Time to reform gun policy; gun violence is a public health issue

As the tragic event in Tucson reminded everyone a few weeks ago, our nation’s love of firearms can have severe consequences.  Unfortunately, those of us who practice in urban neighborhoods plagued by violence are frequently reminded of the impact guns have on our patients’ lives.  Emergency room physicians see the victims themselves.  As a primary care physician, I see the secondary victims: friends and family members of those who are injured or killed by guns.  The mothers of those affected come in heartbroken, either because their children were killed or have gone to jail on gun-related offenses.  Their siblings are bereaved and confused, sometimes wanting to get into the game themselves for revenge, other times feeling anxious and afraid to leave the house.  Those who are killed or sent to prison leave behind yet another set of victims, their children, whose caregivers have limited support to raise them, often leaving them one step behind their peers.

Although the absolute number of deaths from guns is relatively low in comparison with heart disease or cancer, violence is a public health issue, and we need to address it as such.  Among 15-24 year-olds, homicide and suicide are the 2^nd and 3^rd leading causes of death.  The majority of these deaths are gun-related.  Black men are disproportionately affected; the homicide rate for black men is 6 times that of white men.

There are solutions to this problem.  In New York, anti-violence advocates have introduced a bill to enact microstamping; this would imprint a unique mark on every bullet casing, helping officers connect guns to crimes. 

On a national level, legislation has been proposed to close the “gun show loophole,” a loophole in federal law that allows guns to be purchased at gun shows without a background check.  New York Representative McCarthy recently introduced a bill called the Large Capacity Ammunition Feeding Devices Act in response to the shooting in Tucson. 

 To learn more about how we can begin to address the problem of gun violence in New York and nationally, please join our partner Greater NYC For Change at an event on Wednesday February 9^th at 7:00 PM, cosponsored by the American Friends Service Committee and New Yorkers Against Gun Violence, at 15 Rutherford Place (Union Square), New York, NY.

For more information about gun violence statistics, see the following:

Violence Policy Center

United States Department of Justice

Health Reform Benefits in 2011

It’s the new year, and that means new benefits from the Affordable Care Act (also known as the health reform law.) Seniors enrolled in Medicare’s prescription drug plan (Medicare Part D) will spend out of pocket. Currently, when a people with Part D have used $2,830 of their drug benefit, they are required to pay the entire cost until they reach a certain threshold. This is called the Part D coverage gap, or the “doughnut hole”. With the ACA, pharmaceutical companies are required to provide consumers with a 50% discount on all non-generic drugs while they’re in the coverage gap, and a 7% discount on generic prescription drugs. Although seniors will be paying less for their medications while in the coverage gap, the full price will be applied, getting them through the gap more quickly. By 2020 the coverage gap will go away entirely (see the AARP for further explanation).

Also effective January 1^st is the implementation of the minimum medical loss ratio. We wrote about this previously; it requires that insurers spend at least 80% of the premiums they collect on medical care, instead of on advertising or paying their employees.

Doctors will soon find it easier to care for patients relying solely on Medicare. Although most physicians continue to accept Medicare, some primary care physicians find it quite hard to provide their patients with necessary services on the rates they are paid. Starting January 1^st, Medicare payments for primary care and general surgeons in shortage areas will rise by 10%. Unfortunately, this increase will only last through 2015, at which point Congress will likely have to address the issue again.

Also effective January 1, seniors on Medicare will no longer have to pay copays for some preventive services. This will be limited to services that have been rated “A” or “B” by the United States Preventive Services Task Force. These are services that, based on available evidence, are likely to provide either moderate or substantial benefit, either by improving well-being or preventing death. This includes screening for elevated blood pressure, cervical cancer, cholesterol, colon cancer, vision testing in children, counseling for tobacco abuse, screening for osteoporosis, and many other services. Although there is disagreement among different experts regarding breast cancer screening, the ACA also covers mammograms for all women over 40, although the USPSTF no longer recommends routine mammograms for women under age 50.

Another small change you’ll notice is nutritional labeling for all food sold at chain restaurants and in vending machines. We already have nutritional labeling in New York City. There is no evidence that knowing how many calories are in the meals bought at chain restaurants changes behavior, or even that people understand what the numbers mean, but for some people knowing the information is valuable (starts in March).

We can also expect some smaller programs aimed at sparking innovative approaches to improve the way we deliver health care. The Center for Medicare and Medicaid Innovation will design and implement multiple small projects by consulting with stakeholders, including medical providers, insurers, and patients, to improve the quality of medical care by streamlining what is often a fragmented system. The goal is to find new models of health care delivery that will improve care and save money. For more information see the CMS innovations site. Another smaller project will give increased Federal support for 2 years to patient-centered medical homes (also known as health homes).

In Graduate Medical Education, Teaching Health Centers (where residents, or doctors-in-training who have finished medical school) will be funded as residency sites for 5 years. Residency slots will be redistributed to favor primary care training. These changes will occur in July.

Some other behind-the-scenes changes include grants to help Medicaid enrollees develop healthier lifestyles, as well as grants to small employers to develop similar wellness programs. States will receive grants to start planning their insurance “markets”, also known as the American Health Benefit Exchanges and the Small Business Health Options Program Exchanges. Enrollment in the Exchanges is planned for 2014.

Cost-saving measures include no longer paying hospitals for certain preventable infections acquired in hospitals; restructuring Medicare Advantage programs so that they are no longer subsidized at the expense of other Medicare beneficiaries (currently Medicare Advantage plan members receive extra benefits when compared with traditional Medicare beneficiaries, due to a 13% increased payment to the plans compared to those on traditional Medicare; the subsidy will decrease to 1% on average, but it will vary from state to state. See the Wall Street Journal for more information. Those with tax-free health savings accounts will only be able to over-the-counter drugs covered if prescribed by a physician. Individuals earning over $85,000 per year (couples earning more than $170,000) will continue to pay premiums for Part B coverage, but instead of having this threshold increase yearly it remains frozen. This will only affect about 5% of Americans. Similarly, about 3% of Part D enrollees will be subject to a new premium for this drug benefit program. These changes are in effect on January 1^st.

Several other provisions include changes to long-term care, an optional disability insurance program, and several other items. For a full explanation see the Kaiser Family Foundation or www.healthcare.gov

The vast majority of Americans will see many benefits from these changes. A small percentage will benefit, but also will have to pay more for some of their benefits; some may end up saving money despite this increased cost due to full coverage of preventive services.

The grinch who stole health care reform?

Families USA does a great job reminding us of all the good the Affordable Care Act has already done with their holiday-themed post, "Five things the health care grinches don't want under your tree this year." The Republicans (and some Democrats) are looking forward to dismantling the law. We hope they don't want to roll back everything we've gotten so far: coverage for all kids regardless of health problems, no cost-sharing for most preventive services in new health plans, help for businesses to cover their employees, coverage for young adults, and new high risk pools for people with pre-existing conditions. Plus there's more to come in January of 2011, including lower drug costs for seniors on Medicare; free preventive services for seniors; requirements for insurance companies to spend premiums on care, not on advertising; and help coordinating safe discharges from hospital to home for vulnerable patients. Read more at Families USA's Stand Up for Health Care project and at healthcare.gov.

Happy holidays, and we look forward to working with all of you next year as week keep fighting for health for all.

Reform law repeal? Unlikely; many benefits already in effect.

Since the Patient Protection and Affordable Care Act (PPACA, also known as the health reform law) was signed into law, its detractors have been bringing lawsuits everywhere they can find a willing prosecutor. More than 20 suits have been filed around the country, several of which have been dismissed (in Michigan and Virginia), and the majority of which are pending. On December 13^th, the lawsuit in the Eastern District of Virginia was upheld when the judge ruled the mandate for individuals to buy insurance was unconstitutional, and that the Commerce Clause (regarding regulation of interstate finance) does not allow for a mandate to purchase health insurance (for a complete listing of lawsuits and their status, see The Washington Post). Other clauses are also an issue, but I'll leave that to the experts. Although the judge ruled that component of the law unconstitutional, the rest of the law is not affected.

Some constitutional scholars seem less than pleased with this ruling. Professor Stephen Schwinn, at the American Constitution Society Blog, notes that the decision goes far beyond a ruling on the individual mandate. He argues that the ruling is consistent with rolling back decades of judicial thought and returning the role of the courts to those of the first half of the 20^th century. At that time, the Commerce Clause was defined quite narrowly, allowing the courts to obstruct congressional activity considerable. In the late 1930s, the courts moved to a more pliant interpretation of the Commerce Clause, taking into account the complexity of our modern economy. (Please read more about it here http://www.acslaw.org/acsblog/node/17875 as I am not a lawyer). President Obama, himself a Constitutional scholar, clearly believes this law to be appropriate and within the mandates of the Constitution. There are, of course, some scholars who disagree and believe that requiring people to purchase health insurance is not allowed by the Commerce Clause. Most likely this will end up in the Supreme Court, according to policy watchers.

Most supporters of the PPACA believe that an individual mandate to buy insurance is required. Although the individual mandate was in part a bargaining chip to bring insurers on board to support health reform rather than bring their full advertising muscle against it, it also has value in making the system sustainable. If people are not required to buy health insurance but insurers are required to sell it to everyone regardless of their medical history, some people will simply wait until they’re ill to buy the insurance. If everyone does this, there won’t be enough money in the system to pay for expensive hospital stays or surgeries for those who are ill. As a result, everyone who does pay insurance will have to pay more to cover those who are sick, while others get a free ride. Worse, people may still not even buy insurance when they’re sick, then not pay their medical bills. Again, everyone else ends up having to pay more to make up for the people who don’t pay their part. (Here’s a helpful (if dry) video from the Kaiser Family Foundation that explains the concept of the individual mandate more thoroughly)

Nobody wants to have to pay for insurance, especially if they don’t think they need it. On the other hand, none of us want to see our friends, family, and neighbors suffer because they can’t afford to see a doctor. In addition, most people will qualify for coverage that is either free or significantly subsidized. Ironically, many of those calling for repeal are those who will have free health care in 2014 when the full effects of the law take place.

The health reform law is already benefiting many people, by requiring insurers to cover preventive services, eliminating pre-existing conditions for children, extending coverage to young adults, and creating special insurance plans for people with pre-existing conditions (see www.healthcare.gov for details on all of these provisions). In 2014 it will benefit far more people, with improved eligibility for Medicaid, subsidized insurance options for the majority of Americans who are uninsured, elimination of denials for coverage for pre-existing conditions, and many other changes. (Find out how much you can expect to save with the Kaiser Foundation’s subsidy calculator)

The individual mandate is just one part of a large reform package meant to improve the way people get health care in the US. While its future remains uncertain, the remainder of the plan is intact, and many more benefits can be expected in the future.