The Importance Birth Control Access

Birth control has been a controversial political topic for as long as many of us can remember, and it seems like it has gotten more controversial in the last few election cycles.  Although 89% of all Americans think birth control is morally okay (Americans, Including Catholics, Say Birth Control Is Morally OK) and 63% support the federal requirement that all health plans cover birth control (Poll Finds Wide Support for Birth Control Coverage), Congressional Republicans still tried to add a measure that would allow employers and insurers to opt out of covering health services that they object to for religious reasons (House Republicans Target Contraception In Last-Minute Spending Bill).  There are also seven states that allow pharmacists to refuse to fill contraceptive prescriptions for religious reasons, three states have slashed their family planning budgets by more than a half, and six states have tried to block Medicaid funding to Planned Parenthood (Texas was the only state that “succeeded” as it decided not to take any federal funds for its women’s health program).

What Are the Common Arguments Against Birth Control?

1.) Freedom of Religion - the most common argument, as you may have guessed, is that individuals who don’t believe in birth control should not be forced to provide it to others.

2.) Morally Wrong - some believe it is inherently wrong, unnatural and anti life.  They believe it is a form of abortion and prevents potential human beings from being born.

3.) Health Risks - some say that birth control is dangerous to a woman’s health.

4.) Immoral Behavior - another argument is that access to birth control leads to immoral behavior like sex outside of marriage or, in the case of teenagers, leads them to have sex earlier.

Myth V.S. Fact

1.)Religious freedom is important and should be respected; however, the religious (and other) freedoms of both parties are equally important.  Those who do not believe in birth control have the right not to use it, but if we allow insurers, employers and pharmacists to make that decision, then we are allowing them to force their beliefs on others.  These “religious exceptions” would be akin to allowing a doctor who is also a Jehovah’s Witness the option not to give blood transfusions or a Scientologist Pharmacist the right not to fill psychiatric prescriptions.  

2.) If an individual feels that birth control is wrong, she has the right not to use it.  As mentioned before, most do not agree with that and birth control is both legal and medically accepted, so these arguments should not be part of political discourse.

3.) There are some risks to using hormonal birth control as there are with all prescription drugs.  There is some increased chance of stroke and blood clots, especially in women who smoke, but those who say it increases your risk of cancer couldn’t be more wrong as it actually decreases the risk of endometrial and ovarian cancers.  There is also no evidence that it damages fertility. (10 Myths About the Pill Busted).  Compared to some of the other drugs that people take everyday, contraceptives are virtually harmless.

4.) I will not address the religious.individual belief that premarital sex is immoral.  However, the argument that access to contraceptives leads to teenagers having sex earlier is demonstrably false.  Countries vary widely in the average age that a person has sex for the first time, but we can compare the US to the UK to see that access to birth control does not necessarily lead to sex at a younger age.  In the US, the average person has sex at 18 years of age, in UK, where birth control is free, the average age is 18.3 years (Average Age At First Sex By Country).  Some countries with free birth control have younger averages some have older - the same is true for countries with restricted access to birth control.  There is also evidence that teenagers who receive comprehensive sex education, which addresses abstinence and birth control, tend to wait longer to have sex, are more likely to have safe sex when they do, and have healthier relationships (Sex Education Linked to Delay In First Sex).

What Happens When Access to Birth Control Is Unrestricted and Free?

Those who believe in a woman’s right to birth control fight just as hard as those who want to restrict its use.  I could argue extensively about a woman’s right to chose when and how to have children and her right to privately make decisions about her body; however, here I will focus on the societal impacts of birth control.  I do this because although I believe those rights-based reasons are important and valid, they are based on individuals and those who don’t or won’t use birth control are not affected by them.  Societal impacts, however, impact everyone - even those who do not use birth control.

First, the number of unplanned pregnancies and abortions decrease.  This seems obvious, but many who argue against birth control actually believe that without it, people will stop having sex outside of marriage and that all pregnancies within a marriage are planned.  This, however, is not the case which is partly shown through studies of abstinence only sex education (Abstinence-Only Programs Do Not Work - New Study Shows).  

In the US, nearly half of all pregnancies are unplanned and we have the highest rate of births to adolescents in the world (ours is four times higher than in Western Europe).  A study in St. Louis offered women free contraception and counseling about their options from 2007 to 2011.  The abortion rate for the women in the program was between 4.4 to 7.5 per 1,000 women during the study compared to 19.6 per 1000 nationally which is a decrease of between 62 and 78%.  Moreover, the birth rate for women aged 15 to 19 was 6.3 per 1,000 for the study group compared to 34.3 per 1,000 nationally - an 82% decrease.(Free Birth Control Means Drastic Drops In Unplanned Pregnancies).  We can also look to Texas which decided to refuse $30 million in federal funds for family planning because it would require them to continue funding Planned Parenthood.  Fifty clinics shut down.  The Texas Policy Evaluation Project surveyed 300 pregnant women seeking abortions in the state and nearly half said they weren't able to access birth control in the three months before they became pregnant.  The reasons they stated for the lack of access were: cost, lack of insurance, inability to find a clinic and inability to get a prescription. (This Is What Happens When You Defund Planned Parenthood)

Another benefit is that the cost to taxpayers would go down.  As you might have guessed, unplanned pregnancies are expensive.  Two recent studies by the Guttmacher institute found that the cost of unplanned pregnancies for US Taxpayers is on average $11 billion a year and that is a conservative estimate.  The studies only took into account the cost of public insurance and first year infant care.  The estimated savings if those pregnancies were prevented is an average of $5.6 billion a year.  (Nation Pays Steep Price For High Rates of Unintended Pregnancy)

Lastly, there could be positive gains in equity.  Between 1994 and 2006 the total number of unplanned pregnancies fell; however, unplanned pregnancies rates to women up to 199% of the poverty line increased.  The women least able to afford an unplanned pregnancy are more likely to have one (Unintended Pregnancies Are Increasingly Concentrated Among Poor Women Who Lack Birth Control Access).  There is also new paper out that argues that access to birth control, and thus a woman being able to plan her family, increases the educational and economic wellbeing of themselves and the children they chose to have (Access to Family Planning Linked to Higher Incomes Later In Life).

Conclusion

You might be thinking, “well great! the Affordable Care Act requires that health insurance cover birth control at no cost, so all those good things will start happening”.  That’s partly true.  A lot of good things will come from the ACA mandate, but it doesn’t mean we can rest on our laurels.  Many Christian conservatives/Tea Party Republicans still want to fight to restrict birth control and cut funding from Planned Parenthood.  Also, don’t forget those states who already have restrictions in place that the ACA does not affect.  Even if their health insurance covers birth control, women in Arizona, Arkansas, Georgia, Kansas, Idaho, Missouri and South Dakota could find that their pharmacist refuses to fill their prescriptions.  If that is the only pharmacist around, the ACA might not help them at all.  Remember Texas, which gave up all federal funding for family planning services in order to defund Planned Parenthood because they provide abortions (by the way none of the 50 clinics that shut down because of that provided abortions).  Remember that other states like Indiana, Arizona, Kansas, North Carolina, Tennessee, and Arkansas keep trying to defund Planned Parenthood.  

The benefits of increased access to birth control are clear.  Whether you are a democrat, republican, independent, pro-choice or not, help women, children and society by supporting the universal access to birth control.

21 Days of ACA Insurance Enrollment

October 1st was the big kickoff day for the Insurance Exchange Marketplaces, one of the fundamental components of the Affordable Care Act. Using the marketplaces, Obama administration is to sign up 7 million people by March 31, 2014. That’s pretty ambitious, considering many uninsured people are unfamiliar with the Affordable Care Act or even health insurance in general. To help with outreach and enrollment, the administration distributed grants to organizations to hire navigators, in-person counselors, and certified application counselors. Despite the different names, the job titles have the same goals - ENROLL, ENROLL, ENROLL. Many people are interested in labeling ObamaCare - Is it a success? Is it a failure? Is it way too soon to say? Well, like most highly political policy implementations, it depends on who you ask.

What people who believe ObamaCare is failing are saying

• Low enrollment numbers. In the first three weeks at least 115,000 people enrolled in state-based Marketplaces. The exact number has not been released by the administration (look for that number to be available in November), so this is an estimate based on what the states are reporting. At that rate by March 31, 2014, fewer than 3 million people will be enrolled in the marketplace. Three million enrollments is significantly less than the Obama administration’s 7 million goal. Among those who have visited healthcare.gov to look at insurance options, 99% have not actually enrolled. 
• Technology problems have forced people away. At this point, ObamaCare supporters and ObamaCare opponents agree on one thing - there are technology problems. Healthcare.gov, the website for 34 federally facilitated and federal/state partnership insurance exchanges, has been unusable by most accounts. In reference to healthcare.gov, even President Obama said in an interview, ‘The website that was supposed to do this all in a seamless way has had way more glitches than I think are acceptable.” Below are responses from the survey detailing the problems people had logging into marketplace.gov. As you can see, of those surveyed, only 1 in 5 did not encounter any problems. Technical problems in the short term may lead to enrollment issues in the long term if people get so discouraged they stop trying and pay the fine for being uninsured.

What people who believe ObamaCare is succeeding are saying

• Enormous Healthcare.gov website activity. On October 1st, over two million people visited healthcare.gov. The two million people does not include citizens of states that run their own insurance marketplaces. That means that Americans are interested. The call center was jammed and community organizations were swamped with questions. Individuals have until December 15th to enroll in insurance for coverage to begin January 1st. As soon as the website bugs work themselves out, Americans will be enrolling. Below are the results of a survey from CNBC that asked those who had problems enrolling in an Insurance Marketplace  what they planned to do next. As you can see, a majority said they will continue to try and only 2% say they have given up trying to sign up.

• Insurance enrollment in non-federally facilitated exchanges. Some states opted to run their own web-based insurance marketplaces and thus did not work through the federally managed website healthcare.gov. In these states, people have been able to successfully enroll. Below is a summary of four states that was released by the Obama administration on October 18th. Minnesota also released information that 11,684 people completed applications for coverage in the first two weeks. Although these states also had initial technology problems, many Americans have signed up for health insurance through their exchanges. Again, Americans are interested in insurance.

ObamaCare: a success or failure? Waaaaaaay too early to tell!

Healthcare.gov is frustrating. I work at a health center with a grant to enroll people in insurance. We are having a hard time doing our job since I work in Illinois (a state partnering with the federal government) and are stymied by the technical problems of healthcare.gov.

Technology malfunctions do not make ObamaCare a failure. However, ObamaCare is not a success because people jammed the website with activity. I urge people to be patient and remember no one will get coverage before January 1st anyway.

Am I excusing the government? Not at all - our government mishandled the roll out of the exchanges. Implementation of the Affordable Care Act will be messy. But website hits and enrollment numbers do not tell the entire story. The real test will be whether the Affordable Care Act proves the idea that health insurance equals better health.

The Problems With End of Life Care

“Let’s not talk about that”, “That’s morbid”, “You don’t have to worry about that.  You’re healthy”.  Those are some of the many responses I have gotten when I have tried to talk to loved ones about what I would want if something terrible happened to me like a car crash or terminal illness.  For others who have tried to have the same conversations, those phrases probably seem familiar.  For those of us in public policy or those in the medical field, the phrases are different, but they get at the same idea.  Talking about the end of life is difficult, so we, as a society, don’t do it, or we lash out at those who try to.  The problem with this is the only thing certain in life is death.  We don’t know when or how it will happen, but we know it will happen.  This means we have to talk about it - as individuals and as a society.  So let’s talk about it.

What We Pay For

In the US, “Doctors are paid to do things to people, not for people” (Letting Go by Katy Butler).  Insurance companies will pay for chemotherapy, surgery, feeding tubes, respirators and other medical interventions during end of life care but often will not pay for a doctor to talk to a patient about if those actions are wise.  The Affordable Care Act originally included coverage for a doctor to have voluntary end of life care preferences and advance directives discussions with patients every 5 years.  Soon people were crying out that the ACA was instituting death panels that would force patients to stop treatment because it was too expensive - as many of you know, that piece of the law was eventually removed.  The hyperbole surrounding this addition was mostly the result of politics.  However, this tactic was partially successful (it was removed from the ACA but didn't result in the law not being passed) because it tapped into real fears.

Most health insurance companies cover some sort of hospice or palliative care, but often will require that patients stop seeking curative care to receive those benefits.  Many health policy experts believe this is why patients wait until the very end of their lives to use their hospice benefits or why they never have the chance to.  In 2004, Insurance Company Aetna decided to try an experiment - they offered concurrent care (hospice care without forgoing curative care) to a group of policyholders who had less than a year to live.  Even though the policy holders had more options for treatment, they ended up using fewer.  They went to the ER half as often as policyholders without concurrent care.  Hospital and ICU use dropped by more than two-thirds  and overall costs fell by almost a quarter.  (Letting Go)

Currently, Medicare and Medicaid offer hospice care, but not concurrent care to all policyholders.  The ACA required that Medicaid cover concurrent care for children and that Medicare use 15 states to test concurrent care.  While Medicaid has implemented it’s part, Medicare has yet to start. (Medicare Lags in Project to Expand Hospice)

How Palliative/Hospice Care Helps

As stated above, hospice care is less expensive than curative care.  However, most of us would agree that cost is not the most important factor when it comes to whether a person uses hospice/palliative or curative care toward the end of her life.  That’s why it is important to be aware of the other benefits of palliative care.  In 2010, the New England Journal of Medicine published a report that showed that calling in palliative care specialists earlier in a person’s illness substantially improved the patient’s quality of life.  That makes sense as the philosophy behind palliative care is to make a patient more comfortable.  What was unexpected was that on average, those patients in palliative care lives 2.7 months longer than still seeking curative care.  This is most likely because the cures that patients seek at the very end of their lives are more experimental and so often do more harm than good. (The Unexpected Benefits of Palliative Care)  Other studies have found different results, but they often find that there is either no difference in survival rates, or that palliative care extends life expectancy for particular diseases (usually in weeks or months).  Finally, the families of patients who receive palliative or hospice care before death are less likely to suffer from depression 6 months after the patient passes away.

Conclusion

There is no right or wrong answer on how to approach end of life care.  Whether a patient chose palliative or curative care is, and should be, up to that patient only.  However, by offering patients both options simultaneously, we can better help those with terminal illnesses (and their families).  Finally, no matter what, we shouldn't avoid the conversation about what we want for end of life care even though it is scary.  

Employment-Based Health Insurance

The Beginning of Employment-Based Health Insurance

Have you ever wondered why the United States has an insurance system that involves employers? Most other countries do not have employers involved in individual health insurance to the extent that the United States does. Most countries keep employers completely out of insurance and instead finance the health care system with taxes and/or individual premiums.

The simplified reason that the United States has employment based health insurance is a result of the wage and price controls on American employers during World War II. Since employers could not offer higher wages to entice the best employees, employers offered health benefits. (Source) An additional incentive for employers is that employer payments for health insurance are exempt from the employee’s taxable income. Therefore it is ‘cheaper’ for businesses to offer health insurance to employees (not taxed) than to increase wages (taxed).

Historical Trends in Employment-Based Health Insurance

Prior to the Affordable Care Act, it was not the law that employers had to offer health insurance. The peak of employer-based health insurance was in 1980 and has been declining since. According to the Employee Benefit Research Institute, between 1999 and 2004 the percent of workers with employer-based health insurance decreased 3.5 percent. However, with the Affordable Care Act, most employed individuals will have the opportunity for employer-based health insurance. In 2005, the Commonwealth Fund found that 35.9 million employed workers do not have coverage from their own employers.

The Affordable Care Act (ACA) and Employment-Based Health Insurance

The Congressional Budget Office (CBO) projects that the ACA will reduce employment-based health insurance. This is different than what I expected given the financial incentives businesses will have under the ACA to offer insurance. The CBO predicts that 3 million fewer people will have employer based coverage in 2016 through 2019. The CBO based the decline on the increased number of people eligible for Medicaid, assuming that a state expands Medicaid. It is difficult to predict how businesses will act under the ACA. Some analysts believe that businesses will cut back hours (and not offer health insurance to part time employees therefore shifting those employees to Medicaid or the marketplace) or opt to pay a penalty because it is cheaper than offering health insurance. An Urban Institute study shows no drop in employment-based coverage.  

Employment-Based Health Insurance and Health Equity

An insurance system based solely on employers offering health insurance can not be equitable and widens health disparities for three reasons.

1) People unemployed, working part-time or in the lowest paying jobs do not receive employer based health insurance. This is the same group of people that has little if any disposable income to purchase health insurance. Thus it is a double-whammy - no job AND no health insurance.

2) Individuals who are low income (or no income) are more likely to have chronic diseases, acute illnesses, and have poor overall health.

3) An extreme illness can decrease a person’s ability to seek and retain employment and thus makes it difficult to have long term health insurance.

In addition to the three reasons above, there are entire populations that cannot work such as the elderly, children, and the people with disabilities.

Other Health Insurance Options

In an attempt to alleviate the harsh reality for many that no job = no health insurance, the federal government helps out in various ways. One of the biggest unemployed populations are retirees.  Individuals 65 and older receive Medicare. Children are another group that obviously cannot seek employment. Children are either covered by a parent’s employment-based health insurance or through CHIP, the federal program for uninsured children. In many states the Medicaid expansion will help more low income people receive care. Tax credits and subsidies are now available to help people with incomes between 100% and 400% of the federal poverty level purchase health insurance on the exchanges.

More options for families that do not have access to employment-based health insurance is not the magic solution to decrease health disparities. Health insurance alone does not create good health. The reality is that access to affordable and quality health insurance is only one factor in creating good health. However, the Affordable Care Act is a step in the right direction. Since employment-based health insurance is here to stay in the United States, all employers should consider offering health insurance to all employees at affordable prices. Health insurance can help keep the employees health and boost moral.