Legislating Public Health and Medical Care

It is pretty tempting, if you are a legislator and don’t like something, to try to pass a law against it. You can always find a constituency to support you, because there are people who will support almost anything. If you are lucky enough you can find a well-off and powerful constituency, or set of advocacy organizations, and then you are more likely to be successful (ref: see almost all laws passed by the Congress). Health and medical care are no exceptions; bills and laws that impact on public health and even how providers interact with their patients are increasingly common.

Some laws are very good for the public health: banning smoking in public places; requiring cars to have seat belts, airbags, and other safety features; requiring vaccination against infectious disease for entry into school. But the plethora of regulations governing the funding of health care providers from Medicare and Medicaid, the kind of documentation that needs to be submitted, and the rules that need to be followed (generally termed, collectively “compliance”) is bewildering. Complying with all the rules put forth put forth by federal agencies (including different division of Health and Human Services, as well as the Department of Justice and the Department of Treasury) requires large providers to have full-time “compliance officers” and small ones to operate at their peril. Then add in state and local regulations. These regulations are often contradictory, so complying with one violates another. The blame is usually placed on the bureaucrats that write these regulations, but in fact many of these bureaucrats are quite aware of these contradictions, but have no option, because the laws that they have to write regulations to implement are often very prescriptive. Beware the Law of Unintended Consequences!

This law, never to my knowledge passed by any legislative body, has a major impact on those that are passed, and this impact is just as true in laws regulating public health and medical practice. These effects are most serious when the law in question is passed to address a political agenda rather than to improve health. A famous example is the “gag rule” implemented in the early GW Bush years that prevented providers receiving federal funds from discussing the option of abortion with their patients. (Overturning this rule was a major, and under-recognized, accomplishment of the early Obama administration.)  A more recent example is the law passed in Florida (and now, thankfully, blocked from implementation by a federal judge) that would prohibit physicians and other medical providers from discussing gun safety with their patients. Let me be clear: the limitation was not on gun possession or use, but on doctors and nurses and public health officials talking to people about the risks that guns in the home posed to their children and themselves and how to keep the guns that they had more safe to limit accidental discharge, injury and death.  Guess what organization pushed this law? If you said “the NRA”, you’re right, but it was a “gimme”. And of course it was signed by the governor, former “health care” magnate Rick Scott, who as CEO of Columbia/HCA led the company in paying huge fines for Medicare fraud.

Those are the easy ones to find fault with. But, just as with the “compliance” issues described above, efforts to impose “good” medical practice can be flawed. Vaccine safety and benefit is a big topic I will probably post a separate piece on (short answer: get them), but there are many others. One example is the bill introduced by Sen. Jay Rockefeller (D-WV), along with Sen. Chuck Schumer (D-NY), that would require practitioners who prescribe opiates to have 16 hours of continuing medical education (CME) in their use every 3 years. This is motivated by a serious concern for the abuse of opiates, including re-sale by those receiving prescriptions, which leads to many deaths each year (and in which West Virginia leads the nation). There is no question that this is a huge problem.

We have seen two movements, often in conflict with each other, in recent times. One is the increase in the advocacy for patients with chronic pain to receive adequate treatment; the other is concerned with addiction and prescription drug abuse. Unfortunately, as in West Virginia, the same populations are often afflicted by both. Chronic pain often occurs in those who do physical labor, but people from these same populations are the ones often dying of overdose. The problem is that the same drugs that reduce pain also (initially) get people “high”, and in time create physical addiction where the “positive” effect of the “high” is replaced by pain and misery just from not having the drug. Ideally, there would be a pain reliever that was effective, did not cause any pleasurable symptoms (other than relief from pain), and was non-addictive. We don’t have one.

Will requiring this CME of physicians reduce the problem? I think that it will decrease the number of prescriptions written for opiates, and thus maybe the amount of potentially-abusable narcotics circulating in the community, but perhaps not through the intended mechanism. There is no question that there is a lot that many providers could learn about proper use of opiate pain relievers by taking such courses. One example is the use of long-acting pain relievers (methadone, sustained release patches, long-acting morphine) whose slow release controls pain while decreasing the “high” that results from a sudden infusion of narcotic. (An exception is the most widely-prescribed – and advertised, which might be related – long acting pain reliever, Oxy-Contin®, 30% of which is release immediately, making it more popular among drug abusers than other long-acting opiates.) Another is the use of the “pain contract” that limits a patient to receiving opiates from one physician, at determined intervals, refuses to ever refill if a person is found to be receiving prescriptions from multiple sources, and may require urine tests to be sure that s/he is not using other unprescribed substance.

However, for this plan to work it would require that physicians and other providers want to prescribe narcotics. Obviously some do. Many of these do so because they are concerned about the chronic pain so many patients are in; there are pain medicine specialists who come from a variety of medical backgrounds: anesthesiology, psychiatry, family medicine, internal medicine. There are certainly others (relatively few) who are “Dr. Feelgoods” who make their living prescribing narcotics and other controlled drugs in large amounts, knowing that they will be abused. But the reality is that most doctors find chronic pain patients, well, a chronic pain. They find it difficult to feel certain who is a “legitimate” pain patient and who is “abusing”, or selling, their pain medications. Or who is a “legitimate” chronic pain patient whose family members are using, or selling, that person’s pain medication, leading to both the spread of narcotics in the community and having the patient continue with unrelieved pain. These are the patients who, whether “legitimate” or “abusers”, call the office all the time for refills, call in the middle of the night, yell at the staff because they are in pain (or withdrawing from narcotics, or find their livelihood that comes from selling them is threatened). Most providers would be willing to not take the CME, and have a good excuse to not prescribe opiates, and be free from all these problems. This is, according to testimony at the recent convention of the American Academy of Family Physicians, already happening in some places. Of course, that will also mean reduced access for people who do have chronic pain.

I once lived in a moderately large condominium. I had kids, as did a couple of others, but the majority of residents were older, with no children in their homes. The association would sometimes pass rules that restricted what children could do, especially when the working parents couldn’t make the meetings. These rules affected my children and penalized me. My position was that the association’s rules should be limited to things that affected the safety of the building and maintained its property values, not just anything that 51% of the owners could agree upon. Legislatures, whether federal or state or local, can pass any law that they can get a majority to agree on (with the obvious exception of the US Senate, where apparently, at least with the current President, it requires 60% votes – 59% wouldn’t do it). It doesn’t matter how dumb the laws are, or how much they conflict with existing law, or how much trouble they cause the bureaucrats who have to write the regulations, or how confusing or sometimes impossible it becomes for folks to comply with them all. Unless the courts strike them down, they are law (thank goodness for separation of powers!).

But because you can pass a law or rule about something doesn’t always make it a good idea to do so, whether you are a legislature or a condominium association. Because the Law of Unintended Consequences is always present.

The Devil Inside: Access to Mental Health Care in the United States

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This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.

The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.

A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”

As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.

I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”

I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.

The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.

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Postscript from Josh:

In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.
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Tucson is worth struggling for...

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This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.

No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.

I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!

It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.

Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.

Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.

Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.

We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.
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