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Medical Care
Section Newsletter
Fall 2006

Letter from the Chair: Our Web Site, Our Journal and Four Special People

Medical Care is all about people -- the people (who at times are our “patients,” other times our “populations”) we are trying to better serve, and the people whose energies define and drive the Section.


In thinking about how to craft and convey this personal message from the Chair, my mind kept floating back to four individuals who I have, (only relatively recently) met, and who have inspired and helped me relate to our Section and its future.  I single out these folks not to nominate them as the only or best contributors to, or even members of, our Section (since there are so many others who should not be neglected for such an award).  Instead, I want to simply share with you how much they have helped and encouraged me about potential progress and greatness for Medical Care.   And I guess this is a sneaky way to get you up to date about some of the behind the scenes Section projects and goings-on.


Fran Atkinson is the staff-person whose official title is Director of Component Affairs.    Among other duties and responsibilities, she serves as liaison and support for our Section.  Initially, just a faceless and voiceless e-mail address from whom I received dreadline (forgive bad pun) notices about what was due and when, and then reminders that I was past due. Later, she evolved into an e-mail recipient who I could beg for an answer to a quick question, or ask to forward a request to the proper staffer in charge of the program or membership, or policy.  But finally, she materialized as the live, competent and enthusiastic human who performed magic at several key meetings, especially the Chair-Elect Orientation Session that I attended last year and our Midyear Meeting this past March. 


Fran didn’t talk much at these meetings.  But, as far as I could observe, she seemed to know and do everything.  She had an institutional savvy about APHA and what it would take to get any task done, as well as the interest and skills to make sure it did.  The Chair Elect meeting was a magnificent example of dedication of APHA volunteer leaders (such as then Intersectional Council Chair-Elect Susan Radius, who chaired the meeting) being empowered by the institutional support of APHA, all orchestrated and led behind the scenes by Fran.  Not only were the meetings well-planned and organized, in large part thanks to Fran, but she seemed to have a sense of what was important, and how to time our discussions to cover topics in just the right depth based on the item’s priority.  At the Midyear Medical Care Section meeting where time for discussion was more available, and we had a more of a chance to dilate and debate ideas (which is the reason I commend to any/all Section members our next Midyear Meeting in early 2007), she kept to the sidelines and provided the bumpers for us to bounce off of — as we debated single payer strategies with Dr. Benjamin or struggled with how to reverse the slowly shrinking Section membership number (a trend not unique to Medical Care). 


It’s an odd pairing, [and a less long-term one than the pairing of our last two key people Catarina and Jeroan (see below)], but the work of Rishi Rattan in Chicago with Fran in Washington was truly spectacular.  While I was busy on my impatient rotation with the new interns at County this July, Rishi worked as the “summer student intern” for our Section. 


I first met Rishi when he “appeared” at our house as part of a student gathering.  He was a first-year University of Illinois medical student and one of 50 who responded to a invitation for interested progressive students to join us for a dinner (something my wife Mardge and I have been hosting for the past several years and have “seasoned” with Quentin Young and Studs Turkel, who have joined us to share stories and goals).  Unlike other students who talked about wanting to do international health or PNHP national health insurance work, the main interest Rishi expressed was organizing other men, and working as a feminist man to raise consciousness and change behaviors vis a vis women’s oppression and violence.  It was a half year later in late June when we happened to cross paths again -- it turned out we needed a student to help us with Section work, and he was looking for something to do for the summer.   We were also fortunate to secure access to the unspent funds we had saved by our thrifty Section lifestyle (funds that otherwise were about to turn into a pumpkin on June 30, 2006). 


What I immediately saw was that Rishi had incredible computer skills and personal work habits, as well as an eagerness to learn about and contribute to the Section.  The list of tasks we set out for him is too long to list, and what he accomplished is an even longer list, but to name a few: 


a)       Researched a comprehensive history and produced a timeline of the Section (largely from previously prepared but now forgotten reviews);


b)       Cataloged all of the sessions presented by the Section for the past 10 years and entered these into a database (more on this below)


c)       Took our Web site from zero to 60 (actually it was worse than zero, but to continue the car accelerating analogy, it was stuck in the ditch at a “broken link” URL with totally out of date information); 


d)       Collected and collated lists of various awards and past award winners;


e)       Updated our Committee lists, leadership roster, and contacts;


f)         Helped Jim Wolleb (with input from others) put together and distribute a survey of our lapsed members (surveyed why they had left and solicited feedback on how we could do a better job);


g)       Helped assemble and post on the Web a list of our Section Chairs for the past 57 years (dating back to before I was born!);


h)       Assisted the workgroup with revising and updating our Section Brochure;


i)         Worked with me to download every Medical Care journal article for the past 10 years, which we are working to cross-reference with our session topics to create a visual map/taxonomy of topics we have covered and analyze where they cluster (in progress),


j)         Worked on preparing a “new member” packet (in progress); and   


k)       Worked with our student liaison(s) to develop student recruitment strategies (Cristina Thorsen is the official MC student liaison and is enrolled in a one-year MPH program at Harvard this year). 


Rishi is a remarkable guy, and I am eager to have others meet him at our Saturday business meeting and look forward to a long career in medicine and Medical Care for him and other students in our ranks. 


Finally, it’s now “public” so I can make a few comments about the experience of meeting Catarina Kiefe and Jeroan Allison. 


The search committee for the new editors of Medical Care met and interviewed a number of candidates on the Monday of the 2006 Annual Meeting in Philadelphia.  From the moment they walked in the room, the Committee realized that something extraordinary was about to unfold.  Catarina and Jeroan began by each presenting a personal vision for themselves and the Journal and how they intersected.  Catarina described her work first as a mathematician, then realizing she wanted to do something more clinically and socially relevant, she shifted course and became a physician working as a clinician-educator in the trenches.  However, after she became chair of general medicine at Houston’s public hospital, her talents eventually drew her back to epidemiology, biostatitiscs and health services research.  Shaping a research “portfolio” driven by her personal passion for “equity, fairness, and equal access,” (quoting her remarks to the Committee) she went on to become the director of a highly productive and respected 300-person health services research center at the University of Alabama. 


Jeroan Allison was of the junior faculty whose Catarina’s remarkable and charismatic research career touched.  Over the past decade, the two of them have collaborated on more than two dozen major peer-reviewed journal publications.  It was this palpably shining collaboration and working relationship that was perhaps the most impressive aspect of this applicant team.  Jeroan brought to the co-editor team a special interest in the medical literature — how is it generated and used.  He conveyed his passion for positioning Medical Care to help it make a special contribution to this rapidly changing arena of journal content, production, and access. Already a distinguished deputy editor of Medical Care for the past 5 years, Jeroan had significant experience with both the Journal and the review process.  In a 17-page prospectus, he and Catarina outlined their analysis of the strengths and weaknesses of the journal and their “package of targeted recommendations.” 


Both joined us at the Section Midyear Meeting and are, effective July 1, 2006, beginning to take over the reigns of the Medical Care editorship from outgoing editors Colleen McHorney and Carol Ashton (under whose leadership the journal earned the rank of #1 Science Citation Index Health Policy/Public Health Journal in 2002, and was converted to an “all electronic” submission and review process).  Jeroan will be with us at the Monday morning Section business meeting to present an update on the status of the Journal and his and Catarina’s plans for its future.  They have challenged the Section to play a greater role in shaping the Journal, including requesting our input for future special theme issues (suggestions are welcome and please send them to me at Gdschiff@aol.com).

A Democratic Victory Not A Boon To Health Care

Given the horrendous record of the Bush administration in foreign and domestic policy, it is not surprising that many hope a Democratic victory in 2008 will bring dramatic change for the better.  Those of us in APHA have witnessed with dismay the rising number of the uninsured, cuts in public health and health care spending, rising costs of medications and conflicts of interest in medical research and regulation. We could almost forget that our priority is a program for universal quality health care.


Although Democrats from Roosevelt to Clinton have talked about a national health care plan, all have abandoned the fight under pressure from the pharmaceutical and insurance industries. This year’s crop of Democrats, from Hilary Clinton to Barack Obama, don’t even mention the idea of universal coverage. Pretty much they all agree on the same few points, as we heard from Kerry at last year’s convention or as described in The American Dream Initiative, the recent position paper of the Democratic Leadership Council (http://www.dlc.org). They propose promoting electronic medical records, focusing research on particular diseases like AIDS and Alzheimer’s, lowering insurance costs for small businesses, negotiating lower drug prices for Medicare, and expanding coverage for children through CHIP and insurance subsidies. Although all of these steps would do some small good, they do not actually provide the funds to allow nine million children not eligible for CHIP or adults working for small business to be insured, and ignore the gaping needs in the public health and health care infrastructure and the waste in allowing health care to continue as a profit-making commodity.


In a larger sense, the Democrats have plans that will cause even more death and hardship than the Republicans are wreaking on us now. To quote from another position paper, How America Can Win Again (Blueprint Magazine, 7/23/05): “The U.S. faces competitors in China and India that, if we fail to act, have the potential to eclipse our economic might….Economic and military might go hand in hand, and victory can only be assured when all Americans…sacrifice…. Our leaders have failed to arm us economically and militarily for a war that could go on for decades.” They then propose adding 100,000 more troops, requiring colleges to allow recruiters on campus, and a “voluntary” national service program but required for college admission. The purpose of bolstering the middle class and providing people the services they need is seen as needed to win their loyalty and participation for the long struggle ahead. Thus, the Democrats do not have an outlook that puts the well-being of people first, but only see the need for expanding international struggle more clearly than the Republicans.


For us the lesson is that we must rely on organizing rank and file people to fight for what we need, without expecting politicians of any stripe to give it to us.

Interim Recommendations on Health Reform Reflect a Struggle Under Way


A set of six interim recommendations for “health care that works for all Americans” has drawn a wide range of comments from more than a hundred organizations and thousands of individuals. Typically, they proposed revisions. Many appeared to share this writer’s assessment of the recommendations as a mixed bag. The recommendations and their varied presentation over time reflect shifting dominance in policy struggles within the Citizens’ Health Care Working Group that developed them.


Here, as issued July 18, 2006, are the interim recommendations in brief:


1)       Guarantee financial protection against very high health care costs.


2)       Support integrated community health networks.


3)       Promote efforts to improve quality of care and efficiency.


4)       Fundamentally restructure the way that palliative care, hospice care and other end-of-life services are financed and provided, so that people living with advanced incurable conditions have increased access to these services in the environment they choose.


5)       It should be public policy that all Americans have affordable health care. All Americans will have access to a set of core health care services. Financial assistance will be available to those who need it.


6)       Define a ‘core’ benefit package for all Americans.


Each recommendation is elaborated further and is accompanied by a rationale and discussion.


Once the group issues its final recommendations on Sept. 27, 2006, the president will have 45 days to respond with a report to Congress commenting on the recommendations and, if he wishes, adding his own recommendations. Each of the five pertinent committees of Congress is then required to hold at least one hearing on the recommendations.


Recommendations 2, 3, and 4 are largely if not entirely sound. In this article, I highlight major deficiencies in recommendations 1, 5, and 6.


Taken together, recommendations 1 (catastrophic cost protection) and 6 (core benefits) would provide catastrophic coverage while falling short of assuring all medically necessary care. The report notes that “[t]here are many ways that universal coverage against high out of pocket medical costs could be designed.” The particular example described envisions achieving this through a mandate to buy coverage in an insurance market that offers various policies differing in size of the deductible but all covering the same set of “core benefits.” The elaboration of recommendation 5 (universal coverage as public policy) calls for making “financial assistance… available to those who need it,” so as to make low-deductible policies affordable by people with low incomes. But the WG’s acceptance of deductibles ignores the fact that, for people with low or moderate incomes, deductibles are an obstacle to getting needed care.


Standing alone, recommendation 5, which calls for public policy to guarantee affordable health care to all Americans, would be an extraordinarily important advance in U.S. policy. Moreover, the group calls assurance of health care “a shared social responsibility,” but then it goes on to say, “…we need to find a way to reconcile contrasting views about the role of the marketplace and government, of competition and planning, and of individual and shared responsibility.” Yet, the discussion includes a tantalizing, unelaborated sentence, “We also recognize that, in addition to new revenues and [savings], there are ways that current funds could be reallocated within the system to pay for health care that works for all Americans.” The group does not link this to recommendation 3, relating to improving efficiency.


The elaboration of recommendation 3 makes mention of reducing fraud and waste in administration and clinical practice. Also mentioned, without elaboration, is use of the federal government’s purchasing power to enhance efficiency. But one searches in vain for reference to administrative saving in a single payer system, unfair pricing of goods and services, or redundant capital investment by competing hospitals.


In the elaboration and discussion of recommendation 3, there is major emphasis on consumer-usable information on prices of medical services. This looks to the inappropriate and widely discredited notion of patient as active participant in a market for medical services.


The interim recommendations as listed above are actually the second version issued by the Citizens' Health Care Working Group.  The first version, issued June 1, 2006, included the same six bare-bones recommendations listed above, but the recommendations numbered 5 and 6 above were numbered 1 and 2, giving primacy to the public policy commitment. Moreover, the list of recommendations was preceded by the statement, “Americans will have access to a set of affordable and appropriate core health services by the year 2012.” The more recent iteration specifies no target date. Sources close to the working group report that the force of public comments about the interim recommendations will lead to several desirable revisions, including restoration of a target date and a higher priority for public policy commitment to affordable health care for all.


The two-year Citizens’ Health Care Working Group process leading to these recommendations was mandated by a provision of the Medicare Modernization Act of 2003. One of the stated purposes was, “…to provide for a nationwide public debate about improving the health care system to provide every American with the ability to obtain quality, affordable health care coverage.” A major mechanism specified for the debate was a series of community meetings, which, according to the statute, were “at a minimum, [to] address the following questions:  (I) What health care benefits and services should be provided?  (II) How does the American public want health care delivered?  (III) How should health care coverage be financed?  (IV) What trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high quality health care coverage and services?”  (Public Law 108-173; Accessible at http://www.citizenshealthcare.gov/about/law.php).  More than 50 such community meetings were held in the first five months of 2006 to gather responses to a series of multiple-choice questions.


The directive to make health coverage affordable by identifying benefits that could be traded off appears to have led the working group to recommend that a core benefit package be defined. To portray this as a popular mandate, the group, at community meetings and in online polling, posed a question that presupposed a “defined level of benefits” to be desirable. Justification for the focus on catastrophic coverage was generated similarly, with another question.


 


Here and there in the report, something breaks through that suggests turmoil within the working group. Clear evidence of the turmoil: in July, pressure from group members ousted the group’s chairman, one of the group’s most conservative members, from his post.


Finally, for recommendations supposedly generated in a bottom-up process, the  document fails to report that, in both the online poll and the community meetings, when asked to choose among multiple options for assuring coverage for all Americans, respondents’ overwhelmingly preferred to create a publicly funded national health plan through which all Americans would get their coverage. (http://www.citizenshealthcare.gov/community/mtng_files/chcwg_cm_prelim_data_0306.pdf )


The entire report is online at http://www.citizenshealthcare.gov/recommendations/interim_recommendations.php#interimrecs. The public’s comments are online at http://www.citizenshealthcare.gov/speak_out/comment.php.  The comment deadline having now passed, the WG’s final recommendations to the president and Congress are expected on Sept. 27, 2006 – in time for the public to quiz Congressional candidates about their stands.


The 14-member WG was appointed by the U.S. Comptroller General (head of the GAO) from among more than 530 applicants. They comprise a diverse group with a broad range of health care perspectives, including patient advocates, clinicians, academicians, health industry administrators, employers and workers. By law, none is an elected official or an employee or representative of an advocacy or industry association. Their profiles are available at http://www.citizenshealthcare.gov/about/members.php.


APHA’s comments on the interim recommendations are at http://www.citizenshealthcare.gov/recommendations/orgs/apha_ircomments.pdf.

APHA Action Board Report

1) The Action Board, as noted in previous reports this year, is reviewing and archiving APHA policies, a course of action that will continue. It has been useful to update important policies and eliminate some that may be no longer relevant.


 2) The Action Board has actively encouraged engagement with elective representatives to advocate for policies and legislation that would benefit public health. Direct discussions with representatives, especially during recent legislative recess periods, were emphasized. I would like to hear reports from Medical Care as to what extent this has been done by our members.


3) The important issue of APHA advocacy will be presented at the Annual Meeting. Members will be encouraged to consider critical questions regarding advocacy such as: What is Advocacy? How can you make a difference?


The Action Board works closely with APHA Government Relations and Advocacy staff to motivate members to participate in advocacy efforts, policies passed and legislative initiatives that are parallel with the association’s priorities. Our role as Action Board representatives is to make certain that APHA’S Action Alerts are directly relevant to the units we represent (e.g., sections, SPIGs et.al.).


As the public health community knows first hand, education is key.  When citizens learn about an issue and how policy decisions are made, it empowers them to get involved and act. This collective process helps to chart the direction of policy.  Community education and participation of individuals, groups and public health partners in the development and implementation of critical public health policy makes for healthier communities. Education + Action = Advocacy


ADVOCACY EDUCATIONAL OPPORTUNITIES


If you are interested in learning more about public health advocacy, there are opportunities for members to learn about and participate in APHA Advocacy at the upcoming Annual Meeting. The following is a list of sessions and events to keep in mind if you are planning to attend.


 (Note:  See Annual Meeting Program for locations of sessions)


1)3288.0        Monday, Nov. 6, 2006, 2:30-4 p.m.: Mobilizing a Campaign Around A Public Health Issues.


2)3192.0        Monday, Nov. 6, 2006, 12:30-2 p.m.: Advocacy Law Rules and Tools of Non-Profit Lobbying.


3)3008.0        Monday, Nov. 6, 2006, 2006, 8:30-10 a.m.: How to Write a Good Policy.


4)5031.0        Wednesday, Nov. 8, 2006, 8:30-10 a.m.: Impact of the Midterm Elections.


5)3288.0        Nov. 6, 2006, 2:30 p.m.: Vermont: A State Level Advocacy Best Practice.


  6) ELECTION NIGHT PARTY:  On Tuesday, Nov. 7, 2006, 7-11 p.m., YOU are invited to an Election Night Cocktail Party co-hosted by the Action Board and the Student Assembly.  Cast your vote for public health and then come watch the election night returns with your fellow public health advocates!


Where:  Hyatt Regency Boston, Lobby Bar and Lounge, One Avenue De Lafayette.


Featuring: Cash Bar with election night-themed drinks, TVs to watch election night results and analysis, election charts information, APHA voting records, information about APHA advocacy and much more!  Please join us for the party, and remember to vote before you attend the Annual Meeting.


Interested in learning more about the Action Board? Please see the APHA Web site at: http:www.apha.org/private/action_board/2006_core_activities.cfm.

APHA Annual Meeting Program Sessions

This year's Medical Care Section Program at APHA's Annual Meeting in Boston, Nov. 4-8, 2006, consists of 36 sessions organized by the Medical Care Section covering such topics as:  universal access to health insurance, ensuring access to safe and effective medicines, asthma disparities, emergency preparedness, quality improvement and outcomes of care on a national scale, medical imaging, health services research competencies, and the history of the AIDS epidemic.  In addition, the Section is co-sponsoring over 80 other sessions covering such topics as social justice and health equity, breast cancer survivorship, tobacco control, hospital work hour limits, prisoner rights, trade issues in developing countries, and gender-based violence. 


 The link to the sessions organized and sponsored by the Medical Care Section is:


 http://apha.confex.com/apha/134am/techprogram/program_588.htm


 The link to the Medical Care Section business meetings and social events is:


 http://apha.confex.com/apha/134am/techprogram/nt_588.html


 Please join me in thanking Darrell Gaskin for his many years of service as the Medical Care Section Solicited Sessions Chair.  Unfortunately, Darrell has decided to step down from this position at the conclusion of the November 2006 meeting.  He will continue to be actively involved in the Medical Care Section as a Section Councilor.

Interested In Becoming More Involved In The Activities Of The Medical Care Section?


The individuals listed below are the current chairs or co-chairs of the Medical Care Section Committees.  Many of these committees will be meeting at the APHA Annual Meeting in Boston, Nov. 4-8, 2006.  The scheduled meeting time is Monday, Nov. 6, 2006, from 6:30 p.m. - 8:00 p.m.  The meeting will be listed in the program as the Medical Care Section Committee Open Forum.  You are encouraged to stop by and introduce yourself to the committee chairs/co-chairs.  One activity of the committees is to organize sessions for the Annual Meeting.  If you are interested in becoming more actively involved, but are either not attending the Annual Meeting this year or are unavailable during that time slot, just e-mail the committee chair/co-chairs and copy the e-mail to me as well (virgoks@slu.edu).  Please include a copy of your CV.  I will compile a list of all who would like to be more active and supply this to our Section Chair, Gordy Schiff (Gdschiff@aol.com).  The Medical Care Section welcomes your involvement.


Drug Policy & Pharmacy Services:          Robert Eilers (Robert.Eilers@dhs.state.nj.us) &


Stan Edlavitch (Edlavitchs@umkc.edu)


Ethnic & Racial Disparities:                    Ernest Moy (Emoy@ahrq.gov)


Health Economics:                                 Luisa Franzini (Luisa.Franzini@uth.tmc.edu) &


Audrey Laporte (audrey.laporte@utoronto.ca)


Health Services Research:                      Bruce Davidson (bruce.davidson@cshs.org)


Jail & Prison Health:                               Corey Weinstein (coreman@igc.org) &


Patricia Kelly (kellypj@umkc.edu)


Quality Improvement:                              Eileen Ciesco (eciesco@nc.rr.com)


Rural Health:                                         Wayne Myers (wwm@midcoast.com)


Social Sciences in Health:                      Victoria Raveis (vhr1@columbia.edu)


Student Session:                                   Ilene Zuckerman (izuckerm@rx.umaryland.edu) &


Linda Green (green_linda@hotmail.com)


Urban Health:                                        Zoe Clayson (zoeclay@sfsu.edu)


Veterans’ Health:                                   Ben Neufeld (retiring) (beneufeld@adelphia.net)


New Veterans’ Health Co-chairs:             Linda Tsan (linda.tsan@va.gov) &


Katherine Virgo (virgoks@slu.edu or kathy.virgo@va.gov)


Women's Health:                                   Amal Khoury (akhoury@phhp.ufl.edu)

Announcements


We are pleased to present you with an exciting new resource for public health professionals: The Quick Guide to Health Literacy.  The Quick Guide is produced by the U.S. Office of Disease Prevention and Health Promotion and is written for health professionals at the national, state, and local levels.  It contains:


§         A basic overview of key health literacy concepts


§         Techniques for improving health literacy through communication, navigation, knowledge-building, and advocacy


§         Examples of health literacy best practices


§         Suggestions for addressing health literacy in your organization


If you are new to health literacy, the Quick Guide will give you the information you need to become an effective advocate for improved health literacy.  If you are already familiar with the topic, you will find user-friendly, action-oriented materials that can be easily referenced, reproduced, and shared with colleagues.


The Quick Guide to Health Literacy and other tools for improving health literacy can be found at http://www.health.gov/communication/literacy">www.health.gov/communication/literacy.  If you would like to request a hard-copy of this resource, or if you have any questions, please contact Stacy Robison at (240) 453-8271 or at stacy.robison@hhs.gov href="mailto:stacy.robison@hhs.gov">stacy.robison@hhs.gov.