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    The Presidential Policy Series: Affordable Care Act

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    Hillary Clinton and Donald Trump clinched the Democratic and Republican presidential nominations.

    In less than 18 months, the field of candidates vying to win the 2016 presidential election has narrowed from over two dozen contenders to two major opponents. Now, with fewer than two months before Election Day on November 8th (remember to vote!), we’re exploring the Republican and Democratic candidates’ positions on healthcare policy.

    The Presidential Policy Series, we will share where the Democratic and Republican nominees, Hillary Clinton and Donald Trump, respectively, stand on healthcare policy. In this post, we will be discussing the most divisive healthcare issue, the Patient Protection and Affordable Care Act, commonly referred to as the Affordable Care Act (ACA).

    The ACA, colloquially known as Obamacare, has been hotly debated for over six years. Advocates and opponents of the law often fall along party line. The law, which represents the largest regulatory change to the industry since Medicare and Medicaid were introduced in 1965, was designed to bring quality and affordable health care to everyone by transforming delivery to focus on value and expanding insurance coverage.

    Budget Busting

    From a party standpoint, the Republican Party platform views the plan as a “Euro-style bureaucracy to manage unworkable, budget-busting, conflicting provisions.” Many conservatives believe it has raised insurance premiums, increased deductibles, and inflated drug prices while limiting an individual’s access to care within narrow provider networks. Republicans have long called for the law to be repealed, and Mr. Trump, despite previously expressing support for the individual insurance mandate, has fully endorsed a repeal of Obamacare.

    In the Trump healthcare plan, he vows to repeal the ACA during his first day in the Oval Office and work with Congress to implement reforms that follow free market trades. He’s specifically mentioned modifying the existing law that inhibits the sale of health insurance across state lines, implementing health savings accounts and individual deduction for health insurance premium payments, requiring full price transparency, and letting states control Medicaid.

    Rather than expanding Medicaid, Trump says he’d like to focus on policy that grows the economy and provides more jobs. As his health plan currently states, “the best social program has always been a job – and taking care of our economy will go a long way towards reducing our dependence on public health programs.”

    Not Far Enough

    Secretary Clinton, on the other hand, has vigorously defended the ACA and has expressed a desire to work with Congress to get legislation passed that would expand aspects of the ACA. Like most Democrats, Clinton believes the health law has been an important step toward the goal of universal health care, for which she has been a longtime advocate.

    She introduced the unsuccessful Health Security Act in 1993, which was a comprehensive plan to provide universal health care to all Americans. She later helped create and pass the Children’s Health Insurance Program in 1997, which now provides coverage to more than 8.4 million children.

    In the Clinton healthcare plan, she vows to continue these efforts to improve healthcare access.  Clinton plans to work with governors to continue the expansion of Medicaid on the state level and enroll more eligible Americans. She wants to further enact policies that will expand access to affordable health care regardless of immigration status.

    Clinton has also called for the funding of primary care services at community health centers to double over the next decade and has expressed support for President Obama’s charge to triple funding for the National Health Service Corps, the government program that aims to address physician shortage in areas around the country. To address health costs, Clinton supports authoritative action to block or modify premium increases, capping prescription drug costs, and limiting excessive out-of-pocket costs for families.

    Finally, Clinton has stated that she will pursue efforts to make a “public option” of healthcare possible, and expand Medicare by allowing individuals above the age 55 being able to buy into Medicare program.

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    Eric Conner is a graduate of Johns Hopkins University and co-founder of Healthify. At Healthify, he serves as the Chief Revenue Officer — managing sales and marketing operations. Eric works with healthcare companies to help them use Healthify in an effective manner that allows staff to track Medicaid beneficiaries' social and behavioral health needs and connect them with the appropriate community services for care. Before co-founding Healthify, he did community health work in east Baltimore.

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    The Case for Ending the Anonymity of Egg & Sperm Donations in the United States

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    Egg and sperm donations in the United States have long proceeded under the cloak of secrecy. Twenty-five years ago, when I first started interviewing patients who used donors to conceive a child, many intended parents struggled with whether eventually to tell their child about the nature of his or her conception. While some professionals in the fertility industry advised that this was a parent’s personal decision, others encouraged disclosure, and still others recommended never telling a child how they were conceived. The last approach dovetailed with the industry standard that required donor anonymity. In subsequent years, my research has led me to conclude that mandatory donor anonymity is problematic – not only for the children conceived with donor help, but also for donors themselves and the people who created their families with donor assistance.

    After a boom in the late 1980s and 1990s, the use of donor sperm and eggs continues to expand in the United States – and increasing numbers of donor-conceived adults are going to want access to their biological information, including access to the identities of the people who helped create them. The United Kingdom has abolished donor anonymity. Why has the United States not followed suit?

    How Does Anonymity Affect Donors and Donor-Conceived Children?

    Many professionals in the fertility industry maintain that mandatory open donor identity would reduce the number of people willing to come forward to provide eggs and sperm. In countries that have national registries and have abolished donor anonymity, these fears have not borne out. In the United Kingdom, the Human Fertilisation and Embryology Authority reports that the number of sperm donors has increased since anonymity was banned; and since ending donor anonymity, Australia and Sweden have also seen increases in donors volunteering.

    In the United States, given that donors are compensated – indeed, egg donors are substantially compensated – the financial incentive alone is enough to ensure that people will still come forward to provide gametes for other people’s children, even if their identity is revealed to the children born from their gametes. Many donors prefer an end to anonymity. In my current research project, I have to date interviewed over 90 donors and collected 190 online surveys. Only a handful of egg donors, I find, want to remain anonymous in perpetuity – yet the majority reported they were told anonymity was their only option.

    Many sperm and egg donors go to great lengths to meet their genetic children, turning to DNA tests, online registries, and ancestry websites in their searches. Meanwhile, the first generation of children conceived via banked sperm or donated eggs are now young adults, who have their own feelings about donor conception and their own desires for forging connection, or not, with their donors. Some experienced emotional fall-out from being told later in their childhood they were donor-conceived or discovering it themselves after having the truth was concealed for of their lives.

    In my conversations with donor-conceived people, those who seemed most at ease were told at a young age and continued to hear their conception story as they matured. People who were told as adolescents or later, or discovered the “secret” on their own, report feeling a sense of betrayal at having been lied to by the parents they were supposed to be able to trust. For families who decided not to inform their donor-conceived children, the secrecy appears to have been largely rooted in the stigma and shame many people feel about infertility and the inability to have a biological child.

    Dealing with the Downsides of Anonymity Falls to Individuals

    In a quest for identity, many donor-conceived adults report using a combination of techniques to find their donors. Some sign up on registries, such as the Donor Sibling Registry. This service charges a $200 lifetime fee for donors and donor-conceived people to sign up and search for matches, using the donor identification numbers that clinics, sperm banks, or egg donation agencies assign. Others have turned to free online sites – such as donorconception.com – that help donors, donor-siblings, and donor-conceived children find each other by combining donor information, direct-to-consumer genetic tests, and ancestry registries.

    Essentially, anonymity is already obsolete; U.S. policy simply has not caught up with modern technology. The rise of direct-to-consumer genetic testing increases the likelihood of donor-conceived children finding their genetic parents, whether the donor wants that to happen or not. If anyone in a donor’s family does a test and registers on a website like ancestry.com, chances are good a donor-conceived child can find them. While such consumer testing and ancestry sites do raise privacy concerns about the public availability of genetic information, they make it virtually assured that anyone can be found.

    The Need for a Donor Registry

    Many fertility industry professionals have voiced concerns about how a registry would function given U.S. patient privacy law. The industry’s fear that registries reduce donors has not borne out in other countries that have implemented them. And by now, offering anonymity as an option misleads prospective donors into believing that their privacy can be guaranteed, when it cannot. With anonymity increasingly a non-viable option, it is time to consider establishing a national registry for egg and sperm donors. Not only would such a registry make it easier for people to find biological kin, it could also provide other advantages:

    • A registry could keep track of the number of live births per donor in the same geographic area, to reduce the risk of unions between donor-conceived biological siblings.
    • For egg donors, a registry could track completed egg donation cycles to reduce the risk of donors going through more cycles than is considered safe.
    • A registry would allow researchers to track egg donor health to better understand complications and give women considering egg donation more information for their decisions.
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    Challenging Assumptions About the Use of Contraception by U.S. Muslim Women

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    By Henna Budhwani and Kristine Ria Hearld

    Contraception is complicated. Reproductive health scholars can comfortably weigh the protective benefits of condom use compared to the convenience of intrauterine devices. However, for most people, contraception continues to be a sensitive subject not appropriate for casual conversation – and consequently many Americans lack an adequate understanding of their contraception options. Likewise, even the best-intentioned clinicians know little about how minority communities engage with reproductive healthcare and utilize contraception. Due to these knowledge gaps, providers of contraceptive services often struggle with how to approach family planning with individuals from minority populations, particularly those belonging to highly stigmatized groups that are underrepresented in scientific research. This can be especially true for “culturally conservative” populations of clients, among whom sex itself is stigmatized and sexual health is not freely discussed in the home or the doctor’s office.

    Knowledge gaps are especially prevalent about the reproductive health behaviors of Muslim women, arguably one of the most understudied populations in the United States. This dearth of research is not surprising, given that Muslim women are part of a religious minority group that experiences ongoing intersectional stigma and discrimination in American public life. Because past studied have sometimes taken advantage of minority and marginalized populations, groups such as Muslim women may be suspicious of researchers and wary of divulging personal information, particularly on sensitive topics like contraception use.

    Nevertheless, good research is needed, because in its absence, pernicious assumptions can take the place of actual evidence – and myths can misinform clinicians and policymakers as well as the general public. Social scientists therefore have a pressing calling to conduct research that may ultimately dispel harmful myths and give voice to a group of women missing from academic discourse. Our work examines this set of issues, contraception use and reproductive health preferences, in Muslim women in the United States. We collected information from Muslim women themselves about their lives, and our findings refute presumptions that women in this population typically experience low bodily autonomy and high sexual risk factors.

    Path-Breaking Research from the Muslim Women’s Health Project

    In 2015, the Back of the Envelope mechanism at the University of Alabama at Birmingham School of Public Health funded a grant to collect exploratory data from Muslim women across the United States. Our research team developed an online survey that included measures of stigma, mental health, and contraceptive use among participants. Respondents were women who self-identified as Muslim and who were at least eighteen years old and current residents of the United States. To be sure, online surveys have limitations – for example, American Muslim women who did not have a computer in their home or did not regularly use the Internet would likely not have been exposed to the survey at all. Nevertheless, one major benefit of online surveys is their ability to engage difficult-to-reach populations, including respondents in stigmatized populations, minority enclaves, and groups fearing persecution. Data from our respondents, including participants from Muslim subgroups, were analyzed to identify notable barriers and facilitators to various kinds of contraception use – namely use of oral contraceptive pills, condoms, intrauterine devices, and reliance on withdrawal during sex.

    In the United States as a whole, some national estimates suggest that 62% to 75% of women of reproductive age use contraceptives. Rates of contraception use by women in Muslim majority countries varies widely, from a low rate of use by 38.5% of reproductive-age women in Pakistan and to a high rate of use by 62.3% of such women in Indonesia. Because of these statistics, we assumed Muslim women in the United States would use contraceptives at a higher rate than their counterparts in Muslim majority countries, but at a lower rate than other women in the wider-population of Americans.

    Results from our survey showed that our hypotheses were wrong. We found that almost 80% of eligible Muslim respondents used some form of contraception. As we delved further into characteristics of our sample, we realized that the women who responded to the survey tended to be highly educated (over half had completed graduate or professional school) and had relatively high incomes (43% had a household income of over $100,000 annually). They also had high rates of health insurance coverage, given that fewer than six percent were uninsured. A deeper investigation through multivariate analysis showed that education and income were more important to understanding contraception use than religion, ethnicity, or even immigrant status (whether a respondent was born in the United States or elsewhere).

    Essentially, our inquiry found was that when the social playing field is leveled through higher education, increased income, and full access to health insurance, contraceptive utilization increases – even among populations that are predominantly foreign-born and where people may be religious or hail from culturally conservative communities where women hold a secondary social status. Such factors are typically associated with low contraception use, but in our study, we found these factors could be counteracted by positive social conditions associated with empowerment.

    Why Policymakers and Advocates Should Further Overall Improvements

    When officials or advocates aim to boost contraceptive use by racial and ethnic minorities in order to reduce unintended pregnancies and sexually transmitted infections, it may be valuable to address community conditions holistically. Working patient by patient in health care settings can be helpful, but this approach is limited in scope, costly in time, and influences only the identified, targeted health behaviors. The better approach may be to expand women’s overall access to advanced educational opportunities that can lead to socioeconomic success and improved quality of life – even for women who belong to culturally conservative communities. Overall empowerment, we conclude, is the best way to increase rates of contraceptive use and ensure better life choices and opportunities for women in all communities.

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    Democrat-Led States Tended to Have Stronger Response to COVID-19, Which Improved Health Outcomes, Study Shows

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    BINGHAMTON, N.Y. — States with Democratic leaders tended to have responded more strongly to COVID-19 and have seen a lower rate of the spread of the virus, according to new research led by faculty at Binghamton University, State University of New York.

    Binghamton University Professor of Political Science Olga Shvetsova and her colleagues wanted to gain a clearer understanding of how politics affect COVID-19 outcomes. The researchers used data on public health measures taken across the United States to build an index of the strength of the COVID policy response. They combined this index with daily counts of new COVID cases, along with political and other variables that they thought were relevant to the dynamics of the COVID-19 pandemic and governments’ response to it. Using this dataset, they assessed the effects of policies on the observed number of new infections and the difference between the policies adopted in Republican-led and Democrat-led states.

    This study connects the aggregate strength of public health policies taken in response to the coronavirus disease 2019 (COVID-19) pandemic in the U.S. states to the governors’ party affiliations and to the state-level outcomes. Understanding the relationship between politics and public health measures can better prepare American communities for what to expect from their governments in a future crisis and encourage advocacy for delegating public health decisions to medical professionals.

    “The state governments led by Democrats, on average, took stricter measures than the state governments led by Republicans, and the states with stricter measures had the virus spread much slower,” said Shvetsova.

    The difference between the policies made in Democrat-led states and those made in Republican-led states corresponded to an about 7-8 percent lower rate of the spread of the virus.

    According to the researchers, these conclusions reinforce the findings of previous studies that application of public health policy was politicized for COVID-19, and this affected health outcomes.

    “The main lesson of this research is that better public health requires a less partisan approach to the making of public health policies,” said Shvetsova.

    Additional researchers and institutions on the study included: Andrei Zhirnov from the University of Exeter, Frank Giannelli from Rutgers University, Michael Catalano, and Olivia Catalano.

    The paper, “Governor’s party, policies, and COVID-19 outcomes: Further Evidence of the Effect,” was published in the American Journal of Preventive Medicine.

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