Health Law
Section Newsletter
Fall 2003

Message from the Chair

This Fall’s issue brings information about the upcoming Annual Meeting of APHA, including the scientific sessions that will be sponsored by the Health Law Forum. Professor Patricia (Winnie) Roche of the Health Law Department, Boston University School of Public Health, once again has planned a series of sessions that reflects the diversity and range of public health law. We look forward to your participation and thank those who submitted abstracts for consideration this year.

The challenges brought to the field of public health over the past few years have been compounded by historic state budget deficits, and we as public health professionals continue to be called upon to navigate those challenges while maintaining the critical public health system infrastructure. APHA’s efforts at advocacy and grassroots mobilization of its members continue. More information is available on the APHA Web site.

Ross Silverman, JD, MPH, of the Southern Illinois University School of Medicine has edited another comprehensive issue of our newsletter, and remains interested in your submissions and suggestions for upcoming issues. He and I look forward to more communication with you, and to representing you on the Governing Council in the upcoming term.

Christie L. Hager, JD, MPH
Chair, Health Law Forum

Health Law Forum Programming at the Upcoming 2003 APHA Annual Meeting

Click on the program header for a link to session details. Session locations will be provided in the final Annual Meeting program.

Tuesday, Nov. 18, 2003: 2:30 p.m.-4:00 p.m.4208.0: Human Rights and Ethics in Public Health
    2:30 p.m.
    Public Health Ethics and the Universal Declaration of Human Rights
    George Annas, JD, MPH

    2:50 p.m.
    Can Patient Rights Survive Preparation for Bioterrorism?
    Wendy K. Mariner, JD, MPH

    3:10 p.m.
    Is there an Obligation to be Truthful in Public Health Campaigns?
    Leonard H. Glantz, JD

    CE Credits: CME, Health Education (CHES), Nursing, Pharmacy
Tuesday, November 18, 2003: 4:30 p.m.-6:00 p.m.4274.0: Patient Safety, Tort Reform and Public Health
    4:30 p.m.
    Patient safety and patients' rights: Conflicts over confidentiality
    Ross D. Silverman, JD, MPH

    4:50 p.m.
    Therapeutic jurisprudence: Can law improve health?
    Diane Kjervik, JD, MSN, RN

    5:10 p.m.
    Financial and operational impact of implementing a patient safety program: Reducing medical errors and improving the bottom line! Doing it right the first time
    Stephen Hough, MPH, MA

    5:30 p.m.
    Pharmacy compounding: An emerging substandard drug industry
    Sarah Sellers, PharmD

    Cosponsors: Chiropractic Health Care; Epidemiology; Public Health Nursing
    CE Credits: CME, Health Education (CHES), Nursing, Pharmacy
Wednesday, Nov. 19, 2003: 8:30 a.m.-10:00 a.m.5035.0: Legal and Ethical Aspects of Smallpox Vaccination
    8:30 a.m.
    Legal, ethical, and programatic issues from smallpox vaccination: Implications for public health programs
    Howard Backer, MD, MPH, Diana M. Bontá, RN, DrPH, Kevin Reilly, DVM, MPH, David Souleles, MPH

    8:50 a.m.
    Informing Practice: Smallpox Vaccination Process Through the Lense of the Public Health Code of Ethics
    Alan Melnick, MD, MPH, Kathy Vincent, Clayton Williams, MPH, V. James Guillory, DO, MPH, James C. Thomas, MPH, PhD, Beth Quill, MPH, Magdelena Merrill, MPH

    9:10 a.m.
    Balancing the Risks: Legal and Ethical Issues in Smallpox Vaccine Trials with Children
    Jennifer S. Bard, JD/MPH

    Cosponsors: Epidemiology; Public Health Nursing
    CE Credits: CME, Health Education (CHES), Nursing, Pharmacy
Wednesday, Nov. 19, 2003: 12:30 p.m.-2:00 p.m.5105.0: Legal Issues in Access to Health Care
This panel explores ways in which law and/or legal advocates serve to facilitate or impede access to health care.

    12:30 p.m.
    Do indigent, high-risk infants need legal advocacy to receive health and welfare services?
    Laura Barnickol, JD, MSW, Jocelyn A. Hirschman, MPH, Janell F. Fuller, MD, Gopal Srinivasan, MD, Swarupa Nimmagadda, MD, Stephen N. Wall, MD, MSH

    12:50 p.m.
    Health professionals as human and civil rights activists: The Medical Advocacy Project
    Marianne Reiner

    1:10 p.m.
    Public health implications of PRWORA's restrictions on undocumented immigrants' access to health care
    Jeffrey T Kullgren, MPH

    Cosponsors: Chiropractic Health Care; Community Health Planning and Policy Development
    CE Credits:CME, Health Education (CHES), Nursing, Pharmacy

How Are We Doing?

The Health Law Forum Newsletter is an ideal means through which to promote upcoming conferences, announce professional accomplishments, voice your opinion (guest columns are welcome), raise questions and awareness about specific concerns and bring together public health law scholars and practitioners.

Honestly, the Forum Newsletter can be whatever people want it to be, but you have to get in touch with the Newsletter Editor if you want to see additions, subtractions, or your name or institution in print.

Feel free to contact me at the e-mail address below with your questions, comments, concerns, critiques and columns, and I hope to see you in San Francisco.

Invitation to the Health Law Forum Business Meeting

Health Law Forum Business Meeting at the APHA Annual Meeting Tuesday, Nov. 18, 2003: 6:30 p.m. - 8:00 p.m. (Session # 436.0)

Bioterrorism and preparedness. SARS. AIDS. The uninsured and underinsured. Genomic medicine. The obesity epidemic. State, federal and international public health funding.

Today, more than ever, legal and ethical concerns are at the core of critical public health issues facing the United States and the world.

The members of the APHA Health Law Forum are leading scholars and practitioners addressing these issues, and the Health Law Forum Business Meeting at the APHA Annual Meeting is an ideal place for those interested in these issues to come together and help set the course for (and the discourse about) the future of public health.

Please join us Tuesday, Nov. 18, from 6:30-8:00 p.m. (location will be available in the final Annual Meeting program), and help the APHA Health Law Forum become a leading voice for public health.

Additional Annual Meeting Programming of Interest

1. From the APHA home office in Washington, DC, we received this announcement:

    There are many exciting general sessions at this year’s Annual Meeting, but we would like to call your attention to the following three sessions. Each session will include presentations on issues of great importance to the fulfillment of the public health mission in the 21st century by panels of outstanding experts. The panels are designed to provoke participants to view the future of their profession and to develop strategies for assuring public health effectiveness in the future.

    President’s Session:
    Challenges and Opportunities Confronting the Public Health System in the 21st Century
    Monday, Nov. 17, 2:30 p.m. - 4:00 p.m. (Session #3256.1)

      2:30 p.m.
      Introduction, Jay H. Glasser, PhD, MS

      2:35 p.m.
      Future of public health practice and education: The IOM reports
      Harvey V. Feinberg, MD, PhD

      2:55 p.m.
      Health disparities
      Robert Graham, MD

      3:15 p.m.
      Mobilizing public support for universal healthcare
      Dennis Rivera, President

      3:35 p.m.
      State of state public health
      Diana M. Bontá, RN, DrPH

      3:55 p.m.
      Closing Remarks, Jay H. Glasser, PhD, MS

      This session will focus on the challenges and opportunities facing public health in the 21st century. Topics to be discussed are: the Institute of Medicine’s recommendations on the future of public health practice and education; strategies to eliminate health disparities; mobilizing public support for universal health care; and a summary of the present state of public health as a “starting point” for the future.

    Critical Issues in Public Health
    Tuesday, Nov. 18, 10:30 a.m. - 12:00 p.m. (Session #4088.1)


      Panelists:
      The Honorable John P. Walters
      James Hughes, MD
      Risa Lavizzo-Mourey, MD, MBA
      Jeffrey W. Runge, MD

      This Session will further amplify the discussion of issues of central concern in the 21st century. The topics to be covered in this session are: new strategies to reduce the prevalence of substance abuse; approaches towards controlling the epidemic of obesity; strategies to reduce the high incidence of traffic accidents; and dealing with the threat of emerging zoonotic infections.

    APHA Closing Session
    Wednesday, Nov. 19, 4:30 p.m. - 6:00 p.m. (Session #5190.0)


      Moderators: Jay H. Glasser, PhD, MS; Georges Benjamin, MD, FACP

      4:30 p.m.
      Welcome and Introduction, Georges C. Benjamin, MD, FACP, APHA Executive Director

      4:35 p.m.
      Panel Introduction, Jay H. Glasser, PhD, APHA President

      4:40 p.m.
      Impact of genomics on public health in the 21st century
      Wylie Burke, MD, PhD

      5:00 p.m.
      New and emerging communicable diseases
      Julie Louise Gerberding, MD, MPH

      5:20 p.m.
      Helping people to overcome disabilities and develop independent lifestyles
      Glen W. White, PhD

      5:40 p.m.
      Closing Remarks & Introduction of 2004 APHA President, Jay H. Glasser, PhD, MS

      5:55 p.m.
      Close of Session and Annual Meeting, Georges C. Benjamin, MD, FACP, APHA Executive Director

      For the first time, the Closing General Session will feature a panel discussion. Three areas of central concern to public health in the 21st century will be discussed. The topics to be covered are: the impact of the rapidly advancing science of genomics on public health; the threat of new and emerging infectious diseases; and the promise of technology in helping disabled people to overcome their physical limitations.
2. The health law forum also received the following announcement:

    The APHA Network on Globalization and Health Report: Fall 2003
    FTAA Threatens Global Health; Plans Coincide with APHA Annual Meeting

    Ellen R. Shaffer, PhD, MPH

    How does the global economy affect health status and disparities in health status, public health systems and policy, access to coverage within private and public health care systems, occupational health and safety, injury control, environmental health, and access to pharmaceuticals and to safe water, and social and economic equality? What do international trade agreements have to do with public health?

    Members of the APHA Network on Globalization and Public Health will address these and other issues during the APHA annual meeting in November 2003. A Town Hall meeting on Nov. 16, from 2 to 4 p.m. in San Francisco's Moscone Convention Center
    will offer brief presentations, and a chance to network with some local and national research and advocacy groups based in the Bay Area. The meeting will include observers from the September meeting of the international World Trade Organization ministerial in Cancun, Mexico, and members of international public health associations. Join the planning with an email to Ellen Shaffer, ershaffer@cpath.org. (Please see final schedule for exact room location.)

    The CPATH Web site www.cpath.org
    provides additional background information on economic globalization and health. APHA groups involved with the Network include: Medical Care Section, Mental Health Section, Environmental Health Section, International Health Section, Injury Control and Emergency Health Services Section, Occupational Health and Safety Section, Peace Caucus, Socialist Caucus, Spirit of 1848, DisAbility Forum, Hawaii Public Health Association, and the Public Health Association of New York City.

     

Public Health Law News You Can Use

SARS & the CDC's new SARS Guidelines
Since last publication, the worldwide SARS crisis has arisen and faded, but concern about a reappearance of the infectious disease remains high, especially here in the United States. In October, the Centers for Disease Control and Prevention released draft recommendations for community-based preparedness and response to SARS. However, these draft guidelines, should they be implemented, would likely have a significant impact on health service delivery and public health preparedness far beyond preparations for this newly-emerged infectious disease.

The draft guidelines would require that those with respiratory symptoms who enter a hospital, clinic or physician's office would be required to wear surgical masks and be subjected to isolation from other patients. The guidelines also discuss issues of quarantine, designation of medical centers for communicable disease treatment, and the power to call off large public events in the face of a potentially severe communicable disease outbreak. The CDC's main SARS web site can be found here.


Smallpox
Since last year's Annual Meeting, the Federal government has unveiled, implemented, promoted and now, it appears, shuttered its ambitious smallpox vaccination program. The program limped out of the gate, due to a poorly-crafted and poorly-managed policy, little confidence in the program from health care providers, and an unconvincing threat. It was criticized for failing to offer states enough funding to implement the plan, and for failing to offer health care workers enough protection should they be injured by the shots. It's been largely ignored since the war on Iraq has concluded and little evidence of WMD (let alone smallpox cultivation plans) surfaced. As Tara O'Toole, director of the Center for Civilian Biodefense Strategies at Johns Hopkins University opined in the July 16 edition of the Washington Post, "People are now back in dumb-and-happy mode, [and there is no longer the same urgency to vaccinate as there was] when we were going into Iraq, and the possibility of a smallpox attack was seen as much more plausible."


Unpreparedness
On the related issue of Bioterrorism Preparedness, three significant studies were released this summer.

The Partnership for Public Service
released a report titled "Homeland Insecurity: Building the Expertise to Defend America from Bioterrorism" (pdf file) detailing how five Federal agencies primarily responsible for defense against biological agents on the home front -- the Centers for Disease Control and Prevention, the National Institute of Allergies and Infectious Diseases, the Food and Drug Administration, the Animal and Plant Health Inspection Service, and the Food Safety and Inspection Service -- remain unprepared and undermanned. Furthermore, they report that we face a growing talent deficit in these federal agencies, as the Federal government cannot lure new talent into the field as the experts-in-residence gray and retire.

Similar concerns about our nation's unpreparedness were raised in reports examining our Public Health Labs (see the Trust for America's Health report "Public Health Laboratories: Unprepared and Overwhelmed"
(pdf file)).

Finally (if you'll permit the Forum Newsletter Editor to toot his own horn), Thomas May of the Medical College of Wisconsin and Ross Silverman of Southern Illinois University School of Medicine published an editorial on these issues titled "Bioterrorism Defense Priorities," which appeared in the July 4, 2003 issue of the journal Science (see here for the PubMed reference).

Uninsured
In September, the U.S. Census Bureau released its latest numbers on the number of uninsured in the United States. Their data runs through 2002. The Census report is available here
 in pdf form.

The good news: the number of children lacking insurance remained stable at 8.5 million, or 11.2 percent of the child population.

The bad news: everything else.
  • 2.4 million more people were uninsured in 2002 than in 2001, a 5.7 percent increase, raising the total number of uninsured in the U.S. to 43.6 million (15.2 percent of the population).
  • The percentage of those with employment-based insurance declined to 61.3 percent.
  • Small business employees were hit hardest: Only 31 percent of employees working for companies with 25 employees or less have employment-based health insurance; just 54 percent of all employees working in companies with 25-100 employees have employment-based insurance.
  • The proportion of people with employment-based insurance who had the insurance in their own names also declined by 2 percent to 55.2 percent. This number is interesting to note as evidence of the instability of health insurance benefits for nearly half of those who have health insurance. Any change in job, marital or insurance status of the employed spouse or parent can mean those who rely on that employee's insurance benefits for coverage will also be adversely affected. The fact that more and more people rely on this type of cross-coverage means that, as insurance costs continue to rise by double digit levels, greater and greater numbers of insured dependents will have their coverage limited or dropped as employers struggle to shoulder higher premium costs.
  • The average annual cost for family insurance coverage is now over $9,000.
  • Middle class working families saw the greatest increase in uninsured: over 1.1 million more people with incomes between $25,000 and $50,000 a year were uninsured in 2002 than in 2001, a rise of 1.5 oercent to nearly 1 in every 5. There was nearly a half-percent rise in the number of uninsured in families with incomes between $50,000 and $75,000, and a .5 percent rise in uninsured with incomes over $75,000 a year as well, totaling almost a million more uninsured in families with incomes over $50,000 a year. In case anyone has missed the message by now: Health insurance coverage is now a full-fledged political issue for the middle class (see the NYTimes article above for more). The Democratic candidates may disagree on the means through which to expand coverage, but at least they understand that coverage changes need to be made. The Bush Administration has failed to take any serious steps toward improving coverage for the middle class. If that's not a campaign-year issue, I don't know what is.
  • Medicaid enrollment rose during the last year, putting even greater strain on state budgets. In fact, nearly the entire growth in health insurance coverage in 2002 came from people enrolling in Medicaid (thanks to the CHIP programs and Family Care coverage, as well as the rise in poverty levels which meant more people now qualify for government insurance coverage). However, over 30 percent of those living at or below poverty remain uninsured (10.5 million people - a quarter of the total uninsured population).
Medicare reform/FDA
While Congressional leaders and the Administration continue to work on crafting a prescription drug benefit for Medicare, some states, struggling with the skyrocketing costs of prescription drugs under Medicaid, are following in the footsteps of some health care consumers and looking to the Great White North for relief.

In October, Illinois Governor Rod Blagojevich unveiled a new state Web site, www.affordabledrugs.il.gov,
outlining the current crisis facing seniors who cannot afford the high cost of prescription drugs and offering links to Canada vs U.S. price comparisons, pro-reimportation editorials, and information about pending legislation.

The site also features an online petition
 people can sign "[i]f you think Congress and the FDA should allow Americans to purchase safely imported prescription drugs from Canada."

California Governor Signs Mandatory Health Coverage, Domestic Partner Bills
In October, California Governor Gray Davis (D) signed into law two pieces of legislation affecting access to health insurance and other employee benefits for Californians. On October 5, he signed the California Health Insurance Act of 2003 (SB 2), which required that large employers cover either 80 percent of the health insurance premiums, or pay into a state health insurance purchasing fund. Employers with over 200 employees must cover employees and their dependents, and must come into compliance by Jan. 1, 2006, while employers with between 50 and 199 employees must comply on behalf of their employees by Jan. 1, 2007. One week later, Davis signed into law a bill that would require that businesses with state contracts offer domestic partners the same benefits as are made available to married employees. The law will go into effect in 2007. Both laws are expected to face legal challenges.