons with serious mental illnesses -- particularly in lower socioeconomic classes -- are no better off than they would have been if they were born decades ago. Their treatment, if they have access to any treatment, will be nearly as debilitating as the disease. They are likely to be in a prison or ","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"133 1","pages":"687-90"},"PeriodicalIF":0.0,"publicationDate":"2015-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81352395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：