The GOP's answer to ACA repeal: A Disappointing Political Mish-Mash

**Please note that this is my personal commentary, and I am not speaking for any person or entity but myself.

On Monday, House republicans released their long-awaited answer on a replacement to the 2010 Affordable Care Act in the form of two ACA repeal bills (one in Commerce and one in Ways and Means). While Obama's ACA didn't accomplish much in terms of health system reform, its success can be measured in terms of real strides in parity, access, and cost-savings for poorer folks.

I wish I could say anything other than this replacement plan strips many of these strides away. But, I can't. This replacement plan strips many of these strides away.

Since I am a positive and optimistic creature, I'll start with the good stuff. Young adults can stay on their parents insurance until age 26. Payments are increased to FQHCs (Federally Qualified Health Centers that primarily serve vulnerable rural populations). Ummm. States don't have to do much until 2019/2020? Medicaid as a program isn't going away? I'm having trouble here.

OK, we'll get to the bad stuff now. And, I do have to say, when I was a graduate student I was much more even-handed in my blog posts and tried not to let my political views color the topic. Now, I really couldn't give a shit. Here we go.

General provisions:

The public health fund, money provided for necessary preventive care to the CDC to distribute to state health agencies? Gone.

Money given through Medicaid and managed care organizations to "prohibited entities" which include non profit essential health centers and family planning centers that provide abortions? Frozen for one year. *This one is really murky and unclear. A lot of media is touting this as the "Defunding of Planned Parenthood" but it's really not that simple. Federal money has never paid for abortions except in certain situations, and the actual bill language doesn't change this. Much of Washington's family planning medicaid services are provided through a 1915b Waiver, which would also be protected. We need to wait and see on this one, but it may be good to vocalize that this part of the bill should be struck due to lack of clarity alone.

Medicaid "Modernization" (ugh)

This is where it gets really crappy. I'll do my best to summarize what this would mean for our state and the rest of the nation:

The biggest thing here is that we are moving from a federal match program to a per-capita cap program. that means states don't get half of what they spend from the Fed. They get a set amount for each enrollee per year, based on 2016 spending. If we have an outbreak and people need more care, too bad. We also get penalized if our spending goes over a certain amount for the year. This will have a profound impact on states and will result in serious cuts to who gets to enroll and/or what Medicaid actually covers.

Medicaid will be harder to qualify for: No more presumptive eligibility (you need proof of stuff when you apply, instead of having a grace period), eligibility checks happen every 6 months instead of every 12, and income limits will be lowered for children. No commentary here. Just ugh.

Also, they really care about counting lottery winnings as multiple months worth of income for some reason. Go figure this gets its own section. Again, this will reduce the number of low-income folks who are eligible.

Medicaid will lose parity: The ACA required Medicaid plans to include the 10 essential health benefits also required for private plans. This whole section will be repealed, making it up to states what is covered. WA will likely be fine here, but I worry about other states.

Medicaid expansion will be dis-incentivized, meaning coverage for childless adults will eventually diminish, and/or have less federal funding. This part is really unclear in the bill so I can't comment further on it.

Retroactive coverage will go away. Meaning, if you have a heart-attack and get rushed to the hospital but you qualify for Medicaid, you can sign up later and have your hospital bill covered. No longer, unless your care was in the same month you got coverage.


Insurance Marketplace reforms:

This is where it just gets confusing. They are repealing the individual mandate (the part of the law that says you have to get insurance or pay a penalty), but saying if you try to get coverage after not being covered for 63 days or more, you get a 30% surcharge on your monthly premium. For a year! This is basically a politically savvy way of re-packaging the individual mandate.

We need the individual mandate because we need healthy people to self-select to buy insurance. If we don't, then only sick people buy insurance, and insurance companies have to pay for a lot more care with less premium money coming in from healthy people who aren't using their benefits. Even though the republicans hate the individual mandate, the insurance industry needs it or they will collapse. Think bank-bailout situation in 2008. If our health reform relies on the insurance industry, which in this case it does, they can't repeal the individual mandate without doing something like this.

There's this thing about a patient and state stability fund, presumably to prevent market collapse. I don't think anyone really gets how this would actually work. They are also removing reductions in cost-sharing for low and medium income people, and taking away a whole bunch of taxes. Though, tax credits for individuals will stay.

The insurance marketplace portion of this bill is a mess. They want to repeal the politically unpopular parts of the ACA, but keep the insurance industry from collapsing and premium costs from skyrocketing. They also want to provide hefty tax cuts and reduce penalties to employers. In order to do all of this, they are both taking away provisions that stabilize the market while also adding in new ones, but it all appears to be a hodge-podge of what they think will float politically.

To conclude, these bills hack at all three domains that were addressed by the ACA: Access, parity, and cost-savings. Markup (where they go through and revise the bill) should provide some needed revisions, so we will need to wait and see how these do on the floor. I wish I could end on a hopeful note, but I don't have anything other than this: We Washingtonians are lucky. Our state government is dedicated to access and parity, as well as cost-containment and innovation. I should know, these are the projects I work on. But, there are big changes coming. Be vigilant. Health care is complex, necessary, and important. More to come.

Love,
Bonnie

Sex-Ed: Can we teach more than consequences?

In my past job at Planned Parenthood, we often had groups of high school students come to the clinic to take a tour and speak with the staff about sexual health and the services we provided. I was often the point person for these groups, perhaps because I was the youngest employee at the clinic and perhaps because of my enthusiasm and desire to show adolescents who we were and what we did. Through my experience, I was often struck by the complexity of their questions. They wanted to know how to talk about sex in relationships, how to keep their partners happy, why people engaged in certain behaviors over others, and so forth. This nuanced way of integrating feelings, behaviors, and emotions into the way they thought about sex encompassed more than just body parts, pregnancy, and infections. 

Unfortunately, much of the education that teenagers receive about sex is provided in disjointed discussions about physiology and dangerous consequences, leaving out the parts about life. While I have fantasized about alternate ways of teaching sexuality education, I had not imagined a method so refreshing as Al Vernacchio’s way of teaching his Sexuality and Society course at Friends’ Central (a private K-12) in Philadelphia.  In Laurie Abraham’s article Teaching Good Sex, she describes her experience as a reporter sitting in on this class for two weeks, observing and interviewing both teacher and students about their experience. It was overwhelmingly positive for everyone involved, and provides hope that the sexuality education of the future can be much more useful to young people as they enter adulthood.

In reading this article, my thoughts are mostly infused with pride, appreciation, and awe at the courage and innovation it takes to teach like this in our current world. But despite this, I have a hard time picturing how this type of curriculum could be implemented in the real world of public schools and conservative communities, especially those that believe teenagers should not be having sex, and any education that teaches about pleasure is enabling illicit behavior. There is plenty of evidence that fact-based information about sex that acknowledges the good parts merely makes sex safer and does not promote it, but for most people, evidence does not trump ideology.

If we could get Mr. Vernacchio’s style of sexual health education to be implemented in private and alternative schools that have the political environment to tolerate such a way of teaching, the lives of those students would be greatly enhanced. But this will create a widening knowledge gap that may be correlated with class, location, and race. Those who are not privileged enough to be able to attend private school will miss out. Those who live in rural or more conservative areas will miss out. I find this problematic, but am not yet able to come to a conclusion for how to fix it. I know it is merely the job of the reporter to report and the teacher to teach, but I wish that both Ms. Abraham and Mr. Vernacchio were more in-tune with the social justice aspects of this issue. If I believe anything, I believe that knowledge is power. When the political climate prevents the spread of knowledge, this represents the most fundamental kind of problem.

I will continue to wrestle with this issue in my career. And, certain words uttered by Mr. Vernacchio in a recent Skype session with my Safer Sex in the City class give me hope: When asked about political climates, he stated that while things do change slowly, change can be great. If students at Friends’ Central grow up to be influential, and likely they will, they won’t think twice about supporting the kind of sexuality education they received as adolescents. It may take a while, but this could be all that is needed to create a receptive political environment and ensure accurate and life-based sexuality education for all.

Read Laurie Abraham's article here.

Rocky and me: On becoming a Boston bike girl

Rocky

I am a Boston bike girl. Me and my bike, whose name is Rocky, are a team who together take on the gritty urban streets of this city and make it our own. She is my transport, my friend, my ally, and I ride her everywhere. But it wasn't always this way. Here is the story of how I faced my fear of urban cycling in one of the nation's most unfriendly places for bikes, one pedal at a time.

I'm from Seattle where the rain and hills are plentiful, but people still manage to bike all over the place anyway. I had a structurally unsound mountain bike in my possession after college. I never rode it, it just sat there in its vivid purple glory and still managed to look sad. I was living on Capitol Hill after graduation, and my roommate Tim got this beautiful yellow Schwinn on Craigslist. It weighed about 100 pounds, but it was sleek and hip. I  was secretly jealous of his new moving machine and wanted my own badly. Brian, a dear friend and bike enthusiast, found Rocky at a swap meet and managed to get her for an excellent price of $250. Thus began a beautiful friendship between myself and a little red Lotus that continues to this day.

Fast forward a few years and I am accepted to grad school at BU. I disassembled Rocky and put her in a huge box, shipped her across the country and paid a bike shop in Boston to put her back together. But then I took her home and put her in the closet. Why? From the week or so I had been in Boston waiting for my bike to arrive, I had realized that this city was big and scary with no bike lanes and spirals of one-way streets. The drivers were insane and everyone was constantly double-parked. I was already stressed out from starting grad school in a new city, so Rocky just hibernated while I focused on other things.

In the spring, I met Eric. He was a bike messenger and nonchalantly risked his life daily by flying around in all weather, delivering packages faster than any other method of transport the city had to offer. He would not accept my fears and instead piled on intense pressure for me to ride. "Bonnie," he said, "just get on your bike." So I did. I had run out of excuses.

It was terrifying at first. Torn up streets with no bike lanes, drivers yelling, having to go around double-parked cars by cutting into lanes of speeding traffic. But with time and true grit, it got much easier. I started to appreciate the good things about Boston for bikers. The city is actually pretty small. The city is flat. The city has beautiful bike paths, that once you find them are quite a treat. In time, Mayor Menino launched the Boston Bikes Initiative, which included an expansion of the city's bike lane plan to add most major thoroughfares. Even Mass ave in the South End has a bike lane now, which is excellent considering that strip was one of the scariest places I've ever biked. (Some day I'll tell you the story of how a car headed me off there, almost causing me to bike into a sub-terranean construction zone).

Of course, I know many people who would never hesitate like I did. Who would get right on their bikes without fear or worry. But I have a few accidents under my belt, so I know what being thrown on the street feels like, with the adrenaline and blood mixing together to form feelings worth avoiding. I needed time, and now three years later, I feel like a champ. I still wear a helmet, I still stop at red lights even when nobody is coming, and I still leave Rocky at home when the snow comes down. But she and I have conquered Boston, and that's a feeling I'll always be proud of.

Could it be a two-way street? Vasalgel and its potential as male contraception

Birth control. It works wonders for preventing pregnancy, making sexual activity more spontaneous, and allowing heterosexual couples and individuals to plan for when they want children. There are so many reversible methods available to choose from, but only one of those methods is male controlled, namely, the trusty male condom. All others require at least partial female participation, and most of them don't need male participation at all. Many of my man-loving female friends see this as a good thing. With something as important and life-changing as pregnancy, some women like knowing if they took their pill, or knowing whether their ring is in place or their patch is on right. Many of them have told me that they aren't sure whether they would trust a male partner to use birth control. Needless to say, this issue has not come up, as condoms remain the only truly male option...for now.

Enter Vasalgel. Vasalgel is a product, or "system" as business people like to say, that is actually quite revolutionary and intriguing. It is currently undergoing advanced clinical trials in India, and will hopefully make its way to be tested in the US without too much trouble in the coming years. It's a LARC (long-acting reversible contraception) which are the best kind for minimizing user error (the main cause for pregnancy while on birth control) and keeping babies away until you want them, and it is entirely for men without any need for female participation.

So, what is it? Vasalgel works as sort of a temporary vasectomy, but without any snipping. The gel is injected into the vas deferens (the tubes that transport the sperm from the testicles to the urethra) and kills sperm on contact so that ejaculate is just seminal fluid. It has very few side effects, and does not disrupt hormones or sex drive in any way. If the person is planning a pregnancy, another injection is performed that dissolves the gel and the sperm resume their normal trajectory into the urethra. Fascinating. And the whole thing can last for years (like 15 years!).

I find this method heartening, and I really hope it can make a US debut. I feel this for several reasons, one being that this method is long-lasting without requiring the user to do anything to maintain its effectiveness. I don't mean to say that men aren't capable of taking a pill or putting on a cream, but they just don't have to think about pregnancy in the same way women do, so I can see men having more trouble with birth control that requires a lot of pre-planning and assembly to get right. Don't get me wrong, I do trust men. But I would feel much more comfortable relinquishing control of my fertility to a partner who is using a LARC that he can't mess up.

The other thing I like about this method is that it would not disrupt hormones in any way. Many of the other birth control methods that have been in development for men have been hormonal, and the big drawback of messing with male hormones has been decreased sex drive. If a side effect of male birth control is lowered libido, I truly doubt that such a method would have staying power. Of course, lowered libido does happen to be a side effect of female hormonal birth control, but we are better able to tolerate that as a society. Any product that messes with a man's virility is much more difficult to engage with.

Of course, men might not want to have their testicles injected four times over the course of their lifetimes. The product might not prove to be as effective as we thought. Or, the US could have some political troubles engaging in its own tests or releasing the product onto the market. Whatever the case, there are significant hurdles to clear before this method could be a reality for American heterosexual men. Despite this, I truly feel that this is the most hopeful debut of male birth control yet, and think this idea of developing and offering LARCs for men is a step in the right direction. This step could increase male participation in contraception, diffuse the current political fight on women's bodies, and allow men to have more control in the decisions of when and whether to have children. Sounds awesome. What are your thoughts?

Read more about Vasalgel here

Op-Ed Piece: EC access for young teens

Hi there! For this entry I have decided to post an assignment I did for my reproductive health advocacy course that just ended. Our charge was to write an op-ed piece about a topic in reproductive health that is controversial, and work on framing the issue in a thoughtful way. I very much enjoyed writing about emergency contraception access for young teens, so here you are:

The Nature of Evidence: Emergency Contraception Access for Young Teens

Bonnie, Guest Columnist

A fictitious newspaper like the New York Times, March 8, 2012

It is fascinating to examine the nature of evidence. As humans and consumers, we trust the medical system to keep us healthy by providing us with the right service at the right time. It is sound evidence, we hope, that allows providers to do this in a way that maintains our health and well-being. We like evidence because it helps us know that “cold-hard-science” is behind the decisions that get made about what is best for us. Yet evidence can also be used as a political tool to decide who gets what kind of medical services, and the time at which they can access them. In no other recent event has this happened more obviously than in US Health Secretary Kathleen Sebelius’s decision to veto the FDA’s recommendation to allow women under 17 access to emergency contraception.

Emergency contraception (EC) is a hormonal contraceptive pill that prevents pregnancy. Not to be confused with medication that causes abortion (such as RU-486), it does nothing to harm an existing pregnancy.  A woman can take it up to 5 days (120 hours) after unprotected intercourse, though its effectiveness declines with time. It has been behind the counter for women (and men) over 18 since 2006, and over 17 since 2009. It has few side effects, and is not known to cause lasting problems. The efficacy of EC in preventing pregnancy and other knowledge about its use is gleaned from the results of many sound scientific studies. These studies address medical side effects, access patterns and need for the drug, and consumers’ ability to read and understand the drug packaging.

In Ms. Sebelius’s statement regarding her decision to maintain current FDA guidelines and restrict access to EC for teens 16 and under, she wrote that a small percentage of girls in the US are able to bear children by 11.1 years of age, therefore the evidence presented to the FDA council was not sufficient to justify providing behind the counter access to women between the ages of 11 and 16. Indeed, the studies considered by the council only provided data for women 12 years of age and older. However, it is difficult to believe that Ms. Sebelius, with her previous experience as an insurance lobbyist, legislator, and governor, has the scientific authority to demand evidence on such a minuscule subsection of the population, a subsection least likely to be having sexual intercourse. If safety is her primary concern, might it instead be more prudent to study the health effects of childbearing in 11.1 year olds?

Let us consider the evidence that does exist, that which was considered adequate by the medical and scientific experts from the FDA Center for Drug Evaluation and Research (CDER). Remember, this is the body that came to the original conclusion that EC was safe for all women of childbearing age.  These studies showed that younger teens experience the same mild side effects from EC as older teens and adults. They showed that teens are able to read and understand EC packaging. They showed that EC does not cause an increase in risky behavior among teens. And they showed that teens can use EC correctly without medical advice or counseling. While it is perhaps true that the body and brain of an 11 year old is physiologically different from that of a 12 or 13 year old, do we truly believe that this difference is profound enough to cause earth-shaking changes in the way we allow them to prevent pregnancy?

It is clear that Ms. Sebelius has used a scientific argument to maintain the status quo of EC access in the United States, and this kind of argument is difficult to counter. No person wants to claim we do not need more evidence, especially not in a world which holds evidence to such high esteem. She is correct in her statement that data is absent for this subpopulation, but do we truly believe that evidence to support every combination of factors in the universe is our task? Have we specifically tested all headache medications on 11 year olds? Should we? In considering the larger picture of what is at stake for teens, this is an instance where more evidence may not be the answer, and we are instead blinded by politics in a scientific disguise.

Abortions, mental health, and the problem with bad science

Hello everyone! I hope you are all doing well and finding happiness in your lives. I am certainly happy that spring break is upon me, meaning that I only have to work and study for my healthcare finance midterm. Actually, I'm sort of stressed out. But at least I don't have to go to class.

What is on my mind lately in the world of reproductive health politics is the recent de-bunking of the Coleman et. al. study that claimed there was a causal link between abortion and mental health problems in women. The study was published in 2008 in the Journal of Psychiatric Research, which I'm not familiar with but would assume is a legitimate and hopefully peer-reviewed journal. I had heard about this study before, and wondered about how it came to its conclusions. The other research on the same topic was unable to find a causal link, so I found it odd that this one did.

According to the Guttmacher Institute, the study was officially found to be void based on analytic errors. Apparently, Coleman and her fellow researchers did not identify whether the mental health disorder was diagnosed before or after the abortion procedure, and proceeded to lump these women into the same group. They then found that a large number of women with mental health disorders had also had abortions (diagnosed before or after the procedure), and after controlling for current life situations that could account for the disorders, they concluded that the abortions caused the mental health diagnoses.

Uh, what?

There is a lot more detail to get into about the events surrounding this de-bunking, but such information can be found elsewhere (see the bottom of this post for some links). What makes me the saddest about all of this is that we base so much of our decisions as a country on science, and hold "evidence" that is published in journals in the highest regard. We create legislation and programs from this evidence that in turn affects millions of people. Of course, we need to support women in their decisions to have abortions and understand their mental health needs both before and after the procedure, but we can't allow this kind of bad science to dictate how we think about women who have had, or will have abortions.

Yes, abortion is an incredibly difficult decision that nobody wants to make, and such a situation can definitely have repercussions for some people. However, the body of evidence that already exists about mental health and abortion (and physical health and abortion for that matter) shows that abortion really does not cause marked distress in women. In public health school we learn that it is a body of evidence that allows us to conclude that something has a causal relationship, not one or two studies by the same author.

Other studies have shown that the women who do have complicated mental health reactions after their abortions were struggling with mental health issues prior to having the procedure. According to further research on populations who have mental health diagnoses, these same reactions occur after other difficult events in their lives. This is telling, as it shows that it is not so much about the abortion as it is about a person whose coping abilities may be compromised. We need to re-frame this issue as supporting women with mental health issues through all of the difficult times in their lives, not just abortion.

Of course, women without mental health diagnoses who have abortions need support too, because it can often be a difficult, guilt-inducing, and isolating experience. We should be offering support for every woman who has an abortion to help her maximize her recovery, whether she is having a reaction complicated by a prior diagnosis or a more common mix of contradictory emotions. But, we should absolutely not be operating on the premise that abortion is an experience that will always lead to complicated outcomes.

To conclude, scaring women with junk science is bad. Not making a distinction in your study between diagnoses made before an abortion and after an abortion, and then claiming that abortion causes mental health problems is abhorrent indeed. I am so glad this study has been debunked, but what of others? It is my most sincere wish that this example motivates journals to re-evaluate their screening processes, to make sure that science stays as unblemished as possible for the benefit of all of us. What do you think?

Further reading:

Read the Guttmacher article here
And the original Coleman study here
And the letter from the scholars who found the study to be flawed here
And another Guttmacher article about abortion reactions and the evidence behind them here

Why I deleted my Pinterest account

The web would be nothing without social media. Given the explosion of online content in the past several years, platforms charged with the organization and display of this content are imperative in order to make sense of it all and allow users to find and share what matters most. I love trying new platforms, and am consistently motivated to pioneer some of these contemporary offerings, motivated by a search for improved quality and relevance.

When my dear friend Georgia got engaged last year, she took to Pinterest to organize and manage all of her wedding ideas. For my parents and others of you unfamiliar, Pinterest is a social media platform that operates sort of like a virtual corkboard. Users create "pinboards" organized by theme and then "pin" content onto them from the Internet. The interface is photo-based, meaning that the image associated with the content is displayed for other users (your own friends or strangers) to click on and "like" or "repin" to their own boards. It is very visually appealing and easy to use, and can draw you into a mind-bending chasm of wasted time. Unlike me, Georgia used it constructively to compile ideas for wedding hair, dresses, invitations, flowers, and decor, which has allowed her to slowly build a holistic theme for her upcoming ceremony.

It was she who turned me onto the idea in the first place, and I gladly made my own boards. My first red flag came when I had to use my Facebook or Twitter account to sign up, but when I found that I didn't have to publish my Pinterest activity on Facebook, I settled down and began pinning to my heart's content. I slowly began to notice that strangers were repinning my pins, and that more and more people were following my updates that I didn't approve, some of them strangers. While I'm not completely opposed to the idea, it was the systematic lack of my permission that made me the most uneasy. All of a sudden, my content was public to all Pinterest users who could view and share my pins to their hearts content, with my only notifications coming after the fact.

Now, you may be wondering what the big deal is. The internet is public, you say. Pinterest is about sharing, you say. Now, that is all well and good. And while I do not believe the Internet is a private place, I do feel that an online personality within the context of a social media site is something you should expect to be able to control, especially if the platform is a password-protected user community. You should at least be asked if you'd like your content to be available to all users, and you should be able to control who follows your content preemptively, not after the fact. Perhaps I'm getting old, but the whole thing was making me a little queasy. Perhaps I was too used to the older platforms that asked you if you wanted to add someone as a friend beforehand. But all of this was not quite enough to make me stop using Pinterest.

The final straw came last week when I googled myself, as I do from time to time, to see what comes up from my name for the world to see. I was not signed in to any of my accounts, as I wanted to simulate what a stranger or potential employer might see. I was aghast to see my Pinterest account on the first page, attached to my full name. When I clicked on it, all of my boards were public, and you could even follow me with one click. Not that I had anything to hide on the site, but the idea that a stranger could access the totality of the content I intended for friends hit me right in the gut. I then found that I could remove my account from search results, but since cached pages could still lead users to the same destination, I opted to delete my account entirely.

Georgia can do what she wants without judgment from me. After all, she is using hers in a much more productive way than I ever did. Also, she may have completely different views on internet privacy, rendering my argument completely irrelevant, as it could also be for many others. But I am finished, and without a single tinge of regret. I have learned something from all of this, which is that I plan to pay much closer attention to terms of service in the future, and be wary of platforms that link to existing accounts. Linked accounts are a great way to get tons of information about me from the start, information that I want to be more guarded about as I thoughtfully cultivate my online identity.

ALSO: The copyright buzz around Pinterest is pretty fascinating. Read this to learn more, including how it seems that users are solely responsible for the legal expenses incurred against them and against Pinterest in the event of copyright infringement, something the site seems to enable.

What are your thoughts?