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Category: medical ethics (page 1 of 9)

“Public Charge” is a Public Health Disaster in the Making

The following post was written by Sam Aptekar and Dr. Phuoc Le, Associate Professor of Medicine and Pediatrics at the University of California – San Francisco and Co-Founder of Arc Health.

I was born in a rural village outside of Hue, Vietnam in 1976, a year after Saigon fell and the war ended. My family of four struggled to survive in the post-war shambles, and in 1981, my mother had no choice but to flee Vietnam by boat with my older sister and myself. Through the support of the refugee resettlement program, we began our lives in the United States in 1982, wearing all of our belongings on our backs and not knowing a word of English.


Though we struggled for years to make ends meet, we sustained ourselves through public benefit programs: food stamps, Medicaid, Section 8 Housing, and cash aid. These programs were lifelines that enabled me to focus on my education, and they allowed me to be the physician and public health expert that I am today. Looking back, I firmly believe that the more we invest in the lives and livelihoods of immigrants, the more we invest in the United States, its ideals, and its future.

So, when I first learned of the current administration’s plan to make it harder for immigrants with lower socioeconomic statuses to gain permanent U.S. residence, the so-called changes to the “Public Charge” rule, I felt outraged and baffled by its short-sightedness.

Chart courtesy of www.cgdev.org

If this proposal comes into effect, government officials would be forced to consider whether an applicant has used, or is deemed likely to use, public benefit programs like Section 8 Housing, Medicaid, the Supplemental Nutrition Program (SNAP), and Temporary Assistance for Needy Families (TANF).  Additionally, applicants with pre-existing health conditions could be rejected purely on these bases.[1]

The implications of this rule are not hard to predict (and have already been observed throughout the country)[2]: noncitizen parents who are hoping to get green cards will not enroll their citizen children in government healthcare, which they have a legal right to obtain, out of fear that harnessing public benefits will prevent them from gaining legal permanent residence. According to the Kaiser Family Foundation, President Trump’s proposal could lead to a decrease in Medicaid and CHIP enrollment by a minimum of 15% and as much as 35%.[3]  Any proposal that decreases the number of insured American citizens, as this measure surely would, would increasethe financial strain on taxpayers who will be forced to compensate for unpaid coverage. Furthermore, Forbes estimates that Trump’s proposal would decrease legal immigration to the United States by more than 200,000 people a year and therefore “would have a negative impact on the Social Security System”- a deficit that American taxpayers would have to help cover.[4]

If the moral argument that every human being deserves the pursuit of a better life doesn’t work for you, then let the economic one suffice. A 2016 study by the National Academies of Science, Engineering, and Medicine concluded “immigration has an overall positive impact on long-run economic growth in the United States” and “immigration is integral to the nation’s economic growth.”[5]

Whether you are an immigrant or were born in the US, we all have a responsibility to vocalize dissent against the Department of Homeland Security’s morally and fiscally-flawed anti-immigrant proposal. Vote, attend town-hall meetings, write to your representatives, conduct personal research, engage in constructive dialogue, and comment below to get the conversation started. Remember, the Statue of Liberty reads: “give me your poor, your tired, your huddled masses.” If we match xenophobia and ignorance with empathy and facts, we can ensure that America remains a beacon of hope for future immigrants, just as it was for me in 1982.

[1] http://apps.washingtonpost.com/g/documents/world/read-the-trump-administrations-draft-proposal-penalizing-immigrants-who-accept-almost-any-public-benefit/2841/

[2] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.82971bc137f9

[3] https://www.washingtonpost.com/outlook/2018/12/18/proposed-new-public-charge-rule-puts-childrens-health-insurance-risk/?utm_term=.0ac0803db1a9

[4] https://www.forbes.com/sites/stuartanderson/2018/12/14/these-flaws-may-kill-the-public-charge-rule/#17d961c72884

[5] http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=23550

Biggest Health Stories of 2018

Happy New Year, GlassHospital readers.

The year’s end provides the opportunity to reflect on the year that was.

These few stories stuck out as some of the most impactful of the year–and what they portend for the future:

1. Gene editing: In November, at the International Summit on Human Genome Editing in Hong Kong, Chinese biologist He Jiankui shocked the world with his announcement that he had manipulated at least two embryos to change a trait (or more??) in twin baby girls. The reaction was mostly critical, including calls for a moratorium on the use of CRISPR gene-editing in humans.

The upshot: stories like this will be with us for the foreseeable future. While the power of CRISPR to remedy harmful genetic conditions seems hopeful and fantastic, there’s a whole history of eugenics movements that should guide us to avoid the hubris of selecting for ‘desirable’ traits in humans.

2. #ThisisOurLane: Also in November, an NRA staffer (to this point unknown) tweeted a response to an article in the Annals of Internal Medicine recommending that doctors ask patients about gun use and safety as a health measure. The tweet infamously suggested, “someone should tell self-important anti-gun doctors to stay in their lane.” This was met with a firestorm of response from doctors across the spectrum, particularly those that care for gunshot victims (ER docs, surgeons, etc.) who tweeted under the hashtag #ThisIsOurLane.

The upshot: It’s hard to quantify the cumulative impact of the conflict, which is sure to go on, but the Justice Department did just ban bump stocks.

3. Bill of the Month: NPR, in conjunction with Kaiser Health News, started a monthly series examining outrageous and inexplicable health care bills. It’s been one of their (repeatedly) biggest stories of the year, as exemplified by the (insured!) Texas teacher who faced a $108,951 hospital bill after treatment for a heart attack (he was taken by ambulance to an out-of-network hospital–hardly the time, it seems, to price compare).

The good news: His bill was lowered to $332 after the glare of national media attention.

Alex says, “I ALWAYS look to GlassHospital for keen insights.”

Medical Marijuana: Not Up to the Standard

This year Oklahoma voters made a clear choice to legalize medical marijuana, joining thirty other states that permit cannabis for medicinal use.

Unsurprisingly, immediately in the vote’s aftermath, patients began asking me to ‘prescribe’ medical marijuana licenses, as the new law stipulates users must have as a precondition for legal purchase. The new law does not, however, specify qualifying diagnoses for which medical marijuana might be clinically indicated.

My answer thus far has been, “Not now. Likely never.”

This has not been a popular response. One patient looked at me as if I’d put a lump of coal in his Halloween bag.

I’m not a fan of medical marijuana for several reasons. The main issue is the lack of proven medical efficacy. I know there are thousands of anecdotes from people whose pain or anorexia has been diminished by marijuana–and I’m genuinely glad for them. But I’d like to see better powered controlled trials of cannabis products head-to-head with accepted therapeutic agents. Having the FDA weigh in on marijuana’s safety and efficacy would also go a long way toward legitimizing pot’s medicinal use.

Another major problem is smoking the stuff. If we had proven, standardized dosing of edibles, I’d be more supportive of medicinal use. But smoking anything–tobacco, marijuana, vapor juice–is not a healthy practice, and one I counsel patients to avoid. I hear the arguments about the purity of pot and how it’s ‘more natural’ than manufactured tobacco products. The bottom line is that inhaling burning plant matter into your lungs is a terrible idea–regardless of the herb.

If voters want to legalize marijuana for recreational use, I have no objection–provided we put in place a legal framework to make sure that people don’t get hurt. Standardized dosing and measures to assure product consistency would be integral. And we’d need adequate enforcement to make sure that people aren’t impaired when at work or in other situations in which their marijuana use could jeopardize others.

Putting doctors in the middle of what amounts to a political, legal, social, and economic debate steers the medical profession in a race to the bottom–and let’s face it–our profession has enough problems already without being the gatekeepers of grass.

Remember that marijuana is still scheduled by the Drug Enforcement Administration as a Class I narcotic, defined as having “no accepted medical use and high potential for abuse.” So even though medical weed is now legal in my state, I have no interest in violating or abetting violations of federal law.

In fact, as it turns out, since I work at a university, our legal counsel is of the opinion that no provider in our system shall recommend marijuana, since our institution has numerous federal grants and funding streams and must therefore comply with all federal rules and regulations.

Some have suggested that given our national opioid epidemic, marijuana can serve as a safer alternative for pain control. Since most cannabis is homegrown, and where legalized a tax revenue source–this does make medical marijuana a more appealing alternative to propping up the seemingly ubiquitous heroin/fentanyl drug cartels.

This argument makes pot part of a harm reduction strategy, which I’d be more supportive of if the evidence were stronger.

Right now I see the pot economy as a Wild West with hundreds of entrepreneurs and medical professionals looking to stake claims in this new quasi-legal economy.

Get back to me when we have more state/federal legal congruence and clarity on the stuff’s true medical benefits.

This essay originally appeared as a Doximity Op-(m)ed.

Solid Reporting on Liquid Gold

A thousand or more cups of urine arrive most nights by express mail to Comprehensive Pain Specialists clinics. The samples are tested for narcotics and other drugs, both legal and illegal. (Heidi de Marco/KHN)

In a beautifully reported investigative piece, Fred Schulte and Elizabeth Lucas of Kaiser Health News detail the explosive growth of the urine drug testing industry in the U.S.

We’ve written about this once before (more than 4 years ago!), but the growth of the industry fueled by taxpayer dollars (Medicare payment for drug testing) appears to be continuing unabated.

In this new piece, Schulte and Lucas do an expose on an outfit called Comprehensive Pain Specialists, a physician-owned outpatient pain management practice with 54 clinics across 10 states in the southeast U.S.

Let me be clear that CPS is not being singled out for malfeasance — rather, the point of the article is that they are emblematic of a huge surge in Medicare spending for expensive urine drug tests — many of which may be unnecessary.

Ay, there’s the rub. From the piece:

     …there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

The other thing that has government watchdogs and other observers worried is that for many pain specialists, the lion’s share of their revenue is earned by these drug tests. Remember, reasons to order these tests are twofold:

  1. Make sure patients ARE taking the drugs that you are prescribing (therefore suggesting that said drugs are not being diverted–e.g. sold on the street).
  2. Make sure patients AREN’T taking drugs of abuse (which for many pain clinics is a violation of the clinic-patient ‘pain management contract’).

As one government attorney was quoted:

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

The excellent bar graph attached below is included with the KHN story– and clearly demonstrates the trend. What are your thoughts?

 

 

Wrestling with My Inner Trump

medical-deportation_wide-d8d3587daba3c4885aabbfe681ada9e50a893091-s800-c85In a new NPR column I recall a time when my team and I had to decide on the best hospital discharge plan for a newly disabled, undocumented immigrant.

Immigration is always a pretty hot-button issue, never more so than during Presidential elections.

Wonderful accompanying art by Lorenzo Gritti.

When medicine and commerce collide, who is lost along the way?

Posted by NPR on Sunday, April 10, 2016

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