Brain Blogger » Law & Politics Health and Science Blog Covering Brain Topics Fri, 28 Nov 2014 14:49:26 +0000 en-US hourly 1 Are Guns in the Hands of the Mentally Ill Really the Problem? Mon, 25 Nov 2013 12:00:52 +0000 In an effort to appear pro-active in pushing for stronger gun control legislation, some opponents to stricter gun laws, as well as some political leaders, have turned the spotlight on mental illness as a primary concern surrounding mass shootings. But is this focus misplaced?

On April 20, 1999, as news stations across the country broke through regularly scheduled programs, shots continued to ring out at Columbine High School in Colorado. Still reeling from the devastating consequences of this mass shooting, exactly one month later, the echo of gunfire was heard, this time at Heritage High School in Georgia.

Since this time, the violence has continued in what appears to be a cancer spreading across the United States, the effects of which have gun control advocates and civil rights advocates at odds with each other. As legislators struggle to find a cure to this malevolent disease, managing gun control laws in relation to individuals suffering from mental illness has quickly becoming a focal point of the debate.

Over a decade after the Columbine shooting, Americans were faced with the loss of more lives in the mass shooting at Virginia Tech on April 16, 2007. The tragedy resulted in the deaths of 32 students and faculty members along with 17 non-lethal injuries. Gun violence would continue through the years with little progress made in controlling this vicious cycle, until America was once again slammed in the face with another mass shooting on a school campus. This was not just any school, but an elementary school. On December 14, 2012, the quiet town of Newton, Connecticut would lose 20 children and six adults in what some speculate as an avoidable tragedy.

The general rhetoric of the NRA and other political supporters holding the line against stricter gun legislation lobby that the real issue is keeping guns out of the hands of the mentally ill. Yet, there is evidence that suggests this line of thought is inaccurate. Studies reveal that individuals with severe mental illnesses, a small percentage in overall comparison, perpetrate approximately one in 20 violent crimes.

It is not as though American political leaders have never passed legislation in an attempt to control the availability of guns to the mentally ill. Congress passed the Gun Control Act in 1968, making it illegal for individuals that had been committed, involuntarily, to a mental hospital or that had been determined mentally “defective” (a term commonly used during that time) to purchase a gun.

Later, legislation via the 1994 Brady Violence Prevention Act, extended the 1968 Gun Control Act exclusionary clauses regarding mental illness (along with initially the same verbiage), and added provisions to include a waiting period to purchase a handgun in hope of better ensuring proper background checks of potential buyers.

The insinuation that placing stronger reporting mandates on mental health clinicians alone will drastically reduce the number of violent acts committed using a gun, is simply unsubstantiated. Also, the totality of legislation, such as the New York Secure Ammunition and Firearms Enforcement Act of 2013, focuses on past, current, and future individuals seeking mental health services. The law mandates mental health professionals to report patients that may potentially harm others as well as themselves.

The outcome of such action could prove to be less of a deterrent to gun violence and more harmful to individuals with mental illnesses. It has the potential of leading to wrongful identification of potentially violent patients and a systematic response whereby individuals who need mental health services withdraw from treatment or forego treatment out of fear of being reported as mentally unstable. Further, it simply violates doctor-patient’s confidentiality as well as the overall privacy of patients.

Many gun rights advocates and political leaders often quote the Second Amendment to the Constitution as evidence supporting the right to bear arms. Yet, there seems to be little concern by the same individuals regarding breaching patient confidentiality also afforded to individuals, including psychiatric patients, provided under the protection of the Health Information Portability and Accountability Act (HIPAA). Still, the push for more stringent gun control legislation focusing on individuals with mental health illnesses is one that is supported by both advocates of gun rights and gun control.

As the battle continues to ensue over protecting the rights of gun owners and protecting the health and safety of innocent citizens, there is little doubt that something must be done to reduce the overwhelming statistics relating to gun violence. Most professionals within the mental health field support continued efforts to effectively reduce the risks of gun violence at the hands of a severely mentally ill individual. It is through this support that the mental health community believes more doors will open providing greater opportunities in the funding and treatment of individuals suffering from many forms of mental illness.


Fazel S, & Grann M (2006). The population impact of severe mental illness on violent crime. The American journal of psychiatry, 163 (8), 1397-403 PMID: 16877653

Friedman, R (17 December, 2012). In Gun Debate, a Misguided Focus on Mental Illness. The New York Times.

Swanson J (2013). Mental illness and new gun law reforms: the promise and peril of crisis-driven policy. JAMA : the journal of the American Medical Association, 309 (12), 1233-4 PMID: 23392291

Webster, D. and Vernick, J. (2013). Reducing Gun Violence in America: Informing Policy with Evidence and Analysis. Baltimore, Maryland: The Johns Hopkins University Press, 2013. ISBN 10: 1-4214-1110-5.

Image via Sandra Matic / Shutterstock.

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Following the Bouncing Affordable Care Ball Mon, 07 Oct 2013 15:01:56 +0000 Even before the passing of the Patient Protection and Affordable Care Act (PPACA), more commonly referred to as the Affordable Care Act (ACA), the bill was surrounded by argument, anger, disenchantment, and all out refusal to comply. The bill was also surrounded by as much support, honor, and celebration. Yet, many Americans, health professionals, and general population alike, are as confused today as to its inevitable outcome, as they were before the ACA was passed.

Since the enactment of the ACA in March 2010, there have been approximately 40 attempts to overturn the piece of legislation. One of the most recent attempts came in September 2013, as Republican Party members vowed, once again, to retaliate with a government shutdown. This constant battling between political parties has led to approximately seven bills within the Act to either be repealed completely or altered in some manner.

In its initial stages, the ACA promised hope in providing quality healthcare to every citizen in the United States. This included psychiatric care, a component in many health insurance policies that is included more as an afterthought than a viable program within the policy. Efforts were made to streamline ICD and CPT diagnostic and billing codes, as well as increase Medicare Advantage payments to insurers by 2014. Yet the battle continues surrounding whether to increase or decrease these payments.

Still, many hold out hope that the ACA will indeed, provide expansion and improved care to the most vulnerable people in the country. As there is a higher prevalence of mental illness among individuals in lower income brackets, expanded coverage should greatly improve medical outcomes for these individuals. The ACA is set to expand eligibility for Medicaid as well as provide federally subsidized health insurance benefits for those living up to 138% of the federal poverty line.

The Department of Veteran Affairs is well aware of the growing need to provide not only medical care but also consistent mental health services to its growing number of veterans and service members. Enhanced medical services are provided to veterans through the VA healthcare system. These services are provided for up to five years after discharge from active duty. Although many veterans are still eligible for services, active duty personnel are considered first priority, leaving many veterans seeking treatment outside VA centers or going without treatment.

The ACA is designed to expand coverage through Medicaid for veterans who are uninsured. Reports indicate that approximately half of the 1.3 million veterans that are uninsured will be eligible for Medicaid expanded coverage along with an addition 40% that will qualify for subsidized coverage due to the ACA.

Proponents of the ACA suffered somewhat of a loss in the delaying of the mandated employer provided health insurance. Originally set to roll out in 2014, employers were given another year to make necessary preparations in offering and providing health insurance options to full-time employees if the business had 50 or more full-time employees on its payroll. Currently, the mandate is set to take effect in 2015, leaving many employees who thought they would be provided health insurance through their employer, scrambling to make other arrangements.

There is some relief provided through the Health Insurance Marketplace — scheduled to roll out October 1, 2013. The website provided by offers information relating to locating each individual state’s health insurance marketplace/exchange, health insurance options, information for businesses, and how to make the program work the best for each individual. In the coming months, this website will prove to be a much-needed resource as more individuals struggle to meet and comply with the health insurance mandate resulting from the enactment of the ACA and the fall out of the continued dissention among political parties.


Chretien JP, & Chretien KC (2013). Coming home from war. Journal of general internal medicine, 28 (7), 953-6 PMID: 23435767

Golberstein E, & Busch SH (2013). Two steps forward, one step back? Implications of the Supreme Court’s health reform ruling for individuals with mental illness. JAMA psychiatry (Chicago, Ill.), 70 (6), 567-8 PMID: 23553230

American Psychology Association, (2013). Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

Image via A Katz / Shutterstock.

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Change on the Horizon for Psychiatric Medicine Wed, 19 Jun 2013 11:00:23 +0000 Fear and uncertainty has plagued the implementation of the Affordable Care Act (ACA) since its inception. There have been wins and losses on both sides, and medical professionals across the country have had growing concerns that the continued battle amongst political parties would increase the gap between quality care and reimbursements. Recent events indicate more changes directly related to psychiatric medicine are on the horizon.

One of the greatest victories for both the insurance industry and health providers has been achieved with the announcement that the Obama administration has moved to increase Medicare Advantage payments to insurers by 3.3 percent for 2014. This falls on the heels of the Administration’s initial endeavor to cut those same reimbursements by 2.2 percent in 2014. Meanwhile, the field of psychiatric medicine remains vulnerable to new changes implemented through the ACA, such as the recently released ICD-10 and CPT code modifications.

The mandated ICD-10 and CPT code changes has only proven to further increase the problematic issues the public faces in finding, receiving, and paying for mental health services. A 2008 survey conducted by the AMA evidenced that of the psychologists consulted, 33% of their clients paid for their services out of pocket, leaving 67% of service payments made through billing insurance companies. It should be noted that most of these were claims filed with programs funded by federal, state, and local governments.

The ACA has taken measures to try and serve the needs of U.S. citizens who require assistance and treatment from mental health professionals. Mandates are now in place requiring insurance carriers to include comprehensive options for mental healthcare within each health insurance plan. This should result in a large reduction in the growing number of individuals who forgo necessary mental health treatment due to financial constraints.

And yet a major issue remains enticing more private practice mental health professionals to accept both public and private health insurance. In an effort to provide mental health professionals with a better understanding of the ICD-10 and CPT code changes, the APA released a series of documents summarizing major CPT code changes that directly affect the field of psychiatric medicine. Here is a brief summary of these documents (important links to these changes can be found in the references):

  • Document 90862 has been deleted in one of the biggest CPT code changes. It has been replaced with the appropriate 99xxx series E/M code, which requires more documentation, even up to 11 separate elements. The 90862 code paid lower than a 99214 E/M code for Moderate Complexity.
  • Replace 90801 (Initial Psychiatric Evaluation) with:
    • 90791 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation without medical services.
    • 90792 (and 90785 report with interactive complexity when appropriate): Psychiatric diagnostic evaluation with medical services. New patient E/M codes can be used instead of 90792.
  • Replace 90802 (interactive diagnostic initial evaluation) with:
    • 90791 and 98785 report with interactive complexity
    • 90792 and 98785 report with interactive complexity
  • Replace 90804, 90816, 90806, 90816, 90808, 90821 to be used in all settings (in relationship to time with patient and or family) with:
    • 90832: 30 minutes psychotherapy
    • 90834: 45 minutes psychotherapy
    • 90837: 60 minutes psychotherapy
    • Report with interactive complexity and 90785 when appropriate in all three cases
  • Replace 90810, 90823, 90812, 90826, 90814, 90828 to be used in all settings (in relationship to time with patient and or family) with:
    • 90832: 30 minutes psychotherapy
    • 90834: 45 minutes psychotherapy
    • 90837: 60 minutes psychotherapy
    • Report with interactive complexity and 90785
  • Replace 90805-90809, 90817-90822 Psychotherapy & Evaluation Management (E/M) with:
    • Proper E/M code (not chosen based on time) and 90833 add-on code for psychotherapy 30 minutes
    • Proper E/M code (not chosen based on time) and 90836 add-on code for psychotherapy 45 minutes
    • Proper E/M code (note chosen based on time) and 90838 add-on code for psychotherapy 60 minutes
    • Report with interactive complexity and 90785 when appropriate and/or required
  • New Psychotherapy for crisis 90839 and 90840
  • Replace 90857 Interactive group Psychotherapy with:
    • Group psychotherapy 90853 and report with interactive complexity 90785
  • These CPT code modifications present major changes that will directly affect the fields of psychiatry and psychotherapy. This is the first time in almost two decades that CPT code changes have been directed specifically to psychotherapy services. Although some professionals may find it tedious and difficult to make the change, the overall compatibility of the codes and processes will link to those already used by primary care physicians, as well as other service providers.


    American Psychiatric Association, Current Procedural Terminology (CPT) Code Changes for 2013: The Basics.

    American Psychological Association, Insurance Module, 2008 APA Survey of Health Service Providers, (2009, August).

    Kaiser Health News, Medicare Boosts Rather Than Cuts Payments To Advantage Plans, (2013, April 2).

    Image via Krivosheev Vitaly / Shutterstock.

    ]]> 2 Medicare Reimbursement – What’s the Latest? Sun, 17 Mar 2013 11:00:45 +0000 Even with the continued political debate over the economics of the Affordable Care Act (ACA), there remains an even more dominating concern. Great concern remains for the actual viability of the overall Act as it applies to providing access to quality care to all US citizens; more specifically, the continued debate over Medicare reimbursement rates.

    The mandate to ensure the availability to quality care while also containing and reducing the cost of healthcare in the United States remains an illusion to those entities tasked with this accomplishment. Nevertheless, since the passage of the ACA, there have been both macro and micro level changes within the industry specific to Medicare reimbursements.

    Primary macro-level changes that have affected the healthcare delivery system can be noted in cost containment reforms to reduce Medicare and Medicaid spending through restructuring payment reimbursements. This has led to a surge in the implementation of Accountable Care Organizations (ACOs) and the Patient Centered Care Models. It is believed that ACOs are the greatest hope for the much needed and desired delivery system reform.

    Operational changes affected by administrative simplification initiatives have taken a critical role in the fiscal solvency, directly affecting the revenue streams for providers and clinicians. Many are facing long and unexplained delays in reimbursements for their clients who are Medicare beneficiaries. The implementation of the HIPAA Version 5010’s deadline initially set for January 1, 2012, has come and gone, leaving practices that were unsuccessful in fully implementing the change faced with extreme delays in reimbursements. The Centers for Medicare and Medicaid Services (CMS) provided a PDF updated document addressing some of the concerns linked to the delayed reimbursements on March 2, 2012. The implementation deadline was then pushed to June of 2012. News on the front indicates that CMS has initiated a program with Emdeon to research the viability of implementing the HIPAA Transaction Version 6020.

    Another area of great concern within the healthcare community is the implementation of the ICD-10 codes, along with the consistent HIPAA transactions updates. The push for greater access to information by creating wide-spread HIT systems has created a lack of cohesion within transferring systems. Looming implementation deadlines add to an already stressful environment for practicing clinicians who are struggling financially as a result of the delayed reimbursements from Medicare.

    In February 2013, with CMS struggling to overcome a growing level of negative response from practicing clinicians regarding the overall Medicare program, the agency announced continued implementation changes provided through the ACA. These efforts include a proposal to update the 2014 rate-book to mirror the most current Fee-For-Service (FFS) costs, alignment restructuring changes of Medicare Advantage (MA) benchmarks with Medicare FFS costs, and basing some of the MA payment on the quality of the plan. In addition, CMS has proposed a 1.5% increase above the 2013 MA plan payment for 2014, resulting in a 4.91% total adjustment.

    Most likely, the continued efforts by health care professionals and organizations to express the ongoing discontent among clinicians regarding the overall state of the Medicare program, served as a catalyst for CMS’ 2013 legislative proposals, which included much needed provider payment incentives. With approximately 92% of Medicare beneficiaries enrolled in the voluntary Medicare Part B program, this should relate to a greater volume of pay-outs for provider incentives in effecting higher levels of quality care. As Medicare Part B assists in covering mental health services primarily provided outside of a hospital setting, this translates into greater opportunity for mental health clinicians who enroll as Medicare providers to offer their services.

    As the political debate continues over the ACA, many practicing clinicians remain focused on issues regarding the Medicare program. CMS recognizes the need to ensure cooperation within the health care industry to ensure greater access to quality care for all US citizens as mandated under the ACA. As such, this should continue to effect both macro and micro level changes within the health care industry specific to Medicare reimbursements.


    Leibenluft RF (2011). ACOs and the enforcement of fraud, abuse, and antitrust laws. The New England journal of medicine, 364 (2), 99-101 PMID: 21175308

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013, February 15). Details for Rate Year: 2014.

    U.S. Department of Health and Human Services, Centers for Medicare and
    Medicaid Services, (2012, March 4). Medicare Advantage Rates and Statistics.

    U.S. Department of Health and Human Services, Centers for Medicare and
    Medicaid Services, (2012, June). Medicare and Your Mental Health Benefits.

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2012, March 7). Version 5010 and D.0 & 3.0.

    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, (2013). Fiscal 2013 Budget in Brief: Strengthening Health and Opportunity for All Americans.

    Image via S_L / Shutterstock.

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    Legislative Changes in Research Tue, 05 Mar 2013 12:00:59 +0000 Many changes in the overall scope of research and development have come to pass since the initial implementation of the Patient Protection and Affordable Care Act (ACA). Although the majority of conversation regarding the ACA is centered around the health insurance mandate, for many in the field of medicine, the impact of this act is much more far reaching than has previously been discussed. The ACA has provided a greater platform for funding research and development programs, as well as promoting positive changes in providing greater access to these findings.

    The medical community continues to maintain a high profile in discussion that will further impact the roll-out of the ACA. In particular, the American Academy of Neurology (AAN), has created its own resources to assist members in discovering alternative payment methods, as well as engaging in incentive programs that assist in avoiding payment penalties. Through the efforts of the AAN and other health care agencies and professionals, not only can the interests of the general public be preserved, but also the professional and business interests of those medical entities will remain intact.

    The issue of access to research and technology has once again reared its inquisitive head in an effort to spark greater continuity within the research community. On February 14, 2013, the Fair Access to Science and Technology Research (FASTR) was introduced to Congress as H.R. 708 and S. 350. Supported by both the American Library Association (ALA) and The Scholarly Publishing and Academic Resources Coalition (SPARC), the bill is designed to provide a platform for greater sharing of publicly funded research articles. It is believed that by opening access to these findings, a higher level of productivity in science and technology research, as well as a higher level of academic achievement can be attained.

    Since the passage of the ACA on March 23, 2010, The Agency for Healthcare Research and Quality (AHRQ) continues to remain vigilant in its efforts to clarify challenges faced within the healthcare industry. Most recently, the European Federation of Neurological Societies released new guidelines for the diagnosis and management of Alzheimer’s disease, which has been included in the AHRQ data base. Primary issues addressed include providing an evidenced-based, peer-reviewed statement of guidance for practice to psychiatrists, geriatricians, and clinical neurologists, as well as qualified physician specialists charged with the care of patients with Alzheimer’s Disease.

    The ACA also includes several provisions to direct discretionary spending toward specific components that increase the production and productivity of high-risk disease management, such as Alzheimer’s Disease and Parkinson’s Disease. The ACA increased discretionary spending on a number of fronts, opening the door to greater research possibilities. Section 10409 of the ACA allocated approximately $10 million in 2012, with an additional $50 million requested in 2013 for biomedical research. Under Section 10409 these changes reflect the establishment of a Cures Acceleration Network (CAN) program, overseen by the Office of the NIH which will award cooperative agreements, contracts, and/or grants to support the development of treatments for conditions and/or diseases that may be considered uncommon, and where market incentives are deficient. Eligible recipients include both private and public participants, research institutions, biotechnology companies, pharmaceutical companies, research institutions, higher education institutions, medical centers, patient advocacy organizations, academic research institutions, and disease advocacy organizations.

    The NIH continues to reach out to the medical community in an effort to provide much needed funding for research and development. Both the government and the private sector recognize the continued need for progressive and consistent tools for advancement in chronic disease management. Although primary focus remains centered on the health insurance mandate, the stage has been set to increase both funding and transparency in biomedical research and development.


    American Academy of Neurology (2013), The Patient Protection and Affordable Care Act Largely Ruled Constitutional: Now What?.

    American Library Association (2013)., The Fair Access to Science and Technology Research (FASTR).

    Redhead, C., Colello, K., Heisler, E., Lister, S., Sara, A. (2012, October 1). Discretionary Spending in the Patient Protection and Affordable Care Act (ACA). Congressional Research Services (R41390).

    U.S. Department of health and Human Services, Agency for Healthcare Research and Quality (n.d.). National Guidelines Clearing House: EFNS guidelines for the diagnosis and management of Alzheimer’s disease.

    Image via Mesut Dogan / Shutterstock.

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    Politics of Persuasion, Persuasion in Healing Mon, 22 Aug 2011 12:00:23 +0000 If there is anything I know a lot about, it’s persuasion. I don’t mean to say that I am a genius sales person or politician, but I had a big lesson about psychotherapy some years ago. I edited a book about persuasion and did a lot of literature research in the process. I realized just how many persuasion techniques I was using as a therapist—in addition to those that I (and many other therapists) were aware of (e.g., Ericksonian hypnotic language and motivational interviewing in particular). Of the previously unconscious (on my part) techniques, one of the most important is priming, which means activating implicit (unconscious, basically) memory, so that the person is more likely to experience a particular state, or evince a particular kind of behavior.

    Hand-in-hand with other techniques, you can really help lubricate the channel to a new chapter in a person’s life. Or, if you are a sales person, “help” the person buy something they don’t really need. I say this, not as an assault on sales people, but to point out that, if you must use such techniques to sell something, I must raise the ethical questions, “Why is such psychological firepower necessary to sell someone what they need? Are they resisting the truth? If so, who are you to have a higher truth?” Of course, those questions are merely red herrings. The answer is: follow the money.

    And it is in this spirit that I raise another question, “Why is so much psychological firepower needed on American political TV?” As a student of persuasion, I am observing very sophisticated techniques used very consistently; so consistently, that I have no doubt that there is training and networking toward perfecting them. I’m also sure that, just as I am finding with psychotherapy, many of these political media types are more intuitive than studied in their skills. But why? Again, follow the money.

    Here one of my favorite (in a bad way) skills. Watch for them when you see people debating politics on TV or elsewhere.

    Targeted interruption: This is an amazing ability to know exactly when to interrupt the other party so they will not effectively get their points across. After years of watching this, I finally saw someone confronted on this behavior. But Noam Chomsky, a famous intellectual and linguist no less, was effectively undermined at the hands of an expert interrupter, William F. Buckley. Buckley was so talented, he almost made apartheid sound like it was a boon to civilization.

    An ethical use of interruption (and priming): A therapist may use forms of interruption to prevent a client from getting into a state of mind that would block them from succeeding at a task in therapy. For example, consider a couple that is on the verge of having a constructive dialog. They begin to fall into their characteristic conflict pattern. The man begins to feel rage. Family therapist Virginia Satir might put her maternal hand on his belly and say that she could feel the hurt in his voice. Not only did this interrupt the rage state, but it also primed the husband for vulnerable feelings. This created an opening for dialog, with constructive results.

    Would you like more examples? I could go like this all day! Comment, please.

    One of my reasons for wanting people to reflect on these techniques, is that much of the American public appears to be adopting the unethical and illogical methods of debating and presenting that they see on TV. As far as I’m concerned, this is one of the signs of the apocalypse (figuratively speaking, of course). Let’s all work to turn this trend around. Educate! Develop compelling ways to highlight and dispense with unethical moves! If anyone should pick up this mantle, I should think it would by psychologically-minded people, because you can see the meta-level communication such as manipulation of implicit memory.

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    Healthcare on the Hill or in the Home Sat, 21 May 2011 12:00:57 +0000 Our democracy was designed for the Members of Congress to reflect the will of the people. But who hasn’t complained over the same cup of coffee about both the cost of health insurance and the deficit? And did I hear one more complaint that all they do in Washington is squabble? Maybe Washington is behaving closer to the will of the people than we give them credit for.

    It turns out in a poll just released by the Kaiser Family Foundation that Congress is doing what Americans are doing: arguing along Party lines over the projected $500B deficit for 2012 and the future of Medicare, Medicaid, Social Security, and the Patient Protection and Affordable Care Act (PPACA). Those who are self-described Democrats prefer to keep or expand existing programs while self-described Republicans would prefer to see repeal with replacement or repeal outright.

    So is it any surprise that the Republican-majority House is passing legislation aimed at reducing or repealing these laws, while the Democratic-majority Senate is letting the legislation die in Committee?

    If you read through the tracking poll, at the very end of the write-up, you’ll find the interesting tidbit on PPACA:

    Since January, the share wanting to expand or keep the law as is has tricked up from 47 to 52 percent, while the share calling for repeal has declined from 43 to 35 percent.

    One has to wonder if the President will emerge the tiebreaker between the two, divided chambers, if he can manage to sway public opinion. The President has not underestimated the conflict — the White House website contains pages devoted to infomercial style videos and the Executive has spent money on advertising campaigns, including $3.1M for three commercials for Medicare staring Andy Griffith.

    With full implementation of PPACA not due until January 1, 2015, America may see changes yet. There are presidential and congressional elections in 2012, and congressional elections, again, in 2014. Neither the Republican majority in the House, nor the Democratic majority in the Senate should be considered safe.

    And about all that is clear at the moment, is that in spite of annual deficits and mounting long-term debt, American health care programs and entitlement benefits are here to stay — at least until the public changes the channel.


    Kaiser Health Tracking Poll — April 2011. Public Opinion and Survey Research Program

    Personal Correspondence between Pamela Gentry and Tegan Millspaw. Department of Health and Human Services. 10/28/2010.

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    Translational Neuroscience – Untapped Potential for Education and Policy Sun, 10 Oct 2010 12:00:45 +0000 Recent decades have seen extraordinary advances in the fields of neuroscience, molecular biology, genetics, psychology, and cognitive science. In particular, the National Institutes of Health called the last 10 years of the 20th century the “Decade of the Brain.” Aside from the scientific advances made during that time, government agencies, foundations, and professional organizations put forth substantial efforts to increase public awareness about brain development and diseases. A growing number of neuroscientists indicate that these efforts need to be elevated in order for neuroscience findings to be translated into principles that can facilitate sound policymaking relevant to early childhood education.

    Ten years ago, the Institute of Medicine and National Research Council published a report entitled From Neurons to Neighborhoods: The Science of Early Childhood Development, in which great emphasis was placed on the need to utilize knowledge about early childhood development to ensure the health and well-being of young children. Many are now taking this further and emphasize what they call “Neuro-Education” – the utilization of scientific findings about learning and environments to create more effective teaching methods and curricula, as well as to influence educational policy.

    The lofty goals of Neuro-Education are deeply rooted in the knowledge that genes interact with both early experiences and environments to shape the structure and function of the developing brain. On this topic, neuroscience has been more informative regarding the negative consequences of these interactions in cases where, for example, early experiences and/or environments are less than ideal. For this reason, scientific contributions to policymaking have been focused on interventions in the lives of children facing considerable adversity. However, given the plethora of evidence suggesting that enriching early experiences have beneficial outcomes in terms of cognitive abilities, placing greater emphasis on this facet of policymaking holds considerable promise. In order for neuroscience to influence early childhood education and policy effectively, there must now be a focus on what can be done to increase the impacts of current educational interventions, as well as on how they can best be implemented. To this end, the power of critical periods in brain development, during which time experience has a particularly powerful influence, must be recognized and utilized as part of organized efforts to positively influence the cognitive, emotional, and social development of young children.

    It is time for neuroscience to begin to realize its full translational potential in the world of educational policy. Children in the U.S. and beyond are not doing well academically. Arne Duncan, the U.S. Secretary of Education, called the state of education in America a national public health crisis. Importantly, some Neuro-Education initiatives have recently been established in order to begin to address these issues. In 2009, Dr. Thomas J. Carew, Professor of Neurobiology and Behavior at the University of California at Irvine, and then President of the Society for Neuroscience, created the Neuroscience Research in Education Summit, which gave rise to the creation of the Neuro-Education Leadership Coalition that is working to further the goals of Neuro-Education. Also, the Johns Hopkins University School of Education has established a Neuro-Education Initiative, which promotes the applicability of findings from neuroscience to inform and enrich educational practices. In addition, the Harvard Graduate School of Education offers master’s and doctoral degrees in Mind, Brain, and Education, which emphasize the applicability of the biological and cognitive sciences to pedagogy and public policy. Such efforts, however, are only a beginning.

    Neuro-Education provides a framework within which science can inform education and public policy through the application of knowledge gained across multiple disciplines that have not traditionally worked in collaboration. If efforts in Neuro-Education are implemented on a large scale, they may help produce children that are better learners who can rise to the challenges required for leadership in the 21st century. Some have even argued that Neuro-Education may be financially and socially rewarding because, if successful, it may result in reduced costs associated with remedial education, clinical treatment, public assistance, and even incarceration. The existence of so many potentially favorable outcomes of Neuro-Education suggests that we, as a society, cannot afford to continue to do without it.


    Carew TJ, & Magsamen SH (2010). Neuroscience and education: an ideal partnership for producing evidence-based solutions to Guide 21(st) Century Learning. Neuron, 67 (5), 685-8 PMID: 20826300

    Shonkoff JP, & Levitt P (2010). Neuroscience and the future of early childhood policy: moving from why to what and how. Neuron, 67 (5), 689-91 PMID: 20826301

    Shonkoff JP, & Phillips DA, eds. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development (Washington, DC: National Academy Press).

    Society for Neuroscience (2009). Neuroscience Research in Education Summit: The Promise of Interdisciplinary Partnerships Between Brain Sciences and Education [PDF]

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    You Have a Right to Choose if we Agree Fri, 19 Feb 2010 12:00:47 +0000 My first encounter with informed medical consent came as a young law student. I was assigned to assist a lawyer in the defense of an older man who had refused treatment for leukemia. His daughter objected, and asked the court to appoint her to be his conservator so she could compel him to undergo treatment.

    When the father spoke to my supervisor, his position became clear. His atypical choice was informed by his cultural background and personal character. An immigrant from Eastern Europe, he was adamantly against yielding control of his life to his daughter. He had tried the medicines, and found they sapped his strength and made him weak. He would rather go on strong for as long as possible and remain his own master.

    At the hearing, the lawyer told the judge that his client understood his illness and the prospect of oncoming death, and still chose for his own reasons to turn down further treatment. After confirming this with the man himself, the judge denied the daughter’s request, leaving him to live or die on his own terms.

    In the aftermath, it occurred to me that there had been no true issue concerning the man’s ability to comprehend the situation or express his feelings. Yet, he was still forced into a court fight because he decided to turn down treatment. Shouldn’t his clearly stated opinions be enough?

    Dr. Alec Buchanan of the Yale Department of Psychiatry evaluated the existing state of law and practice concerning informed consent and reported his findings in a paper in the Journal of the Royal Society of Medicine. Examining medical and legal approaches to the issue of capacity in such matters, he found that “mental capacity is not the sole determinant of what will happen when a patient chooses a course of treatment that doctors consider against the patient’s best interests.” Other factors included the views of relatives, “previous expressed views of the patient,” the opinions of medical staff, and the values of society as a whole.

    Buchanan pointed out that acceptance of a patient’s medical decision by professionals and family depends in part on the complexity and gravity of the issue. The harder the choice, or the more grave the potential outcome, the higher the level of scrutiny to which any choice will be subjected. Legal opinions have also followed this logic, holding that “the more serious the decision, the greater the capacity required.”

    Such scrutiny is in conflict with the value of autonomy, the ability of the individual to act freely in accordance with their own perceptions and belief. Buchanan says that in the context of medical consent, the importance of autonomy increases with the level of a person’s capacity.

    While it is clear that these observations correctly describe how the real world works, it is disturbing that they reflect true disrespect of individual autonomy. If it is acceptable to drag clearly lucid people into court to measure their mental capacity for medical consent, why not question capacity for other decisions? The potential outcome of a poorly chosen marriage might be a devastating divorce, with tragic paths for children of the union. A business contract might eventually lead to unforeseen results which could end in someone’s lifetime ruin. Yet we do not find clearly lucid individuals brought into court in advance so they may be judged as to their ability to make those decisions. At most, poor outcomes in domestic or business pursuits might result in a later determination of incompetence.

    Of course, in the area of medical treatment, a poor choice may result in permanent injury or death. For this reason, the law permits family, medical staff, and “other interested parties” the option of advance intervention in health care decisions. Such action is a direct negation of the individual’s right to choose in the most crucial and intimate of matters.

    How to both assure competence and maintain autonomy?

    From the standpoint of the medical profession, the appropriate emphasis should be on ethical and legal education for professionals to assure that the rights of individuals are not violated.

    From the standpoint of the patient, there is no substitute for a properly drafted advanced medical directive or power of attorney which clearly sets forth his or her specific desires and which names an individual who can honestly, quickly, and accurately discern a patient’s wishes in the context of medical treatment. Such an individual can sustain the decision of a patient if a question of capacity arises.

    The ability of a physician or of the state to override the wishes of a patient and to violate their body should be closely and exhaustively controlled. It should not depend on the subjective assessment of capacity made by someone else, regardless of their qualifications.


    Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment Journal of the Royal Society of Medicine, 97 (9), 415-420 DOI: 10.1258/jrsm.97.9.415

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    Who Should Decide the Survivability of Newborns? Sat, 06 Jun 2009 16:37:10 +0000 Among the most controversial of medical issues is the resuscitation of newborns that are unlikely to survive. The Born-Alive Infants Protection Act (BAIPA), enacted in 2002, and the enforcement guidelines later issued by the United State’s Department of Health and Human Services (DHS) outlined clinical procedures to be used in the resuscitation and care of infants born between 20 and 24 weeks gestation. (A normal, full-term pregnancy is 37 to 42 weeks of gestation.) This act has gained remarkably limited attention, and many neonatologists are not familiar with the act or DHS guidelines concerning its enforcement. A recent study published in Pediatrics suggested that most neonatologists surveyed did not agree with the legislation, but that it did have the power to change medical practice if it was enforced.

    The BAIPA was initially understood to be antiabortion legislation, granting legal status to all live-born infants in the United States, regardless of whether birth was spontaneous, by Cesarean section, or induced by an elective abortion. Immediately after the passage of the BAIPA, the Neonatal Resuscitation Program Steering Committee issued an opinion that the law should not change neonatology practice with respect to the extremely premature infant. However, the DHS soon released enforcement guidelines that threatened investigations of violations of long-standing regulations — the Emergency Medical Treatment and Labor Act and the Child Abuse Prevention and Treatment Act — if any lay observer claimed that medical care was withheld from a newborn. The enforcement guidelines did not include a stipulation for a physician’s medical training and knowledge to prevail over the layperson’s observations. With the threat of hefty fines and litigation, many physicians and hospitals worry about the day when the BAIPA will actually be enforced.

    The last several decades have seen vast improvements in technology and understanding of neonatal physiology, but surprisingly minor improvements in the actual survivability of extremely premature and low birth weight babies. Much debate still surrounds the gestational age and birth weight limits used to identify an infant’s ability to survive outside of the mother’s womb. In most cases, survival of infants born at less than 25 weeks gestation is unlikely. Most practitioners agree that aggressive measures of resuscitation for newborns born at less than 23 weeks gestation is futile and unwarranted. In such cases, neonatologists are more likely to provide comfort care to the infant and the family until the infant dies naturally.

    The decision to resuscitate a newborn that is unlikely to survive is a complex one that should involve physicians, other health care professionals, and parents. However, these decisions must also be made quickly. In these cases, timely and appropriate decision-making can decide whether an infant dies, survives with impairment, or survives intact. The consequences of the decisions — positive or negative –- are almost immediate. Medical professionals bring their judgment and experience, as well as perceived obligations and legal mandates to the decision-making; parents bring cultural, personal, ideological, and religious beliefs to the decision-making. Who should be permitted to make the final judgment of what treatment is in the best interest of the child?

    The American Academy of Pediatrics recommends that neonatologists perform complete prenatal consultations with parents in the likelihood of an extremely premature birth. Most physicians are comfortable discussing clinical issues with parents, but far fewer are comfortable discussing quality-of-life issues, expected long-term outcomes, or parental preferences. Physicians should provide parents with the medical information necessary for informed decision-making, and but should also foster parental involvement in the care of their child. A framework for newborn resuscitation may be necessary to clarify each practitioner’s role in the care of likely nonviable newborns, and to aid in decision-making, but the government should not be mandating medical procedures or making therapeutic decisions in a complex life or death decision of a child.


    Campbell, D., & Fleischman, A. (2001). Limits of Viability: Dilemmas, Decisions, and Decision Makers American Journal of Perinatology, 18 (03), 117-128 DOI: 10.1055/s-2001-14530

    HUSSAIN, N., & ROSENKRANTZ, T. (2003). Ethical considerations in the management of infants born at extremely low gestational age Seminars in Perinatology, 27 (6), 458-470 DOI: 10.1053/j.semperi.2003.10.005

    Partridge, J., Sendowski, M., Drey, E., & Martinez, A. (2009). Resuscitation of Likely Nonviable Newborns: Would Neonatology Practices in California Change if the Born-Alive Infants Protection Act Were Enforced? PEDIATRICS, 123 (4), 1088-1094 DOI: 10.1542/peds.2008-0643

    Sayeed, S. (2005). Baby Doe Redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: A Cautionary Note on Normative Neonatal Practice PEDIATRICS, 116 (4) DOI: 10.1542/peds.2005-1590

    Lakshminrusimha S, Carrion V. Perinatal phsyiology and principles of neotal resuscitation. Clin Ped Emerg Med. 2008;9:131-139.

    Bastek, T. (2005). Prenatal Consultation Practices at the Border of Viability: A Regional Survey PEDIATRICS, 116 (2), 407-413 DOI: 10.1542/peds.2004-1427

    Partridge, J. (2005). International Comparison of Care for Very Low Birth Weight Infants: Parents’ Perceptions of Counseling and Decision-Making PEDIATRICS, 116 (2) DOI: 10.1542/peds.2004-2274

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    Transparency in the Pharmaceutical Industry Mon, 30 Mar 2009 12:31:30 +0000 Law and Politics CategoryWith the intensifying call for transparency in corporate America, several pharmaceutical companies have announced plans to jump on the proverbial bandwagon early. In anticipation of the passage of the Physician Payments Sunshine Act in the U.S. Senate, Eli Lilly and Merck have announced plans to establish online registries of payments made to physicians. Additionally, Glaxo Smith Kline, Pfizer, and AstraZeneca will disclose charitable giving and change the way they financially support educational programs.

    CapitolThe Physician Payments Sunshine Act — a bipartisan piece of legislation introduced by Senators Chuck Grassley (R-Iowa) and Herb Kohl (D-Wisconsin) — was first introduced in 2007, but has failed passage to date. With ever-increasing scrutiny of government and corporate organizations, many expect the amended bill to pass successfully this year. The bill would require drug companies to submit a report to the Secretary of Health and Human Services detailing any payments, gifts, food, trips, samples, rebates, or other type of compensation given to physicians.

    While almost no one would argue that transparency in industry — any industry — is bad, and patients and the rest of the public have a right to know for whom their doctors are working, some income should be a private matter. Most professions consider the thought of having the details of all income given or received published on the Internet for general consumption anathema. Plenty of the work carried out by physicians for pharmaceutical companies is legitimate, and the particulars about the amount and quantity of honoraria or compensation are no one’s business except the person completing the work. Many physicians have already declared an end to any work with pharmaceutical companies if the payment details are released. This means that physicians may not be willing to participate in much-needed clinical trials or speak at conferences. These may be unfortunate consequences of a well-intentioned plan.

    The line between compensation and bribery becomes blurrier when conflicts of interest are present that affect patient care and professional responsibility. Any financial or proprietary agreement that makes a physician more or less likely to support a particular drug or product than he otherwise would creates an impression of distrust and weakens the medical establishment. Physicians receive support from drug companies in many ways: research support, assistance with manuscript preparation and publication, speaking fees, consulting services, grants, stocks, and many other material items. While many physicians argue vehemently that these arrangements do no harm to patients or the medical profession, and that a drug company can never unduly influence physicians, stacks of literature report otherwise. Not only are physicians, in fact, influenced by these relationships with the pharmaceutical industry, but also these relationships are driving up the cost of health care. For example, one study reports that physicians are many times more likely to prescribe a particular drug after meetings with drug company representatives or participation in conferences sponsored by the industry, even if that drug was not the best-choice agent. When newer, often more expensive agents, are prescribed, the costs to the patient and the insurance carriers increase unnecessarily.

    Safeguarding the public is paramount in today’s medical climate. Change is likely coming to the organization and structure of the American health care model, and the public is paying more attention to conflicts created by inappropriate relationships between physicians and drug companies. Americans spend approximately $200 billion annually on prescription drugs, and this is the fastest growing piece of the health care budget. Patients want to make sure that this money is being used appropriately and for the right reasons.

    Make no mistake: the pharmaceutical industry is not all bad. Certainly, modern medicine would not be where it is today were it not for the innovative research and development of the drugs and devices made possible by private pharmaceutical companies. Drug companies do provide low- and no-cost drugs to uninsured and indigent patients and do help fund professional meetings and medical journals that provide current and candid information. But, the industry is a for-profit business whose sole purpose is to make money. Like any for-profit company, the pharmaceutical industry seeks profits through wise investments. The investments, in this case, are relationships with physicians.

    Why do physicians engage in relationships that some deem, at the very least, questionable? Many are motivated by entitlement. One study reported that, despite strong efforts of medical schools to discourage gift taking from pharmaceutical companies, an overwhelming majority of medical students felt entitled to these gifts. Even those that reported being troubled by the gifts accepted them. Recognition and belonging motivates other physicians to accept the largesse offered by the drug industry. It is undeniably desirable to be recognized as an expert, or at least invited to a fancy steak dinner to mingle with colleagues. And, in this day of decreased reimbursement and increasing costs of medical education and business ownership, money is an irrefutable, and understandable, motivator for many physicians.

    Many academic medical centers and professional organizations, including the American Medical Association, support the new federal legislation and have previously renounced the idea of industry handouts. Gifts — in any form — from the pharmaceutical industry to physicians have the potential to compromise the objectivity of treatment decisions, increase the costs of health care, and erode the trust of the patient-physician relationship. While federal legislation disclosing financial details of these relationships may not be the answer, physicians need to carefully examine their own relationships with the pharmaceutical industry and consider the implications on their professional relationships.


    Kondro, W. (2008). Pharma giants to create databases on gifts to physicians Canadian Medical Association Journal, 179 (11), 1118-1118 DOI: 10.1503/cmaj.081669

    LICHTER, P. (2008). Debunking Myths in Physician–Industry Conflicts of Interest American Journal of Ophthalmology, 146 (2), 159-171 DOI: 10.1016/j.ajo.2008.04.007

    MARCO, C., MOSKOP, J., SOLOMON, R., GEIDERMAN, J., & LARKIN, G. (2006). Gifts to Physicians from the Pharmaceutical Industry: An Ethical Analysis Annals of Emergency Medicine, 48 (5), 513-521 DOI: 10.1016/j.annemergmed.2005.12.013

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    McCain’s Health Issues Reflect His Character Mon, 03 Nov 2008 16:45:21 +0000 You can’t have skeletons in the closet if you want to be the Commander in Chief of the U.S. Armed Forces.

    As Election Day draws near, I imagine that both McCain and Obama are exhausted; both have been run through the ringer. After all, they must endure non-stop campaigning schedules, high pressure debates, and the constant scrutiny of the press. Along with this, every aspect of their lives are being examined under the most powerful of microscopes. From tax records to religious affiliations to personal friendships, both men are left bare, no secrets uncovered.

    This openness extends to their health histories as well. Both candidates issued records or statements detailing major health issues. Not surprisingly, Obama, 25 years younger than McCain, has a clean bill of health; the only exception is his difficulty kicking the smoking habit.

    John McCainMcCain’s record is fairly impressive as well even though he is 72. Along with his past problems with melanoma he may need joint replacement therapy down the road, a result of his time spent as a Prisoner of War (POW). Along with this, his records note that he tried to hang himself, eight months into his 5+ years spent as a POW. He was found to be mentally stable after being examined for mental disorders and we can assume that his suicide attempt was a rational decision considering the circumstances he was in.

    Initially I was surprised upon reading this. After all, McCain’s strength of character, proven by his perseverance during his POW days as well as through other reports from those who know him well, seems to be contrary to this act of desperation. Don’t get me wrong, I don’t fault McCain because of this; he is a human susceptible to human weaknesses and certainly he was in the midst of more devastation and pain than many of us can imagine. This image just didn’t concur with the fiery candidate that I see on TV.

    But eventually my surprise over his health details gave way to curiosity. Today he still suffers from ailments related to his time spent representing our country. This coincides with the reports that McCain’s patriotism and dedication to his country is intense. And it seems as if this would go a long way towards drawing voters. After all, for a future president, what speaks louder than loving your country so much that you are willing to suffer intensely?

    Well, quite a bit it seems.

    Most polls show McCain trailing Obama by a substantial margin. It seems that there is something more important to people than patriotism, the good old-fashioned War World II Generation-goodness. Don’t get me wrong, I do not doubt Obama’s patriotism but McCain’s past is textbook-flag-waving-country-first-stuff.

    What is it that Americans value more highly than what McCain offers? Obama’s calmer and steadier demeanor? Liberal views? A change in ranks? Do our changing values represent progress? I don’t know.

    But what I do know is that McCain’s type of patriotism may be dying. Excluding the military, you seldom hear young people talk about their country in endearing terms. And you certainly don’t see many who feel so strongly for their country that they are willing to put country above all else.

    Obama may be the face of the future but for the sake of our country, I hope that McCain’s brand of patriotism isn’t a thing of the past.


    F. Charatan (2008). Records of presidential candidates show McCain has had melanoma and Obama is using nicotine replacement therapy BMJ, 337 (oct27 2) DOI: 10.1136/bmj.a2260

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    Obama and McCain – Friend or Foe of Science? Sun, 02 Nov 2008 14:09:38 +0000 In the last presidential debate there were only a few zingers. One came from John McCain who, after Barack Obama compared him to G. W. Bush, emphatically stated, “If you wanted to run against President Bush, you should have run four years ago.”

    Since the debate Obama’s running mate, Joe Biden, responded to McCain’s implications with, “If it walks like a duck, if it looks like a duck and it quacks like a duck, it’s a duck!”

    But regardless of the promises or perceived merits of either candidate, no one really knows what a McCain or an Obama country would look like. We listen to their words, review their records, and seek out the truth but as to the reality of their campaign promises, it’s anybody’s guess. And as to Biden’s duck analogy… well, it’s a possibility but not a guarantee.

    John McCainStill though, McCain’s ties to the conservative voter base rattles me somewhat. Not that I’m against his views particularly but I worry about the attitude that seems to be prevalent among some republican supporters. In extreme cases, there seems to be an undercurrent of intolerance, sometimes to the point of crazed hatred. When your supporters yell, “Kill him,” that’s taking campaigning too far. It makes me wonder if the Republican base is healthy? Are common sensibilities and the ability to be un-objective when necessary less prevalent among this group?

    I direct this question to republicans instead of democrats for two reasons. One, mentioned above, has to do with the dangerously frenzied sort of atmosphere that has been reported at republican rallies. And my second reason has to do with Bush, the current republican president. It seems that the Bush administration hasn’t exercised common sensibilities regarding health issues. In a BMJ article, Douglas Kamerow points out that over the last eight years this administration has made choices in regards to health issues and policies that seems to shrug off scientific knowledge in favor of personal views and interests. It seems that many times Bush was “an army of one” when dealing with hot-button and high-profile issues — refusing to use science as a basis for decisions and doing… well, what he (or his administration) just wanted to do. The Union of Concerned Scientist has documented many of these instances including:

    • Insisting on and publicizing the effectiveness of abstinence only sex education, despite a lack of evidence for it.
    • Censoring testimony before Congress by the Centers for Disease Control and Prevention (CDC) on the health hazards of climate change.
    • Posting erroneous data linking abortion and breast cancer on CDC’s website.
    • Distorting evidence on the effectiveness of condoms in preventing HIV transmission and prevention
    • “Stacking” a federal advisory committee on prevention of lead poisoning to prevent more stringent standards.
    • Adding non-scientific proponents of positions favored by the administration to sessions at scientific meetings in the guise of providing “balance.”

    Along with these actions, this administration directly influenced other key issues by refusing to publish evidence, allowing invalid data to influence decisions, and changing test results. Even more disturbing is that this administration, “…prevented its own surgeon general from speaking out on topics in the areas of mental health, global health, and secondhand smoking.” In other words our health policies have been based, at least partly, on a very biased and self-serving administration.

    Is this pattern related to the republican’s large evangelical christian voter base? Possibly knowing that many of your constituents agree with the outcome, if not the means, may have allowed Bush to endorse these methods. But I am going to venture to say that most members of this subgroup would not sanction these unethical methods. Most rational opponents of say, sex education or abortion would not want misinformation to lead the argument for policy changes. Logical arguments that are not based in science exist for every issue so there is no need to distort scientific results; this only leads to more governmental distrust and is misguided.

    Both ideologies, support bases, and candidates have taken on a life of their own by this point in the race. Will McCain’s views cause him to do the same as his party’s predecessor? Could Obama push his views or his constituent’s views via this same avenue? I hope not. An intolerance to science is dangerous for everyone — regardless of party ties.


    D. Kamerow (2008). Politics and science: a cautionary tale for the presidential candidates BMJ, 337 (oct14 4) DOI: 10.1136/bmj.a2093

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    Where Accessibility is a Dream – Disability Worldwide Thu, 16 Oct 2008 13:42:28 +0000 The Americans with Disabilities Act (ADA) of 1990 was officiated so that people with disabilities may continue to work, play and participate in day-to-day tasks and activities. It states that no employer may discriminate amongst or terminate employees based on a physical or mental impairment when they are capable of performing the job with or without reasonable modifications. Employers are responsible for maintaining the security of his employees’ job functions, and also for workspace modifications if they are within acceptable financial and location criteria.

    The ADA opens up wonderful opportunities for people wanting to pursue their careers even after a severe medical condition. It also has several guidelines for accessibility of the community — from specifications of the height of water fountains and sinks to measurements on width of doorways and hallways. These regulations allow easy maneuvering of wheelchairs and other equipment, making the community completely accessible to everyone without discrimination.

    Disabled signIt is extremely heartening to see children and adults with disabilities benefiting from these legal guidelines. Because of such regulations, families can attend local community events, travel, and even take long vacations together. Granted, it takes some additional planning and effort, but at least they have the option. Not all countries are so accessible or inviting to persons with disabilities. In some countries, a disability pretty much means the end of life as one knew it.

    The terms “disability” and “handicap” take on a much more literal and ominous meaning in developing nations. A young boy with a complete spinal cord injury in the cervical area will be confined to bed; unless carried by his family member or an aide. An elderly gentleman with a stroke will remain restricted to mobility within his apartment because he cannot navigate stairs, and his multi-storey apartment does not have an elevator. The concept of wheelchairs is a luxury — available only to the really affluent who can afford to have equipment custom built or imported from other countries. Corrective bracing and artificial limbs for persons with muscle imbalance or amputations is available, but very rarely used effectively. This is due to many factors like cost, lack of awareness, poor education and social stigma.

    One hopes that the trend will gradually change. More businesses in the USA are taking ownership for issues around the world. Some companies that manufacture limb prosthetics and braces work closely with patients and their families. They collect old braces that patients have outgrown and donate them to countries that require them. Other companies offer financial support to smaller businesses in poorer nations. The World Health Organization (WHO) also funds educational programs that spread awareness about issues such as these. They even provide specific training programs for bracing and prosthetics.

    All of this will lead to a more global solution to the effects of disability and loss of function.

    Online Resources

    The Americans with Disabilities Act.

    The World Health Organization.

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    Health Care and Politics II – The Democrats Sat, 11 Oct 2008 16:09:27 +0000 Most Americans are willing to pay higher taxes to make health care reform possible, but, like politicians, they disagree about what reforms should take place.

    Should the government mandate a health care plan or should insurance carriers do a better job of providing coverage?

    The Democrats, led by Presidential candidate Senator Barack Obama, plan to rely on a “play or pay” system that would improve access to insurance and move the United States toward universal coverage. This system builds on the predominating employer-sponsored insurance coverage that has been a cornerstone of the American workforce since the 1940’s. Under the Democrat’s plan — which is a resurgence of the plan of choice for many Democrats in the 1990’s — employers would be required to offer employees insurance coverage or pay a tax.

    Barack ObamaThis plan would retain private insurers, but would heavily regulate the industry to ensure that all Americans had access to coverage. Provisions are in place to allow currently insured Americans to keep their current coverage, if they so choose. Under Obama’s plan, Americans without access to other group coverage could either choose a new government health care plan that would be similar to Medicare, or choose a private insurance option from a national health insurance exchange.

    Obama also plans to establish purchasing pools for businesses to increase access to coverage, provide subsidies to low-income families for the purchase of health insurance, and expand current government programs, like Medicaid and the State Children’s Health Insurance Program to cover more low-income Americans. Further, regulations would be in place to prevent insurance companies from denying coverage for pre-existing conditions or charging high premiums to sicker individuals.

    The impact that Obama’s plan might have on coverage is impossible to assess. It depends on the extent of subsidies offered, prices of premiums, and total payroll tax offered to employers. For example, if the employer’s tax is set too low, many employers would likely choose to pay it rather than continuing to offer coverage, and enrollment in a national plan could be substantial – substantial enough that the funds may not exist.

    Also, like McCain’s plan, Obama’s plan may not cover all of the uninsured Americans today. The Republican’s plan offers no mandates for coverage, but the Democrats do mandate coverage for children. With no mandate on adult health care, many uninsured adults could remain without health insurance. (Obama has not ruled out a mandate for adults in the future if the plan does not lead to universal coverage.)

    The Democrats plan to finance this new health care system by repealing tax cuts adopted by the Bush administration for families making more than $250,000 annually. (Interestingly, the Congressional Budget Office already plans on these tax cuts expiring in 2010, so their expiration may not generate the necessary $50 to $65 billion to finance the program.) The tax paid by employers who do not offer coverage would also help fund government coverage.

    Like the Republican plan, the Democrats also plan to control costs by encouraging the use of electronic medical records, promoting disease management, emphasizing prevention and public health, and paying providers based on health outcomes. All of these are certainly laudable goals for either side of the political aisle, but it is unlikely that any of these measures will significantly reduce costs in the short run.

    Senator John McCain and the Republicans support a system of free markets and deregulation, while Senator Barack Obama and the Democrats support employer mandates and new regulation as a means of reforming our broken health care system and expanding access to health coverage. Both of the candidates promote a platform of health care reform, but there are certainly no guarantees that any reform will come about in a timely fashion. Even if he can incite reform, the likelihood of a new system looking anything like either of these two plans is remote. Both plans still leave behind uninsured Americans and lack significant funding sources. Change is coming, but which change is best for all Americans?


    J. Oberlander (2007). Presidential Politics and the Resurgence of Health Care Reform New England Journal of Medicine, 357 (21), 2101-2104 DOI: 10.1056/NEJMp078202

    J. Oberlander (2008). The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform New England Journal of Medicine, 359 (8), 781-784 DOI: 10.1056/NEJMp0804659

    R. Steinbrook (2007). Election 2008 — Campaign Contributions, Lobbying, and the U.S. Health Sector New England Journal of Medicine, 357 (8), 736-739 DOI: 10.1056/NEJMp078151

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