The ABC’s of the ‘Health’ Bill…

Ok back to health policy…many of you may be aware of the group the USPSTF – the US Preventative Services Taskforce.  From their site they are, “non-Federal experts in prevention and evidence-based medicine” who “develop recommendations for primary care clinicians and health systems”.

They have had some controversial recommendations in the last couple of years. The first was a well publicized recommendation concerning the need for women under 50 to receive a mammogram. They recommended –no.

There are problems with this.  Some aggressive forms  of breast cancer , hit younger African American and Hispanic women at higher rates than for White women.  The recommendations are based on research- the same research that has historically not included minorities for a variety of reasons.  Will this result in more health disparity, while trying to save the health care system money? Considering cost-effectiveness is one of their charges.

A more recent recommendation is similar around prostate cancer- that is wait and watch after diagnosis but don’t treat as the treatment may be worse than the disease.  The problem here is that there is no real answer.  People who are not treated and should have been will suffer, and those who are treated needlessly may suffer.

The answer then, one would think, is to have the treating health care practitioner make treatment decisions in concert with the patient.  What a concept! The recommendations should be just that- recommendations. They are based on available research and evidence but are certainly not –conclusive. I have no doubt that the taskforce members do due diligence with available evidence and come up with their recommendations.  The recommendations are likely good for 80% of the population.  It is the group for which they may not make sense for that I am most worried.

And then, when the recommendations affect payment streams, funding, policy etc. they in effect come between the patient and their practitioner.  The practitioner, who knows the patient’s history, ethnicity, stress levels, eating and exercise habits and so forth should decide with them as to what screening, treatment and medications they may or may not take. They may decide a ‘C’, ‘D’ or ‘I’ recommendation makes the most sense.

The Health Law and USPSTF

In the Affordable Health Care Act- you will find the following:

SEC. 2713. <<NOTE: 42 USC 300gg-13.>> COVERAGE OF PREVENTIVE HEALTH

SERVICES.

“(a) In General.–A group health plan and a health insurance issuer

offering group or individual health insurance coverage shall, at a

minimum provide coverage for and shall not impose any cost sharing

requirements for–

“(1) evidence-based items or services that have in effect a

rating of `A’ or `B’ in the current recommendations of the

United States Preventive Services Task Force;

Now on its surface-I am sure that probably reads as reasonable-until maybe you LOOK at what does and more importantly does NOT fall under A and B.

I focus my work in large part in aging-

Screening for Dementia

Not A or B

“The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults.”

-50% of all persons over 85+ years will have Alzheimer’s. FIFTY percent!

Interventions to Prevent Falls in Older Adults

Not A or B

Screening for Hearing Loss

Not A or B

“The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults ages 50 years and older (I statement).”

 Screening for Impaired Visual Acuity in Older Adults

Not A or B

“The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults.
Grade: I statement.”

Behavioral Counseling in Primary Care to Promote Physical Activity

Not A or B

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity.
Grade: I Statement.”

Disclaimer

While there is the disclaimer in the bill that nothing precludes plans from adding these things on their own dime ostensibly- A and B are the minimum- i.e. what will be covered unless the plan goes over and above.  In this economic climate what do you think the chances are?

Are the Boomers, diverse persons and their practitioners actually reading this bill? And if they did, did they get past A and B????  I encourage all of you whether consumer or practitioner to see what is paid recommended for you!

Exotic!…not!

I’ll never forget being in my doctoral program one day when one of the faculty for the course referred to me as exotic.  I politely but swiftly corrected her and said, actually I was the only non-exotic person in the room.  This set off quite a discussion and the 2 faculty members apparently fact-checked me after class (no hand-held Google back then).  They had all thought exotic to mean ‘different’ or ‘rare’ etc.  They were shocked to find that exotic was defined as ‘not native’ and or ‘introduced from abroad’, and that it fit the class to a ‘T’, myself excluded.  My class (including the faculty for the course) was comprised of: An African American; a citizen of the British Isles; 4 Caucasians and; myself.  As an indigenous person, I was ‘native’ to the continent, and ergo the only non-exotic in the school room.

Now, other than being mildly amusing on some front, I thought, if THESE people don’t get it understand the differences, what hope is there for the larger community? And the health care community in particular…What does any of this have to do with policy and politics?  The short answer is that sovereignty is arguably the number one issue in Indian Country.  Inherent sovereignty or the sovereignty that nations enjoyed pre-contact, although retained in spirit has now been redefined and reassigned.

American Indians are often lumped in to the ‘minority health’ realm.  The lumping does 2 things: 1) It effectively knocks them out of sight due to small numbers (the other 1 %), and 2) fails to apply historical and geopolitical concerns that must be known and figured into care, i.e. what difference does exotic vs. indigenous make?  For one, they are the only people in American to have had the following in their history: (forgive the abbreviated nature of this)-

  • The Removal Era (including the Trail of Tears) conceived of by President Jefferson (with words such as ‘extermination’ bandied about) and notoriously carried out By President Jackson (the people’s president, father of the democratic party- just sayin’…);
  • The Reservation Era where American Indian people were forced to live in many cases far from their traditional lands and way of life, or as in my tribe’s case with other tribes, related or not.  And usually, in areas that were difficult under even the best of circumstances.
  • Allotment and Assimilation Era where plots of land were assigned in the hopes of them becoming so divided through passage by one to many after death that it would essentially end American Indian holding of any territory.  And of Indian Boarding Schools where indigenous language, culture, roles, religion, dress etc. were literally beaten out of the children. Families often never saw the children again, many children died. Many were traumatized and the effects have been passed on to today’s Natives through historical trauma.
  • The Termination Era where the federal government un-recognized 100 tribes effectively cutting any further responsibility for them.
  • And American Indians were among the last group to gain –widely- US Citizenship in 1924.

If health care providers were to understand these histories, or if US citizens and residents were to understand all that has happened in a few short hundred years, versus the ten thousand or more that American Indians held inherent sovereignty over this land, they would be hard pressed to see them as ‘exotic’, or as lump-able. They would understand that American Indians deal not only with historical trauma (trauma to their ancestors) but increased individual trauma.  This complication lead can lead to depression, loss of identity, roles, shame and all the attendant behaviors. The environment, whether reservation or city has contributed to some of the lowest years of expected average life span or available health care.

Admittedly, the ‘exotics’ have their own stories, but all were ‘introduced from abroad’ and they do not have the sorrows or the joys over this land in quite the same way. They do not know where the medicine is, or where the spirits are…Indigenous medicine, people, and spirits.

For citations on these ideas please see my article: Margaret P. Moss, American Indian Health Disparities: By the Sufferance of Congress? Hamline Journal of Public Law and Policy, V32, No.1, 2010, p.59-81

The Silence is Deafening!

It occurs to me as I go full swing into the fall conference season for academics; there will be a deafening silence.  Again, I will have at my disposal literally thousands of papers and posters presented at nursing, gerontological and other health related conferences with few to none reporting on the health status, interventions tried, or clinical trial outcomes of America’s first peoples.

Year after year I attend these conferences, and year after year out of those thousands, I may see 5 or 6 presentations on American Indian health.  I am usually giving one of them.  For example, at the Gerontological Society of America’s conference in Boston next month, I searched for ‘Indian’ (and other related terms) and 1 symposium came up.  The one of which I am a part.  Now, I find it is part of my personal and professional mission to ‘spread the word’ surrounding the history, current circumstances, law, policy and related health issues of American Indians and especially elderly.  But, if there is no one else speaking- then I can’t learn….I will be on a panel with others at the symposium, the usual wonderful suspects.

I remember many moons ago, I was giving a paper at a conference in Texas as a doctoral student and 3 people came to my breakout on American Indians and Aging.  I am constantly baffled by the lack of interest in this population.  Mind you I realize that I am somewhat biased, but it can’t be good that there is a whole slice of the American population that is constantly overlooked.  Even at 1% of the population you would expect 40 papers at a conference with 4000 given.  We are never even close.

To be fair, I spend a good amount of my time answering the call to ‘spread the word’ as requested by people and groups around the country.  But, until we can increase the number of American Indian academics who do research and teaching, we can’t get more students in to learn to take over and so on.

There are around 28,000 doctorally prepared nurses in this country.  A rough count of doctorally prepared American Indian nurses is – 20.  Of those with doctorates in nursing itself- it is fewer.  For the total to be representative of 1% of the population there should be close to 300 of us.  Why aren’t there 300? The reasons are many.  They include cultural clashes, high school dropout rates, identity and role issues, the written word, geopolitical barriers and the disturbances of historical trauma.

I was on faculty at the University of Minnesota in the School of Nursing for about 10 years.  I chose Minneapolis to live as one of the largest cities with an urban Indian population, and I had access to 11 surrounding tribes.  Eye-opening to me: Minneapolis high school graduation rates for American Indians are abysmal.  Only 21% made it to graduation in 2009. 21%!!!  No Child Left Behind? We are leaving 80% of our American Indian children behind!  Race to the Top??? How about race to ANY rung on the ladder and hang on for dear life??

Until America can figure out the education gap issues in this country, many, many voices will be silenced. They will be silent from high school classes, high school graduations, college classes, industry, innovations, health care, policy making and conference offerings.  I am blessed that I had total encouragement in the education arena but I don’t pretend that that is the total answer either.  I hope to help make an impact on education and I call any and all to find solutions ASAP.   In the interim, I will pack my bag, jump on the train northward and do what I can to break through the silences…

Things that make you go …hmmmm!

Ok, let’s talk healthcare. We constantly hear about the uninsured and the underinsured (an undeniable problem in this country). I am over insured! By thrice! Could this be one solution?

Some things I know about healthcare from education [a degree in Biology; 3 degrees in Nursing; a Law degree focused in health, elder and American Indian law; a postdoc fellowship in aging research; and a health policy fellowship staffing the Senate Special Committee on Aging]. Some things I know from working in the healthcare space- bench science research, nurse for over 20 years- positions in large VA Medical Centers, positions in a tiny Indian Health Service (IHS) Hospital, positions in academic Medical Centers, and private facilities, nursing faculty in research 1 institutions, literally coast to coast and north to south. But some things I know just from being f (cough) ty something years old!

This is one such of those latter things. In August of 2008, I moved my family from Minneapolis where I was tenured faculty in the school of nursing, to Bethesda, MD (coincidently where I grew up-a story for another time). I had been accepted as an RWJF Health Policy Fellow and settled in for a long-ish temporary relocation.
My family of six settled into its new routine. By ‘benefits open season’ in December of that year, I realized I was paying for 6 people to have healthcare which none of us could access as we were WAY out of area. My husband had healthcare in our new area and that is what we all used. So, thinking I would save us all some money as we maintained the house in MN and rented in MD, I dropped all but myself (employer rule) from all plans- health and dental. I eagerly awaited my paystub for the next month. But it was decidedly lower! By hundreds.

Since this was a pretax issue, it would have been less expensive for me to keep insurance I would never use—are you seeing solutions from this challenge??—than only insuring as it made sense to insure. When I worked in IHS and in the VA there were programs to donate vacation and sick time to other employees when they had either a catastrophic illness, several maternity leaves in a few short years, etc. Now call me crazy, but what if I could have donated the healthcare I had ‘just laying there’ to a family in the system? It would have been less expensive for me, insured several other people (a family?), and cost the US federal system-nothing.

The current numbers being bandied about are 45 million, or 14% uninsured. Of these the current wisdom is that 12 million are undocumented immigrants and another 10 million ‘opt out’ (i.e. could pay and have access to signing up and don’t). That leaves 23 million uninsured-likely NOT of their own choosing. Could such a program make a dent in this population? Was there a family at the University whose primary breadwinner either didn’t work the necessary 32 hours a week or was not in a benefit earning position or who could only afford to take the employee benefit but not the additional cost of a family benefit? Believe me I searched for ‘real numbers’ but no-one is reporting on over-insured as regards to health care. How many families like mine had HealthPartners- MN; Kaiser-MD; and Indian Health Services? How many people are doubly insured and never use the secondary insurance??

Now trust me I am not so naïve as to not see that there would be questions as to matching families, or health statuses, or …..(fill in the blank). But if ‘risk’ is a barrier- it is important for the reader to know that no one asked my family of 6 what health problems we may or may not have had when we enrolled- just sayin’.

This is the type of solution that gets me excited- this type of thinking- whether this particular solution or any iteration therein could ever work or not, this is another facet of how and what we need to ‘fix’ healthcare…This is a thirty fifteen thousand foot view of a possible solution. It sits as an example of an ‘innovative solution’ that doesn’t seek more government, more taxes and maybe makes just a little too much sense…