Thursday, July 29, 2010

Health Care Reform Basics Explained

The family issues activist group MomsRising met with HHS Secretary Kathleen Sebelius in a web chat recently to ask questions that they had gathered from their million-plus membership of mothers. Since I've questioned MomsRising's tactics in the past, I was curious to see how this chat would go. It's certainly an important topic: a HealthDay/Harris Poll of 2,100-plus Americans, released today, showed that many are deeply confused about what changes to expect from the Affordable Care Act that passed in March.

Actress Fran Dreschler, who survived uterine cancer and now works to improve cancer awareness among women through her website Cancer Schmancer, joined Sebelius and MomsRising's National Campaign Director Donna Norton in the web chat.

It was an odd collection of personalities: the articulate, calm Sebelius; the passionate and occasionally off-topic Dreschler; and the smiling, friendly Norton, who wore a MomsRising T-shirt (as MomsRising representatives do when meeting publicly with government officials, a habit that I dislike) in contrast to the smartly-dressed Sebelius and Dreschler.

The web chat touched on some changes coming in 2014 (the health insurance exchange), but focused on what will change in 2010. Changes to expect this year include:
  • preventative care coverage without out-of-pocket costs to the consumer 
  • new insurance pools for people denied coverage due to pre-existing conditions
  • expanded health care coverage for adults up to age 26
  • elimination of annual caps on insurance coverage for individuals
Sebelius, Norton, and Dreschler also discussed more innovative disease-prevention strategies included in the bill, such as calorie labeling on menu items in fast food restaurants. I was glad to see MomsRising lead a substantive discussion of health care reform.

A timeline of when various benefits will begin is available on the new site, which also has an interactive section that lists health insurance options for different groups of people.

It's unclear to me whether health insurance will become less complicated under the new law. Billing paperwork from health care insurers and providers is currently so complex and error-prone that Quicken has developed Health Expense Tracker software that interacts electronically with certain health insurance companies to help consumers keep track of everything. The 1996 HIPAA bill was designed (in part) to reduce and streamline insurance paperwork; instead, it has increased it.

On the other hand, the Affordable Care Act offers Americans assurances that their medical expenses will be covered more fairly. To pay for this, the bill is structured to provide financial incentives for insurers (and other organizations) to focus on preventing disease, rather than dropping patients when their diseases become too expensive. With more than half of all U.S. bankruptcies caused by unpaid medical expenses, it's about time for the change.

Friday, July 23, 2010

Skin cancer, tainted sunscreen, and Vitamin D: Sorting it all out

A 2009 study published in the Archives of Internal Medicine found that about three-fourths of teens and adults in the U.S. are deficient in vitamin D, as are 90% or more of African Americans and Mexican Americans. This is bad news, because vitamin D might help protect against a host of modern ills, including osteoporosis, heart disease, cancer, and dementia. Equally disturbing, though, is the controversy over how to get enough vitamin D.

Your body can get vitamin D from sunlight, certain foods, or dietary supplements. To help prevent skin cancer, though, the American Academy of Dermatology recommends that everyone avoid sun exposure as much as possible, and use sunscreen and protective clothing. Some people, however, believe that high rates of vitamin D deficiency are a result of too many people following these recommendations. Others believe that dermatologists have exaggerated the threat of skin cancer in order to attract more patients.

Earlier this month, for example, a Huffington Post blogger posed as a patient and visited several San Francisco dermatologists, covertly (and illegally) recorded his conversations with them, then criticized their recommendations on removing moles and avoiding the sun. The blogger accuses dermatologists of (among other things) scaring people into getting moles checked out or removed, then trying to upsell them cosmetic skin procedures. The flaws in the blogger's argument, including his questionable ethics, were called out by doctor and blogger Peter Lipson.

Sunscreen itself came under attack earlier this spring, when the Environmental Working Group came out with a report that condemned almost all the sunscreens currently available. The EWG stated that some sunscreens might actually contribute to skin cancer rates. Sunscreens that are inadequate, or inadequately applied, create a false sense of safety in the sun and increase sun exposure, says the EWG. Some sunscreen ingredients, such as retinyl palmitate or oxybenzone, might cause skin cancer or other problems as well.

The EWG's recommended sunscreens use the minerals zinc or titanium to block the sun. Alternatively, you can use sun-protective clothing and hats to provide protection. That's my preference; I'm a fan of the Sun Precautions line of clothes.

It's hard to know exactly how much vitamin D you need as well. Current recommendations range from 200 to 1,000 IU (international units) or more per day, depending on your age, gender, and other factors - such as what health source you consult.

The National Institute of Health's Dietary Supplement Fact Sheet on Vitamin D, for example, suggests 200 to 600 IU daily. The National Osteoporosis Foundation increased this recommendation to 800 to 1,000 IU daily for adults 50 and over. For people at risk for heart disease, a study released in March suggested that they should talk to their doctors about taking up to 1,500 to 5,000 IU daily, even though this exceeds the currently recommended daily maximum of 2,000 IU for adults.

Fortunately, the Institute of Medicine is currently wrapping up a two-year study of vitamin D and calcium recommendations. Their results should be available in October or November. Meanwhile, I'll stick with sun safety, a moderate amount of vitamin D supplementation, and a diet that includes D-rich foods (such as oily fish; D-fortified milk, orange juice, yogurt, and cereal; and egg yolks).

Friday, July 16, 2010

Should HIV-Positive Women Bear Children?

The modern HIV/AIDS epidemic began in California and New York in 1981, and was seen primarily as a disease limited to gay men, injection drug users, and hemophiliacs (remember Ryan White?). Today, however, the disease demographic has shifted radically. About half the people living with HIV/AIDS worldwide now are women of childbearing age, and many of these women want to become pregnant.

The Harvard School of Public Health just released a report that explores this issue, "The Pregnancy Intentions of HIV-Positive Women: Forwarding the Research Agenda." Despite its academic tone, the report is full of riveting information about HIV-positive women and pregnancy worldwide that is sure to spark discussions among the people who read it. The report favors supporting HIV-positive women who want to become pregnant, even in resource-poor countries where health care funding is already strained.

An HIV-positive woman who wants to become pregnant faces three main issues. First of all, she might transmit the virus to her male partner. Even if both she and her partner have HIV, they could still transmit different strains of HIV to each other. Secondly, the woman needs to try to prevent transmitting HIV to the child during pregnancy, labor and delivery, and while breastfeeding (the HIV virus can be transmitted through breast milk). Lastly, the woman needs to stay healthy enough to raise the child.

To help HIV-positive women become pregnant without infecting their partners, the report suggests providing access to assisted reproductive technologies, such as in-vitro fertilization and artificial insemination. The report's authors admit that this is not a great solution. They explain that:
For those who are already on antiretroviral therapy, the combined expenses of ART [antiretroviral therapy] and assisted reproductive technologies are simply out of reach. Even when available, the idea that assisted reproductive technologies could be used by women who are HIV-positive appears to be strongly opposed. This is an area where stigma and discrimination are highly manifest.... many health care providers express the view that HIV-positive women should not have children and should certainly not have access to expensive technologies to help them do so.

Once an HIV-positive woman is pregnant, keeping her and her child healthy is another expensive, complicated hurdle. The woman needs to consistently take expensive antiretroviral therapy (ART) drugs throughout pregnancy and breastfeeding to help prevent transmitting HIV to her child. She also needs to take ART for the rest of her life to suppress the virus and its symptoms and stay healthier.

Parts of the report made me think that helping HIV-positive women get pregnant in resource-poor countries was a Very Bad Idea. For example, paying for reproductive technologies in a resource-poor country is a questionable use of resources. In poorer countries, less than half of people who need HIV treatment get it, according to the HIV/AIDS charity AVERT. Shouldn't limited health care money be used for HIV/AIDS education, prevention, and treatment, where it would do a greater amount of good for a greater number of people, rather than insemination services?

Apparently not. The Harvard report states that "some NGOs [non-governmental organizations] globally are beginning to pressure governments to provide assisted fertility services for people living with HIV/AIDS." The report's authors believe that HIV-positive women (and their partners) should have the same reproductive rights, including the right to bear children, as women who are not HIV positive.
Other details from the Harvard report, however, made it clear that this issue is far more complicated than it first appears. Here are a few things that struck me from the report:

  • Culturally, motherhood confers far more status to women in some countries than anything else they might achieve. A woman who does not have children might be ostracized by her community.
  • In some cultures, women who do not have children  might be accused of being HIV positive, which makes them seek out pregnancy as a protective measure (even if they are HIV positive).
  • In some cultures, women don't feel empowered to insist that their partner use a condom to keep the women from contracting HIV.
  • Violence against HIV-positive women is a problem worldwide. Along with physical violence, some HIV-positive women have been forced or coerced into being sterilized. Mexico, Chile, and Namibia, for example, have all been accused of forcing or coercing sterilization on HIV-positive women.
There are no simple answers to the problems that HIV-positive women face. But I question the report's assumption that it's best to enforce local cultural norms by helping these women become pregnant.

Women in every country need to be able to achieve both social status and financial security independent of whether they are mothers or in a relationship with a man. When women are only valued as child-bearers, they lose much of their influence in both personal and community relationships. They become vulnerable to poverty, violence, and diseases such as HIV/AIDS.

International organizations should take the wider view and focus on improving the status of women worldwide to decrease the incidence of poverty, violence, and disease. For example, microloan programs and organizations such as Heifer International, which help women and families become financially self-sufficient, are a great success story. When you improve the lives of women, you solve a lot of underlying societal problems.

Thursday, July 8, 2010

Fireworks, California Style

Where I grew up, my town put on a spectacular independence day fireworks show every year on the football field at the local high school. My neighbors and my family also lit Roman candles, sparklers, firecrackers, and who knows what else on our block. It got so noisy that one neighbor had to sedate her skittish dog each year.

Here in Northern California, though, it's a different story. The fourth of July falls at the worst time of year for fireworks: the dry season and the foggy season (yes, these two seasons co-exist; the cold marine fog creeps in along the coast all summer long, pulled by the heat of the Central Valley to the east, but the rains generally don't fall from June through September).

Years ago, a friend and I hiked to the top of a hill with a view of downtown San Francisco, wrapped in thick coats against the fog, to watch the fireworks show. Undeterred by the weather, the city shot the fireworks into the fog. Although I heard the booms when they were lit, all I could see were a few pale colors reflected in the overcast sky. Fun.

Putting on your own fireworks show with store-bought ("consumer") fireworks is not an option for most people here. It's illegal to set off your own fireworks in many Bay Area cities (including all of San Francisco and Marin counties), because of the dry-season fire danger and the risk of personal injuries.

The bottom line is that safety laws, combined with the often fog-shrouded coastal fireworks shows, mean that the Fourth of July celebration out here is, well, a dud.
Yes, fireworks are dangerous; the tips of sparklers get as hot as 1200 degrees Fahrenheit (!), according to the National Fire Protection Association. Because children are most likely to be injured by store-bought fireworks, the American Academy of Pediatrics (AAP) is opposed to all consumer fireworks.

The few local towns here that do permit consumer fireworks only allow "safe and sane" fireworks (in general, fireworks that are not shot into the air). In these towns, nonprofit groups often sell consumer fireworks as a fundraiser, providing much-needed funding in a time of budget cuts. Many of the groups are raising funds for charities that benefit children (hoping, of course, that children don't light their wares). 

Are consumer fireworks more fun than dangerous, or more dangerous than fun?  This issue raises perhaps the most fundamental question facing today's parents: should we let our kids do what we did?

Most years we've just thrown up our hands and skipped the whole fireworks thing. This year, though, we drove our fireworks-deprived kids to a rural town to watch a fireworks show.

Fortunately, the day was fog-free, and it stayed clear as it got dark. The kids squealed with delight when the first firework went up and lit up the sky with a flower shape. They had never seen a live show before, and for the next half-hour, they ooohed and ahhhed their way through the display.

It was more subdued than the celebrations I remember from my childhood, but it was good to give them something to watch.