Instead of funding these programs because they're crucial sources of coverage and care for large portions of our population, House Republicans are trying to use them as leverage to weaken other aspects of public health. Vox's Dylan Scott reports:
Republicans want to pay for CHIP and health center funding by cutting Obamacare and cutting entitlement spending.
The House GOP plan would:
Cut Obamacare's public health fund by $6.4 billion over 10 years
Cut the grace period for Obamacare enrollees who fail to make premium payments. Under current law, enrollees can miss three months of payments without losing their coverage. The House bill would shorten that grace period to one month or allow states to set their own.
Repeal Obamacare's Independent Payment Advisory Board, the controversial panel created by the law tasked with reducing Medicare's costs if the program's spending grows at too fast a rate.
Increase Medicare premiums for high earners (individuals making $500,000 annually)
Aim to cut Medicaid payments for prenatal care and preventive services for children in circumstances when another insurer could instead be liable for the costs
Let's all remember what this says about the values of current members of Congress when the next election arrives.
More reasons to oppose the latest awful iteration of GOPcare
Many of us were cheered by Senator John McCain’s announcement of his opposition to the horrible Graham-Cassidy bill that would gut Medicaid and wreck the individual insurance market. But Senate Republicans could still pass this bill, and will keep trying until the clock runs out at midnight September 30th.
Senate Republicans are rushing to vote before the Congressional Budget Office can complete its analyses on how many people will lose insurance coverage or how premiums might respond to the destabilization of the individual market. In the absence of a CBO score, Matthew Fiedler and Loren Adler of the USC-Brookings Schaeffer Initiative for Innovation in Health Policy have used CBO’s estimates for prior legislation to analyze Graham-Cassidy’s likely impacts. They calculate that, compared to the status quo, the legislation would lead to 21 million more uninsured by 2026, and 32 million uninsured after 2026 (unless Congress acts before then to authorize additional funding to replace the block grants that will expire in 2026).
Another important point comes from the New York Times’s Margot Sanger-Katz, who dug into the details of how states might use the block grants that Graham-Cassidy offers. Senators Lindsey Graham and Bill Cassidy are promoting these block grants as a way to allow states rather than the federal government to decide how to assist the portions of their populations that don’t have employer-sponsored insurance — though they’re not mentioning that the total federal transfer to states will be about $160 billion less than it would have been for 2020-2026. The idea of local solutions to local issues might sound good in theory, but it also means states will have to devote a lot of resources to identifying and setting up those local solutions. Sanger-Katz writes:
In 2003, health care policy makers in Massachusetts agreed that the state should build a system to expand coverage to its uninsured residents.
It took four years before Romneycare was fully up and running.
In between, politicians had to think hard about how they wanted the system to work: how money would be raised and spent, what benefits would be offered, whether and how markets should be used to distribute coverage, whether people who didn’t buy coverage should be penalized. They had to build a computer system to help people check their eligibility and understand their options. They had to recruit insurers to participate. And they needed to find uninsured residents and persuade them to enroll.
A new health care bill before the Senate would require all the states in the country to make a similar soup-to-nuts evaluation of how they’d like their health care systems to work, to build such a system and be ready to open their doors in substantially less time — just over two years. That may not be realistic.
In answer to criticisms about millions of people losing coverage, the bill’s backers point to a pot of federal money that will be divided amongst states. States that expanded Medicaid will see their federal funds plummet, while those that didn’t will get relatively more money — but still far too little to actually solve the uninsurance problem that the ACA did so much to address. And the states wouldn't be required to direct the funds toward increasing coverage for low-income populations.
Failing to wait for a CBO score before holding a vote is irresponsible in the extreme — but, alas, something we’ve seen already from this Congress. With or without a CBO score, a vote on Graham-Cassidy is very likely to happen in the next two weeks. That doesn’t leave much time for Senators to hear from their constituents what they think about a bill that will affect so many millions of people.
CDC warned earlier this year that syphilis rates are on the rise throughout the US. Primary and secondary syphilis, the disease’s most infectious stages, rose 19% in a single year (2014-2015), and that trend appears to be continuing. The majority of these P&S cases are among men who have sex with men, but rates are also rising among women and some newborns. Pregnant women with untreated syphilis can pass the disease to their fetuses; congenital syphilis, which can cause stillbirth as well as severe illness and death in infants, has also been increasing since 2012. CDC’s map shows Oklahoma as one as several states where the syphilis rate experienced a 101-200% change from 2011 to 2015; Oregon, Idaho, Utah, North Dakota, Nebraska, Kansas, Iowa, West Virginia, and Hawaii showed changes of more than 200% over the same time period.
Source: Centers for Disease Control & Prevention, 2017: CDC Call to Action: Let’s Work Together to Stem the Tide of Rising Syphilis in the United States
A few months before that, when CDC released its STD surveillance report for 2015 (read Kim Krisberg’s report on that here), the agency’s news release sounded an alarm:
“We have reached a decisive moment for the nation,” said Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild and expand services – or the human and economic burden will continue to grow.”
In recent years more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services.
Chlamydia, gonorrhea and syphilis are curable with antibiotics. Widespread access to screening and treatment would reduce their spread. Most STD cases continue to go undiagnosed and untreated, putting individuals at risk for severe and often irreversible health consequences, including infertility, chronic pain and increased risk for HIV. STDs also impose a substantial economic burden: CDC estimates STD cases cost the U.S. healthcare system nearly $16 billion each year.
In addition to testing for and treating STDs, we also need prevention efforts that help people avoid unprotected sex. The Trump administration has attacked these, too, with abrupt early termination of Teen Pregnancy Prevention programs in communities across the country. As Kim Krisberg reported recently, grantees were testing and disseminating sexual health interventions aimed at improving sexual health, including strategies to reduce STDs and sexual violence. One of the projects facing early termination, she noted, is the Seattle-King County FLASH curriculum, which is in the process of rolling out to schools across the country and “is designed to be inclusive of LGBT students and is just as relevant for young people who decide to abstain from sex as it is for those who don’t.”
Among TPP grant programs — all of which appear to have lost funding — are three in Oklahoma. Choctaw Nation of Oklahoma is “replicating evidence-based teen pregnancy prevention programs in middle schools, high schools, and alternative schools in Choctaw, McCurtain, and Pushmataha counties, three counties in Southeast Oklahoma with some of the highest teen pregnancy rates.” Oklahoma City-County Health Department collaborates with local partners to bring elementary and middle schools evidence-based programs such as Cuidate!, Making Proud Choices, Making a Difference, Be Proud! Be Responsible!, Draw the Line/Respect the Line, and Sisters Saving Sisters. Youth Services of Tulsa, Inc. by 2020 aimed to serve 10,000 youth in middle school, high school, alternative school, juvenile detention, community-based, specialized, and clinic settings. Unless their TPP funding is restored or replaced, thousands of teens will miss out on important sexual health education as a syphilis outbreak threatens health in their state.
Evidence-based sexual health education that’s inclusive of LGBT students — or adults, for that matter — is especially important for stopping the spread of syphilis, given that the majority of cases are in gay and bisexual men and other men who have sex with men. Turning away from inclusive, evidence-based sex ed and taking an anti-LGBTQ tone, as this administration has done, risks cutting LGBTQ individuals off from information that can help them make healthy decisions when it comes to sex. “Abstinence-only sex ed and ‘no pro homo’ laws keeps kids in the dark, leaving them with bodies they don’t fully understand and experiences they have no context for,” writes BuzzFeed contributor John Paul Brammer. “I was uneducated — about gay sex, about consent — and that made me more vulnerable.”
Reading about hardworking Oklahoma public health investigators in the New York Times makes me proud of what public health can do — and fearful of how bad things will get as support for effective public health programs keeps eroding.
The Partnership is a nonprofit, nonpartisan organization whose mission is to help make our government more effective, and the Sammies honorees represent the many exceptional federal workers who are doing just that—breaking down barriers, overcoming huge challenges and getting results. Whether they’re defending the homeland, protecting the environment, ensuring public safety, making scientific and medical discoveries, or responding to natural and man-made disasters, these men and women put service before self and make a lasting difference.
The 2017 list of honorees includes 26 individuals and teams whose work has contributed to the public good. A few examples:
At CDC, Tedd V. Ellerbrock has played a leading role in the President’s Emergency Plan for AIDS Relief (PEPFAR), which since 2003 has helped more than 11 million people worldwide receive HIV/AIDS treatment.
At EPA, Surabhi Shah and an interagency Urban Waters team advance “partnerships with local, state and federal agencies, businesses, nonprofits and philanthropies to clean up pollution; spur redevelopment of abandoned properties; promote new businesses; and provide parks and access for boating, swimming, fishing and community gatherings.”
At HHS’s Centers for Medicare and Medicaid Services, John Pilot and Heather Grimsley started work in 2001 on the model for today’s Accountable Care Organization structure, which is helping us move towards a system that rewards the quality, rather than just the quantity, of care that healthcare providers deliver.
At the US Forest Service, Sarah Jovan and Geoffrey H. Donovan developed a way to use tree moss to detect localized air pollution, which led to tighter monitoring and regulation of polluters in Washington state as well as other cities adopting this low-cost method of pollution monitoring.
At HUD, Thomas R. Davis and the Rental Assistance Demonstration Team established public-private partnerships to generate $3.9 billion in private investments for the rehabilitation of 60,000 affordable housing units. The number of private-sector dollars invested for each dollar of public money has doubled since 2015.
The stories of all 26 honorees are inspiring, and they represent just a small fraction of all the excellent and valuable work federal employees do for this country. Let’s honor their contributions, and encourage our elected officials to make sure they have the resources necessary to continue their essential work.
NASA team provides free satellite public health data to researchers and communities
by Dominika Heusinkveld, MD, MPH Researchers at NASA and the University of Arizona, among others, are hoping to make real-time air quality forecasting a reality in the next few years. The NASA Health and Air Quality Applied Sciences Team, or HAQAST, is collaborating with health departments, county and state agencies, and university researchers to get the word out about its satellite data. The data, available for free online, can help track air quality indicators, heavy metals in air, dust, and other atmospheric components which can affect human health.
Photo courtesy of NASA Image Library
NASA satellites have been collecting data for years on nitrogen dioxide, ozone, particulate matter, and sulfur dioxide. The time period of available data depends on when the individual satellite was launched. The HAQAST team hopes to encourage local stakeholders to make use of it. NASA HAQAST Team Leader Dr. Tracey Holloway says, “Hopefully when [agencies] see that satellite data and other NASA resources can answer their [public health] questions, they will take advantage of all the amazing satellite and other data available.” A past NASA project, the Air Quality Applied Sciences Team (AQAST), was the genesis of the current HAQAST project. AQAST aimed to increase the utility of satellite data to researchers and public agencies while improving communication with stakeholders such as the public and government officials. “We publish papers in journals but it’s not really percolating into policy,” said Avelino Arellano, Jr., Associate Professor of Data Assimilation and Atmospheric Chemistry at the University of Arizona’s Department of Hydrology and Atmospheric Sciences. The AQAST project was an important way to connect the data to stakeholders. One of the AQAST projects resulted in a brief video with President Obama explaining how satellite data has been helpful in tracking nitrogen dioxide, a common air pollutant. Arellano sees the video as one of the success stories of AQAST. Another was improving communication and relationships between agencies like NASA, the EPA, and NOAA. “AQAST was instrumental in showing how satellites can ‘see’ trends in air pollution, even in areas where no other monitors exist. As a result, the EPA used satellite data in their public report on clean air trends for the first time in 2016,” says Holloway. HAQAST plans to build on those successes with a wider emphasis on human health, says Holloway. Input from satellite data can greatly improve current air quality forecasts, but these are still not accurate on a local scale and require finer resolution to be more useful. “We don’t really have a good forecast for air quality yet,“ says Arellano. For instance, air pollution is worse during rush hour, but many of the older satellites only pass over an area once a day, so the differences in air quality between morning and afternoon rush hour are not seen. A new satellite, called GOES-16, should fill in some of the blanks and provide finer resolution data. According to a NASA website its instruments “can provide a full disk image of the Earth every 15 minutes, one of the continental U.S. every five minutes, and [have] the ability to target regional areas…as often as every 30 seconds.” In addition, more research will be needed to fully utilize the data and to integrate it with human health. “In forecasting I’m not really sure that there’s a connection between what the satellite sees and what you breathe,” Arellano says. “We need to connect studies on air quality and data on air quality to health.” For example, while pollution has been linked to cardiac events (such as heart attacks) and lung disease, more studies need to be done on the relationship between air quality and hospitalization events. These relationships are extrapolated in much of the current research; direct correlations would provide a clearer picture. Arellano would like to see public health agencies and federal agencies such as the National Weather Service utilize the satellite data. He would also welcome collaborations with nonprofit agencies. The main limitation he encounters is lack of connections between researchers and nonprofits. Fortunately, outreach is an important part of HAQAST’s mission. “We have a Twitter account (@NASA_HAQAST), the new website, a semi-monthly newsletter, and even a YouTube channel,” Holloway says. In addition, the team hosts two meetings per year with a variety of local and national agencies. “We’ve found…that listening is the most important part - we need to hear where new information could be helpful… then the scientists on our team work to figure out new ways to answer open questions,“ Holloway says. She encourages interested agencies to contact the team. “Our mission is to serve the public and maximize the benefit of satellite data for health and air quality. ” Want data? Here’s where to get it:
Worldview: Users can make layered maps from daily, monthly, and yearly data. Good for new users, and user-friendly.
Giovanni: Users can make maps, map plots, and download data. Also good for new users.
ARSET: the Appled Remote Sensing Training program. Offers online training on how to use satellite remote sensing data.
Dominika Heusinkveld, MD, MPH is currently a graduate student in the University of Arizona's Environmental Science and Journalism programs. Her interests are environmental health, health communication, and science journalism.
Update, 8/16: I put this post together on Saturday morning. Since then, of course, the horrific events in Charlottesville have put racism and domestic terrorism into sharp focus. Here are some of the best related pieces I've read:
Trump administration’s de-regulatory agenda: “Watching the American safety net unravel before our eyes”
In late July, while many of us were preoccupied with Republican Senators’ attacks on healthcare, the Trump administration released its first regulatory agenda (technically, the Current Unified Agenda of Regulatory and Deregulatory Actions). These routine updates are published so the public can see what they can anticipate from federal agencies in the way of rulemaking. (Celeste Monforton has been tracking the Department of Labor regulatory agenda for years.)
The Trump administration’s first entry into this genre is better described as a de-regulatory agenda. It’s a dizzying array of delays, abandonment of in-process rules, and decisions not to act for the foreseeable future on a wide array of public-health hazards. Fortunately for those of us who have insufficient time to digest the many horrors coming out of the Trump administration, the Center for Progressive Reform has sorted through the agenda specifics. CPR Executive Director Matt Shudtz aptly responded to the Spring 2017 Unified Agenda by stating, “We are watching the American safety net unravel before our eyes.”
CPR’s Rena Steinzor and Elise Desiderio took a look at the reg agendas for several agencies important for public health: Environmental Protection Agency (EPA), the Food and Drug Administration (FDA), the Department of Labor (DOL) Wage and Hour Division (W&H) and Occupational Safety and Health Administration (OSHA), the National Highway Traffic Safety Administration (NHTSA), the Consumer Product Safety Commission (CPSC), and the Consumer Financial Protection Bureau (CFPB). They compared the Trump administration’s first regulatory agenda to the Obama administration’s final one and generated a striking set of charts. They report that the Trump administration appears to have abandoned 131 rules that appeared in the 2016 agenda but not the 2017 agenda. This is in addition to at least 42 rules that Steinzor and Desiderio identified as being delayed between January 20 and July 14 of this year.
Steinzor and Desiderio analyzed the kinds of rules that the Trump administration dropped to see if some rationale might be evident. The abandoned rules were “notable winners for public health, consumers, workers, and the environment,” and we don't have evidence that the hazards are effectively addressed by state governments, the market, or voluntary programs. So, they consider other explanations, writing:
Clearly, the administration had some kind of quota in mind and was slashing as many rules in both the proposed and final stages of development as possible. President Trump wanted to brag that he had cut hundreds of regulations. As devoid of a coherent policy explanation as this approach may be, we suspect something even more disturbing was going on.
We envision conference rooms at the Chamber of Commerce, the Business Roundtable, the American Petroleum Institute, the American Chemistry Council, the Heritage Foundation, and law firms along the K Street corridor. Occupants of these rooms are compiling lists of the rules that their constituents find irritating and unduly expensive in response to the White House siren song that anything and everything could get moved to the chopping block. Some of these organizations have released very public complaints against many of the abandoned rules, although no one has bragged about transmitting lists to the White House that were cut and pasted into the Trump regulatory agenda. President Trump, though, constantly extols his efforts to help business "thrive again" and even sent "landing teams" to the agencies soon after his inauguration to make sure they were brought under control. We cannot prove definitively that the cuts resulted from industry lists because participants aren't talking, but we are confident that's what happened.
Various blog posts from CPR legal experts take a closer look at problematic rule delays and losses from specific agencies:
Department of Energy:Hannah Wiseman explains, “The U.S. energy sector, finally catching up with the rest of the world, has modernized by leaps and bounds in recent years with the help of limited but targeted governmental support. But Trump's agenda would bring this all to an abrupt halt and send us skidding back into the dark ages of energy.” The Trump administration’s agenda slashes pending programming at DOE’s Office of Energy Efficiency and Renewable Energy while repealing modest regulations on hydraulic fracturing and delaying (likely with an eye toward revising or rescinding) a rule on methane emissions from oil and gas wells on Bureau of Land Management lands.
Environmental Protection Agency:Matt Shudtz writes of EPA's Office of Chemical Safety and Pollution Prevention, “the office is in a deep freeze, with nearly all actions delayed, save for a few items that are obvious handouts to favored industries. What's striking about this list is the degree to which regulatory delay and shifting priorities undermine a core function of toxic chemical regulation – protecting people from the hazards that can cost them dearly in terms of health, well-being, and the ability to earn a living.” Problems include delayed action on formaldehyde, lead paint, pesticides, and solvents, as well as slowing more than a dozen rules that would have increased public access to information on chemical manufacturing, releases, and hazards.
Food and Drug Administration:Steinzor and Desiderio highlight FDA’s proposed delay of a rule prohibiting compounding pharmacies from making or selling three drugs that are no longer for sale from manufacturers because they are either unsafe or ineffective. This rule, they note, came after steroid injections from the New England Compounding Center were contaminated with fungal meningitis, leaving 64 people dead and more than 700 seriously ill.
Housing and Urban Development and US Department of Agriculture:David Flores warns, “If we were a society that made substantial investments in community resilience, we might accept policies that curtail implementation of disaster assistance programs. But America has historically – and, with President Trump, will very clearly continue to – vastly and dangerously underinvest in pre-disaster mitigation, climate adaptation, and community resilience needs.” He notes that the Trump administration has halted USDA rules for assisting disaster-affected agricultural producers and low-income communities and appears to have abandoned HUD rules providing emergency housing for homeless individuals, veterans, and rural communities.
National Highway Traffic Safety Administration:Steinzor and Desiderio note the death of a rule that would have required heavy trucks to install speed limiting devices in order to reduce the death toll from crashes. The “free” market won’t fix this problem, they warn, because trucking companies hold so much power over drivers.
Occupational Safety and Health Administration:Katie Tracy asks whether OSHA is getting out of the worker protection business, citing the Trump administration’s weakening of recently finalized Obama-era beryllium standard, proposed delay of electronic reporting of workplace injuries and illnesses, and slow-walking of standards to protect emergency workers from on-the-job hazards, healthcare workers from infectious diseases, and workers in a range of industries from combustible dust fires and explosions. She writes, “The White House released the agenda amid what it called 'Made in America' week, but instead of recognizing workers and advocating for safe and healthy jobs and fair wages, Trump brought manufacturers to the nation’s capital to show off their products. When it comes to working families, Trump is ignoring what should be his highest priority – ensuring that every person who leaves home for a job in the morning returns at the end of the day without injury or illness.”
And looking at the big picture, CPR's James Goodwin writes, “All of this may seem like technical 'inside baseball,' but the Regulatory Agenda, if carried out as planned, would have significant real-world impacts on workers, consumers, families, and communities. It would place an especially heavy burden on the backs of the most vulnerable among us, including low-income and working-class families and communities, children, and workers in dangerous industries, while benefiting well-connected corporate special interests.”
Each of these abandoned and delayed rules involved countless hours of work from agency staff who used research, stakeholder input, and expert advice to draft rules and revise them based on public comment. This work can be undone quickly, though, and with little apparent thought for the lives that will be lost as a result.