I'm a primary care physician and over the years I have seen a significant number of patients coming to me with dental problems which fill me with frustration. Today I thought I will just write about it. I even taught my students that oral health reflects underlying socioeconomic status and health habits. Don’t forget to notice dental caries and evidence of gingivitis I reminded them. I resorted to making friends with some nice dentists. Recently, email was circulated to publicize the two-day free dental clinic that came to town in July 2017. I thought to myself sarcastically--another band-aid solution and then walked in to clinic a familiar patient of mine who has diabetes and arthritis, who lives with pain every day of his life but this time, he said he had been so miserable for months from dental pain. He could not sleep; he thought the poison was all over his body. I did my due diligence to make sure he did not have an abscess or blood infection, gave him a short course of antibiotics and yes gave him the information for this free dental program. I had given him repeated referrals to the only free dental clinic in town that I know of, couple other ones with sliding scale fees and usually he would postpone, next appointment another month of 2 away, could be the pain got better or he just managed to ride the pain until it resurfaces another day.
The ADA has identified access to dental health care as top priority for years. The National Academies published a report in 2011 on improving access to oral health care for vulnerable and underserved populations. I don’t know why we treat our teeth differently than the rest of our body. We tend to carve out, compartmentalize our body as if certain body parts are luxury items and disposable? The same thinking possibly has impacted how mental health is often disconnected from physical health and so we have separate coverage for vision health and contraception, etc. Public health dentistry has done a decent job with our children through programs such as dental sealants but we have neglected adults who need good teeth to eat, to chew, to engage socially, and to avoid downstream complications such as infection and surgery. My patient had 3 teeth pulled out that day. He was told that they could not do more because they did not have enough time. He was so grateful to have the “poison pulled out of him.” This time, he got a follow up appointment with the free dental clinic to get the remaining teeth removed…in 3 months.
Speaking of complication from dental infection, when I was on inpatient service recently, I took care of a young woman with intellectual disability and severe hip arthritis. She was residing in a skilled nursing facility and sent to the ED for facial swelling. The oral surgeons took her to the OR to drain the abscess and extracted 2 teeth. They told the father that there was a third infected tooth near the abscess site which will need to come out in the near future but that could be done as outpatient. The father was furious. He did not understand why the surgeons did not remove all the infected teeth because bringing his daughter back and forth is not an easy thing. With the hip arthritis, she is not able to walk and arranging for transportation is a big deal for him. Moreover, he was also worried about insurance coverage. At the time, there was talk of repealing ACA, cutting Medicaid, etc. (still going on now I guess). The surgeon could not give the father a good explanation. All I could do was just to listen and assure him that I will do everything possible to coordinate a return appointment. I did not follow up to see if it happened…I was afraid to know.
We need to advocate for dental coverage as part of health insurance benefits. Interestingly, my limited research into dental coverage in other OECD countries shows that they too are skimpy on coverage for adults and that dentistry coverage is separated from the rest of health care even in countries with universal coverage. UK’s NHS provides some coverage but apparently there are still significant out of pocket costs. Sigh.
This is a brief synopsis...
PA Act 139
In November 2014, Pennsylvania’s Act 139 went into effect. Designed to prevent overdose deaths, it focused primarily on increasing access to naloxone, a medication that reverses overdose caused by prescription opioid pain relievers and heroin. In simple terms, Act 139 does three things:
This bill is currently in the works. Representative Gainey is the co-chairman of the HOPE Caucus (PA HEROIN, OPIOID PREVENTION & EDUCATION CAUCUS (PA-HOPE)) with Rep. Kaufer. It would provide additional funding for treatment defined as “licensed long-term residential addiction treatment facilities, including licensed halfway houses;" funding for purchase of naloxone for local police and first responders and the provision of training on the use of naloxone; drug and alcohol addiction counseling in county jails; costs to the criminal justice system related to drugs and alcohol addiction; establishment and maintenance of procedures to ensure the transition of overdose survivors to addiction treatment programs; fund prescription drug monitoring.
I and other community activists would also like to see opioid replacement therapy and naloxone for distribution through community programs for people at risk of opioid overdose themselves. It would be so good for our patients if all hospitals in PA provide actual inpt and/or oupt substance use treatment services (not just smoking cessation) or linkage to substance use counseling and referral 24/7, on-demand. Where will we get the funding for this you ask? These programs will pay off in the long run, not just in addressing overdose deaths but also ED visits, hospital admissions, health care utilization and other related consequences of addiction to our communities.
There is a very interesting legislation proposed by Maryland delegate Dan Morhaim (HB 908) . For a wide variety of reasons, hospitals are an excellent location to initiate treatment. This bill requires acute care hospitals to have an addiction treatment counselor available or on-call 24/7 to patients in emergency rooms and in-hospital and to have defined arrangements for transfer to appropriate detoxification and rehabilitation care services. The bill also calls for the State’s hospital regulatory agency (HSCRC) to develop cost-effective strategies to support hospital capital and operating expenses. He also proposes the Safe Consumption and Poly-Morphone Programs but these are considered too radical for the US (have been implemented in other countries). You can read more http://www.huffingtonpost.com/entry/dan-morhaim-heroin_us_56b3c342e4b08069c7a69b86
I need a little inspiration to resuscitate this blog. Our group is hard at work "addressing the social determinants of health." We are working on curriculum, talks, posters, workshop, etc. But it is usually some sort of patient encounter that prompted me to act...I recently admitted a very young woman with a hand infection due to injection drug use. She was studying to be nurse a one point, had less than ideal childhood and family circumstances, literally homeless but she wanted to quit. She did well on buprenorphine for 2 years, lost her insurance recently (you name it). She wanted to go to a nearby hospital for detox and rehab but we just could not get her in. Luckily she did not have bacteremia or endocarditis and she was also resourceful; she knew various treatment programs in the community. She had friends whom she knew she would quickly relapse if she went to stay with them. She found a friend who was in recovery who was willing to let her stay on his couch for 1-2 weeks until her hand got better. The inability to provide ready access to addiction treatment has always been so infuriating to me. Her story is not unique. As a primary care provider, I see a lot of intersection between pain and addiction. I'm concerned that in our war on drugs and in the efforts to curb the opioid abuse epidemic, we have overlooked pain treatment. Yes, of course, there are "physical" pain and "emotional" pain and all shades in between but they are all pain, pain managed with physical therapy, talking therapy, alternative therapy, anti-depressant/anti-anxiety medications and yes even opioids. There is also pain that comes from the lack of opportunities in our society, pain from inequality, social injustice, social isolation and a culture that thrives on financial success, individualism and personal responsibility. Is there a medication for that? In the next segment, I will summarize legislation that tries to address this issue.
Studies (as well as common sense) have suggested the connection between greater time spent watching TV and ill health. TV watching is a sedentary activity coupled with snacking and exposure to food advertising. Smith et al. recently published in JECH the results of tracking a British birth cohort over 30 years. What's most interesting is the association betweent childhood socioecononomic position and adult television viewing, adding to the evidence that socioeconomic circumstances across life could generate persistent unhealthy behaviors.
We also know that TV viewing (or screen time) in adolescence and adulthood contribute to later cardio-metabolic risk. Sleep deprivation might represent one pathway from TV time to obesity. McAnally and Hancox in their commentary question the possible role of government in regulating excessive media consumption. There is no easy answer.
Education alone about the harmful effects of TV and screen time won't change this trend in our digital society. It is undoubtedly a very affordable form of entertainment. Education has not compelled many of us to do the right thing. Could we be "nudged" or provide incentive to change our behaviors? Such interventions could also have the potential to cause further health disparties.
Happy July 4th to Americans everywhere!
The Supreme Court has sided with Hobby Lobby stating that the federal government cannot force owners of closely held for-profit companies to provide birth control to female employees if they object to the requirement on religious grounds. A recent poll conducted by Moniz et al. published in JAMA 6/25/2014 showed that 69% of respondents supported a policy of mandated coverage of birth control medications in health plans, with significantly higher odds of support among women, non-Hispanic blacks, and Hispanics. We could debate whether contraceptives are in the same category as immunizations and other preventive measures like screening tests (colonoscopy) and medications (statins), whether birth controls should be part of the "package" of health insurance, or the "illogic of employer-sponsored health insurance," or the influence of religion on the use of contraception, BUT it is one more reason why we need single-payer national health insurance, also known as "Medicare for all."
You think that small business owners and even big companies would favor a single-payer system. According to data compiled by the Kaiser Family Foundation, employers pay on average 80% of total premiums, an expense that burdens American companies and not their competitors in other countries with single payer and universal coverage. Employer-based health insurance also exacerbates health and economic inequalities. People with better education and higher incomes will have better access to health care!
Ideology and anti-government sentiments trump rational and moral thinking. Health care is a human right? (noone seems to care about that argument any more).
President Obama has supported a substantial increase in the federal minimum wage from $7.25 to $10.10. Based on a report released by the Congressional Budget Office in February 2014, raising the minimum wage would help get 900,000 people out of poverty but it could cost 500,000 jobs. Contrary to popular opinion, the bulk of minimum wage workers are mid- or full-time adult employees, not teenagers or part-timers. According to the Economic Policy Institute, an increase to $10.10 would either directly or indirectly raise the wages of 27.8 million workers and provide a modest boost to U.S. GDP. A report by the Center for Economic and policy Research points to small employment effects with modest increases in the minimum wage. Other economists and policymakers favor expanding the earned income tax credit over the minimum wage or the combination to support working low-income Americans. The economics of the living wage is complex and its health benefits could be summarized as followed:
Obesity - Melter and Chen using data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1984– 2006 found that a $1 decrease in the real minimum wage is associated with a 0.06 increase in BM. The real minimum wage in the US has decreasedReal minimum wage decreases can explain 10 percent of the increase in BMI since 1970. Other researchers have also found that low wages increase obesity prevalence and body mass.
Mortality and health status – analysis of a proposed living wage ordinance in San Francisco by Bhatia and Katz demonstrated that a modest gain in income would be associated with substantial health benefits, improvement in educational attainment of workers’ children and decreased risk of premarital childbirth.
Access to health care - a study by McCarrier et al. examined associations between state-level minimum wage policies and respondent-level indicators of access to health care and showed that minimum wage policies do not adversely affect health care access. In fact, they found evidence that higher minimum wages are significantly associated with reduced odds of workers reporting cost-related barriers to needed medical care. Even with expansion of health insurance under ACA, high-deductible health plans could increase out of pocket cost for most Americans. There is also evidence that the benefit of providing health insurance for low-income workers is more cost effective than living wage increase.
UPMC currently faces challenges from Highmark, the City of Pittsburgh, and labor organizers. The following outline is an introduction to what are complex and intertwined legal, political, and economic issues.
UPMC versus Highmark
UPMC and Highmark are engaged in a multifaceted struggle over the health care market in southwestern Pennsylvania. The most contentious issue: will Highmark plan members continue to have access to UPMC services after the current contract ends on December 31, 2014?
City of Pittsburgh versus UPMC
During the Ravenstahl administration, the City of Pittsburgh sued UPMC to have its nonprofit status revoked. The city argues that UPMC is not acting as a charity. The closure of UPMC Braddock Hospital, investment in international services, and executives’ salaries are among the justifications of the allegations.
UPMC labor debates
SEIU has been attempting to organize workers at various UPMC sites. Make It Our UPMC is the coordinating body for this activity, which is not entirely separate from the city’s lawsuit.
Politicians Involved with Make It Our UPMC
UPMC Fair Hiring
Compiled and written by Collin Schenk (MS1 at UPSOM).
A child who grows up in Pittsburgh, PA with parents who earn in the 10th percentile, ends up, on average, in the 40th percentile based on data from Raj Chetty and Nathaniel Hendren, Harvard, and Patrick Kline and Emmanuel Saez, U.C. Berkeley (interactive graphics by the NYTimes). These researchers are part of the Equality of Opportunity Project which finds (1) upward income mobility varies substantially within the U.S. Areas with greater mobility tend to have five characteristics: less segregation, less income inequality, better schools, greater social capital, and more stable families, (2) Contrary to popular perception, economic mobility has not changed significantly over time; however, it is consistently lower in the U.S. than in most developed countries.
Pittsburgh has one of the highest mobility rates compared to Atlanta or Memphis. As a whole, kids have a better chance rising out of poverty in the Northeast, Great Plains and West compared to the Southeast and industrial Midwest.
What are the policy implications for these findings? Racial discrimination is playing a role but investment in education and community development will result in poverty reduction and higher income mobility. Details, details, details.
"We are so desperate for jobs in West Virginia, we don't want to do anything that pushes industry out," said Maya Nye, president of People Concerned About Chemical Safety (excerpt from the NYTimes). Last week, MCHM, a chemical used to wash coal leaked from a storage tank into the Elk River in Charleston, W. Va. depriving safe water to about 300,000 residents in the "Chemical Valley."
This latest calamity stirs up the classic clash of jobs-vs-the-environment. Drilling for natural gas by hydraulic fracking, New Jersey Pinelands natural gas pipeline and the Keystone XL are just some examples. The debate pitches industries, towns, workers against environmental groups but jobs seem to trump everything especially when the economy is just dragging. Of course, the health consequences to environmental degradation is palpable. A analysis of China’s Huai River policy, which provided free winter heating via the provision of coal for boilers in cities north of the Huai River but denied heat to the south, results in life expectancies about 5.5 y lower in the north owing to an increased incidence of cardiorespiratory mortality.
It is sometimes difficult to assess the health risks to a community or even when the risk is statistically real, the priority on everyday survival often takes precedence. We see this in our patients making choices about prevention practices such as smoking cessation, eating healthier or quitting a job that is stressful, physically painful or killing you slowly with toxins over years. The inertia is overpowering especially when patients have limited options or coping ability and overwhelming pressing needs. Furthermore, our society feeds on vulnerable people who have a scarcity mindset.
We should NOT have to trade personal health or environmental health for livelihood and opportunities. What we need more than technological innovations is social innovations. Perhaps the chemical spill in W. Va. could be averted with better regulations or economic development that is less dependent on coal and fossil fuel. We also need to focus on strengthening the public health emergency response, educating ourselves about risk-reducing strategies and engender a collective responsibility for each other well-being as w communities and global growth. In health care, we call this single-payer!
I believe the author Marjorie Holmes said that. The concept of home is vastly different depending on who you are, what you do and where you come from. It is indeed an extension of oneself--an abode to uphold or a victim of our neglect, and ideally a source of nourishment. The neighborhood is an even broader encapsulation of one's existence.
At this festive holiday season, allow me to transgress to bring the realities of homelessness into our consciousness. We all agree that it has been a stormy year in health care. The one aspect of the ACA that is relatively popular is the Medicaid expansion and subsidies that allow low-income Americans to obtain affordable health insurance. Many states are looking for innovative solutions to cut rising Medicaid costs. New York State is implementing an ambitious supportive housing program targeting Medicaid patients who have high health care costs under the motto Housing as Health Care.
Providing supportive housing for those who experience homelessness and mental illness has been shown to reduce hospital use, decrease health care costs and improved health parameters especially for high utilizers. Tenants in supportive housing programs have affordable apartments and easy access to a network of professionals to help them stay housed and healthy. Numerous studies have quantified the disproportionately high service utilization of homeless people with disabilities including hospital-based acute care such as emergency rooms, psychiatric hospitals as well as shelters, jails and prisons. As mentioned above, a significant and growing burden of this cost is borne by Medicaid funding.
Studies have shown that supportive housing helped save taxpayers millions of dollars but upfront investment costs lead state and federal governments to embrace these programs less enthusiastically. Evidence of cost effectiveness is not yet available from the NYS program.
We know that housing quality and neighborhood sociodemographic characteristics are associated with mental health. A study by McKenzie in Europe suggests that neighborhood physical quality could counteract the adverse impact of substandard housing. Lower income individuals and families rely on strong social networks and support in the neighborhood to maintain psychological well-being. Put it bluntly, even if you place is a dump, having access to positive social interactions (safe green space, gardens, shops, fitness facilities and other community amenities) provides respite and stress relief.
For 2014, if wishing for everyone to have a cozy home comforted by loved ones is too starry-eyed then we should work to build neighborhoods, develop social ties and safe play areas for our children. Then the world will be a better place and wishes for good health will come true. Of course, we need to first end and prevent homelessness.
Joy and peace to all.
"I wish to do something Great and Wonderful, but I must start by doing the little things like they were Great and Wonderful"