Repealing the ACA will be catastrophic for America's mental health

On December 18, 2019, a big piece of healthcare news went relatively unnoticed amidst the impeachment vote in the United States House of Representatives. A federal court based in New Orleans ruled that the “individual mandate” within the Patient Protection and Affordable Care Act (ACA), the provision that imposes a tax penalty on those in the US who do not have health insurance, was not constitutional. The court failed to make decisions on the rest of the law, asking a lower court to decide if the ACA could hold up with the individual mandate removed. Democrats in favor of the healthcare bill have vowed to fight for its longevity, and it’s expected that it will eventually be heard before the US Supreme Court. 

Still, the future of the ACA is once again in question, and the countless Americans who have accessed healthcare in the last decade with the help of Medicaid expansion and marketplace subsidies now face uncertainty. So far, the bill is estimated to have saved the country about $2 trillion in health costs. But with the repeal of the individual mandate, 13 million Americans are expected to choose to go without coverage by 2027, leading to an expected 10% increase in annual premiums on average for plans in the individual marketplace. For many, this translates to even higher costs in a country that is already spending disproportionately more on healthcare. Those of us that live with a mental health concern have particular cause for concern. 

How the ACA Changed Mental Health Care in the US

  • The ACA required that a number of preventive care services, including certain screenings, be available to patients at no cost. One of these screenings was the inclusion of a yearly screener for depression, alcohol misuse, and cognitive impairment. 
  • Insurance companies could no longer deny plans to individuals based on their pre-existing conditions. This was a big win for the mental health advocacy community, as serious mental health concerns (major depression, anxiety, etc.) were the second most common reason cited for health coverage denials. Even mental health counseling for situational or acute concerns (grief, trauma, etc.) could count as a “pre-existing condition” prior to the ACA.
  • The legislation also expanded the existing mental health parity laws in the US (Mental Health Parity and Addiction Equity Act of 2008). The former parity laws required that mental health services had to be covered in a way that was equal to physical health services but only IF mental health services were offered by the plan. Many plans got around these laws by simply not offering coverage for mental health and substance use services. The ACA closed this loophole by listing mental health services as one of the ten “essential health benefits” for individual and employer-provided health plans (different parity laws apply to plans offered by Medicaid and Medicare). 
  • The Community Health Center Fund, established by the ACA, generated over $11 billion in grants for community health centers, the primary care clinics seeing a huge portion of the country’s under- and uninsured population, to expand services in their communities. Behavioral health services were one of my qualifying service targets eligible for funds. 

As a result of these provisions, million uninsured Americans were able to obtain coverage. The number of patients with mental health concerns that were uninsured or could not afford treatment dropped post-ACA implementation. The ACA has allowed providers and health networks to find innovative ways to integrate physical and behavioral health. As a result, patient satisfaction with providers and treatment has, not surprisingly, increased. Nearly one-third of Medicaid dollars are now spent on mental health or substance use disorders. Those living at 138% of the Federal Poverty Line, those who may have previously had to delay seeking care for mental health concerns, are now able to receive earlier intervention and more consistent care. 

Image Source: https://twitter.com/ObamaWhiteHouse/status/819607805552394241/photo/1

Having a mental illness isn’t cheap, and healthcare reforms have been instrumental in improving access to care for countless Americans. A 12-month prescription for antidepressants costs approximately $800. An in-patient hospital stay costs more than  ten times that. Individuals with depression have more than twice the number of outpatient visits per year than those without and more than three times as many prescriptions. Repealing the Affordable Care Act or dismantling its’ individual provisions could mean that the United States returns to a not-so-distant past where nearly 20% of individual plans offered no coverage for mental health services. With Medicaid expansion removed, 3 million low-income Americans with with serious mental health concerns could find themselves with nowhere to turn for care. Repealing the essential health benefits would allow insurers to go back to side-stepping parity laws. And should states be allowed to reduce Medicaid eligibility again, individuals living with a mental health concern will be disproportionately impacted. 

There’s still time for major portions, if not all, of the ACA to be saved. Due to the lengthy court proceedings, the case would not make it in front of the Supreme Court until after the 2020 elections, lending hope that a new wave of elected officials might hinder attempts to dismantle the legislation. But whatever the next year of divisive American politics brings, those living with mental health concerns should not be punished. At a time when illness attributed to mental health or substance use are on the rise in the United States, and at a time when more economic productivity is lost to mental health concerns than any other non-communicable disease, weakening the current mental health delivery system is more than irresponsible: it’s dangerous. 

News Round Up

Politics & Policies

Today, the field of “global health” strives to create equitable and just relationships between wealthy and impoverished regions, places and peoples. But it is still a field with markedly unequal power dynamics: racism, classism and many of the residual exploitations of a terrible colonial past.

In June, a public health professional serving as an International Health Specialist deployed to Iraq as part of Combined Joint Task Force – Operation Inherent Resolve.

Global health, a field dedicated to improving the health and wellbeing of the poor and most vulnerable, has quietly developed a penchant for highly-paid management consultants and their business world tools.

One of the greatest threats to public health today, in the United States and around the world, isn’t a new exotic hazard. It’s antibiotic resistance: the potential failure of one of our most important and well-known disease-fighting tools.

The world is not on track to reach the 2020 targets of the End TB Strategy, according to the World Health Organization’s latest Global Tuberculosis Report, published on Thursday.

The nation’s hospital groups sued the Trump administration over a new federal rule that would require them to disclose the discounted prices they give insurers for all sorts of procedures.

Programs, Grants & Awards

More people around the world than ever before led healthy, productive lives in 2018.  It was the year that transmission of wild poliovirus was cornered to the smallest area in history, the first new treatment for relapsing malaria in 60 years was approved, and the number of women in developing countries using modern contraceptives reached record levels. Innovations in sanitation, financial services and healthcare were brought to refugees, a billion people were treated for neglected tropical diseases, and 100 million mobile money accounts across Africa were made interoperable—allowing people to send and receive payments more quickly, safely and affordably.

Inaugural Nipah virus conference convenes leading experts to strengthen global collaboration, improve efforts to combat deadly virus.

Research

Many people under 60 who develop stomach cancer have a “genetically and clinically distinct” disease, new Mayo Clinic research has discovered. Compared to stomach cancer in older adults, this new, early onset form often grows and spreads more quickly, has a worse prognosis, and is more resistant to traditional chemotherapy treatments, the study finds.

Diseases & Disasters

The Samoas, an island nation of 200,000 was unprepared for the 300% increase in measles worldwide. While it had 90% measles vaccine coverage in 2013, that percent had fallen to 30% by 2018.

In 2019, the World Health Organization and partners have responded to 51 emergencies in more than 40 countries and territories and have investigated 440 potential health threats in 138 countries and territories. 

The future of global HIV response must be very different from today’s efforts. It must be youth focused and youth led. Otherwise, many of our successes against HIV may be endangered by the rapid growth of vulnerable youth populations in the highest burden countries.

More than two years after doctors in Jerusalem removed thousands of barklike lesions that had prevented Mahmoud Taluli from using his hands for more than a decade, he continues his battle with a rare, incurable skin condition.

New Zealand has ordered 1,292 square feet of skin to treat patients injured in Monday’s volcanic eruption on White Island, authorities said Wednesday.

Rising temperatures across Asia and the Americas have contributed to multiple severe outbreaks of dengue fever globally over the past six months, making 2019 the worst year on record for the disease.

The Pacific island nation of Samoa will shut down government services for two days so that civil servants can focus on a nationwide immunization drive as the country struggles to end a measles outbreak that has claimed more than 50 lives, most of them children.

Technology 

After more than two decades of research, the world finally has an approved Ebola vaccine.

Researchers have developed a new tool to predict the global spread of human infectious diseases, like dengue, and track them to their source.

Environmental Health

At Boulder High, students are prohibited from smoking cigarettes or vaping electronic cigarettes anywhere on school grounds. But Lewis and other school employees still regularly pluck e-cigarettes from students’ hands or find the used pods scattered all around.

Equity & Disparities

The United Nations said on Tuesday it was procuring food assistance for 4.1 million Zimbabweans, a quarter of the population in a country where shortages are being exacerbated by runaway inflation and climate-induced drought.

Yemen’s civil war has exacted an enormous toll on people with disabilities, who find themselves on the margins of society and excluded from badly needed humanitarian assistance, Amnesty International said in a report released Tuesday.

Women, Maternal, Neonatal & Children’s Health

Children continue to pay a deadly price as they succumb to a nearly three-fold rise in attacks over the last 10 years in conflict-ridden areas, the United Nations has said.

What does it mean that more seasoned pediatricians are also wanting to become more engaged in global health work?  We asked Dr. Suzinne Pak-Gorstein, a pediatric leader in global health efforts, to weigh in with an accompanying commentary.

As technology advances in the things we use every day, it’s generally accepted they also become safer. But according to one UBC engineer, that may not be true for a large portion of the population.

Eastern Ukraine has become one of the most mine-contaminated places on earth, despite recent developments aimed to protect the rights of girls and boys affected by more than five-year-long conflict.

Top Five Global Medication-related Controversies in 2019

The onslaught of biomedical interventions has allowed healthcare professionals globally to provide more effective & efficient treatment. Medications, in particular, have equipped healthcare systems with chemical entities to combat infectious diseases, manage chronic disease states, and provide targeted oncology therapy. However, these synthetic agents are not without controversy or significant glitches. Despite the intention to do no harm, humanity is often burdened with the negative consequences of the biomedical age. As the global health community reflects on this past year, there is substantial insight to be gained by reviewing these controversies that occurred in 2019. The following five issues encompass a few of the biomedical controversies in 2019, so that internationally, our fragile species can learn and grow to further improve the lives around the globe. 

#1: Global Drug Deaths – Opioid Pandemic 

In June of 2019, the United Nations Office on Drugs and Crime (UNODC) released the 2017 World Drug Report that highlighted the reach drug addiction has on humanity. The UNODC found that 35 million individuals were suffering from drug use disorders and required addiction treatment services. This is a 30% rise from near the end of the last decade. Of the deaths that occurred due to drug use disorders, 2/3rds were attributed to opioids alone which include both heroin and legal pain relievers. An increase of opioid use in Africa, Asia, Europe, and North America in concert with the single largest yearly production of cocaine – 2000 tons – are thought to explain this rise in opioid deaths. In addition, this study discovered that parts of West, Central, and North Africa have been flooded with tramadol leading to this opioid’s abuse and the increase in global figures. 

Unfortunately, this study noted that only one in every seven people are receiving effective treatment for their drug-use disorder. Evidence-based interventions are either completely unavailable in their area of inhabitation or inaccessible due to cost, distance, stigma, or saturation of available treatment centers. This report concludes by encouraging nation states and the global community to increase their efforts and funding to providing this vital care to each patient seeking these services. 

#2: Medication Recall – Zantac 

GlaxoSmithKline (GSK), a UK based pharmaceutical industry, issued an October 2019 statement that informed the public on a recall of a common medication to treat peptic ulcer disease (PUD) – Zantac, also known & sold by its generic name ranitidine. The impurity N-nitrosodimethylamine (NDMA) was found in unacceptable limits as this chemical is known to be a potential carcinogen. All prescription dosage forms were recalled which included tables, syrups, and injections, and changes in the manufacturing process are thought to have caused this increased level. This recall follows the 2018 recall of the class of anti-hypertensive agents called angiotensin II receptor blockers (ARB) that were adulterated with the same unacceptable limits of NDMA. 

#3: The Resurrection of Biogen’s Alzheimer’s Medication 

In March of 2019, the pharmaceutical industry Biogen announced that it was terminating its phase three clinical trial of a novel entity in the treatment of Alzheimer’s Disease. The termination of the monoclonal antibody, aducanumab, was due to no significant statistical differences between the treatment and placebo study arms. Aducanumab targets beta-amyloid plaque which has been the substiantal focus in Alzheimer’s treatment throughout the last several years. The preliminary results released by Biogen shocked the Alzheimer’s medical community, as this treatment showed so much promise in early stage trials. It was also the last potential target in this medication class, forcing many to believe a novel treatment modality would need to be pursued. 

However after a retrospective analysis of the complete data, Biogen reversed its decision in October 2019 and restarted their phase three clinical trials. The company stated that the researchers, initially worried about brain swelling and other side effects, increased the dose of aducanumab late in the study. This increased dosage showed increased effectiveness, 25% reduction in the rate of decline compared to placebo, when the researchers conducted the analysis after the initial cancellation. This increased dosage is still marred in controversy as two different trials, EMERGE & ENGAGE, both utilized the high dose regimen with the EMERGE participants seeing the aforementioned positive results while the ENGAGE participants actually seeing an increase in their cognitive decline. Biogen will file approval for the US Food and Drug Administration (FDA) early in 2020, but experts are split on whether it will be approved or will require additional trial data. Regardless of the decision by the FDA, the success of aducanumab will shape the future of Alzheimer’s treatment and research. 

#4: A halt to Pediatric HIV Structural Violence: Quadrimune

Cipla, a generic manufacturing company based out of India, announced in late 2019 that they were going to start production of an antiretroviral pediatric formulation for just $1 per day. Quadriume, which contains ritonavir, lopinavir, abacavir and lamivudine, is strawberry flavored to increase the adherence rates for young children afflicted with this infectious disease. Before the availability of this formulation, UNAIDS estimated that globally 50% of the 160,000 children infected with HIV die each year before the age of two largely from access issues and inability to tolerate the older formulations. The older formulations had tolerance problems such as a metallic taste and need for refrigeration while also encountering HIV resistance. The western world’s pharmaceutical industries has continued to turn a blind eye to this population of humanity for the sake of profits, while Cipla has been undertaking pragmatic approaches to HIV care for several years. Cipla hopes to receive FDA approval followed shortly by the World Health Organization (WHO) approval in May 2020 while Doctors Without Borders has already started clinical trials in Uganda to receive support from African health leaders. 

#5: Samoa’s Measles Outbreak: Ill-prepared Vaccines 

The island nation of Samoa announced in December 2019 that 53 individuals, 48 being children under the age of five, have died due to large measles outbreak. In total, approximately 4000 measles cases have been reported in a population of 200,000. Throughout the country, public gatherings have been banned and schools/universities has been closed. Although experts believe the myth of autism being caused by vaccines have led to decreased vaccination rates (31% among young children), there may be a more significant reason for distrust in vaccinations. In July 2018, two nurses in Samoa mistakenly reconstituted the Measles, Mumps, Rubella (MMR) vaccine with a muscle relaxer instead of distilled water. This led to two infant deaths, five years in prison for the nurses, and a plethora of misinformation spread to the island’s inhabitations. This Samoan outbreak reflects a trend across the globe with a quadrupled amount of measles cases in the first three months of 2019 compared to the same time frame in 2018. 

A Promising Outlook: 2020

Despite these biomedical obstructions to a healthier global society in 2019, 2020 promises great advancements in the way humanity’s well-being is cared for. With the perspectives gained from this past year, the following health innovations are due to be initiated to achieve equitable healthcare for all: 

  • A novel class of migraine medications, oral calcitonin gene-related peptide receptor antagonists, is due to have its first agent approved in 2020. Ubrogepant, manufactured by Allergan, will offer an effective therapy for those who cannot tolerate the current gold standard migraine agents – triptans. 
  • The future of the fight against HIV will be equipped with a once-monthly injection of antiretroviral therapy in 2020. The combination therapy of cabotegravir/rilpivirine (Cabenuva) produced by ViiV Healthcare has shown to be as effective as current once daily therapy options. 
  • The eradication of malaria will discover if a vaccine candidate could add to its arsenal of biomedical interventions. Sanaria has developed the PfSPZ vaccine, and will conduct phase three clinical trials in Bioko, Equatorial Guinea in 2020. This new candidate has, thus far, shown to have a more protective effect (48.3%) than the currently approved RTS,S vaccine. 

Sustainable health through social enterprise

After five years of working towards the Sustainable Development Goals (SDGs) the global health community still has a long way to go to achieve health related goals by 2030. To improve health and well-being for all global health organizations need to reflect on the successes and challenges to date, as well as reflect on how to make programs more sustainable. One way to create and maintain sustainable health programs is through the social enterprise model.

Social enterprises are for-profit organizations that utilize business practices and the marketplace to advance social justice and development. To be defined as a social enterprise a program must address a social need, generate income mainly through commercial activities and primarily focus on the common good. Types of social enterprises include: one, opportunity employment – organizations that provide jobs to those with barriers to mainstream employment (i.e. Goodwill); two, transformative products or services – creating social or environmental impact through innovative products or services (i.e., World Bicycle Relief, Grameen Bank); and three, donate back – organizations that donate a portion of profits or goods to meet social needs (i.e. TOMS).

Global Health and Social Enterprise

There are several examples of successful global health social enterprises that can be leveraged to create new, or modify existing, programs. In some low-income countries the social enterprise model has been used to strengthen and empower the nurse and midwife workforce. In other examples, Unite for Sight, a non-profit organization working to deliver eye care to low-income countries, partners with clinics all over the world and engages with social entrepreneurs to increase patient access to vision care; and Dispensary of Hope, utilizes the donate back social enterprise model to provide free medications from pharmaceutical companies to health clinics all over the world.

Another successful social enterprise working to solve a global health problem is Days for Girls International. While on a trip to Kenya in 2008 founder Celeste Mergens discovered girls having their periods were sent to their rooms for days, sometimes going without food, and were forced to sit on cardboard until they stopped menstruating. Days for Girls set out to address this issue by designing a washable, long-lasting pad since many of the women and girls without access to menstruation products also lack access to sanitation and safe disposal of pads. 

To date Days for Girls has reached over 1 million women and girls in 125 countries with their Days for Girls Kits (DfG Kits). The Days for Girls Social Enterprise Program trains local women to produce and sell DfG Kits, as well as provide women with menstrual health education. According to the Days for Girls 2018 report, 81% of participants in the social enterprise program reported earning an income, and overall the program has created jobs and increased women’s confidence and ability to become business leaders in their communities.  

Untapped potential

 In the development world terms such as social enterprise and social entrepreneurship are often used, but not often defined. Social enterprises are businesses which maximize social good and financial return, while social entrepreneurship is about creating change agents by investing in the ideas of social entrepreneurs. While the latter is important it is equally, if not more important, for sustainable change in global health to invest in, create and support social enterprises that can provide in-country jobs and economic stability, as well as solve important health problems. 

As we head into 2020 and plan for achieving the SDGs in the next ten years, finding innovative ways to solve global health problems will be critical. Global health organizations need to capitalize on the success of current social enterprises, and partner with in-country social entrepreneurs in order to solve intertwined health and development issues. Creating sustainable change means moving beyond charity and finding ways for low-income countries to prosper; because in a global economy when low income countries thrive – everyone thrives.

 

 

 

 

 

 

 

 

 

 

 

 

 

Global Health and Diabetic Retinopathy-“Protect your vision: Steps for someone with Diabetes”

“Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems, especially the nerves and blood vessels.” -WHO (2018)

The prevalence of Diabetes has increased in low and middle-income countries. Diabetes increases the risk of a range of eye diseases, but the main cause of blindness associated with diabetes is diabetic retinopathy.

According to the World Health Organization (WHO), diabetic retinopathy causes blindness in almost 5 million people worldwide. As the leading cause of vision loss in working-age adults, diabetic eye disease thus represents a significant global socioeconomic and healthcare problem.

What is diabetic retinopathy and what causes it? 

Diabetic retinopathy is an eye condition caused by diabetes. It affects the small blood vessels and light sensitive tissues in the back of the eye (retina). This condition is primarily caused due to high blood sugar levels and if left untreated can lead to vision loss.

Am I at risk for vision problems? 

If you have any type of diabetes you can get diabetic retinopathy. This includes people with type 1, type 2, and gestational diabetes, which is diabetes that occurs during pregnancy. Your risk gets higher the longer you have diabetes. More than 2 in 5 Americans with diabetes have some stage of diabetic retinopathy. The good news is that you can lower your risk by controlling your diabetes!

When should I get an eye exam?

The best diagnostic for diabetic retinopathy is a dilated eye exam.

  • If you have diabetes, get a dilated eye exam once a year
  • If you have diabetes and become pregnant, get a dilated eye exam as soon as possible and ask your doctor if you will need more eye exams during your pregnancy

What can I do to prevent diabetic retinopathy?

Losing your vision to diabetic retinopathy is sometimes permanent, but can be prevented. Studies have shown that the best ways to prevent it are to:

  • Keep your blood sugar level close to normal (this also reduces getting kidney and nerve diseases)
  • Control any elevated blood pressure and cholesterol
  • Exercise regularly
  • Choose healthy foods
  • Follow your doctor’s instructions for taking any medications and ask questions about your health

Is there a treatment for diabetic retinopathy?

Yes. However, treatment for diabetic retinopathy is often delayed as symptoms are unnoticeable until the condition starts to progress, or when Diabetic Macular Edema (DME) occurs. DME is when blood vessels leak fluid into the back of the eye, causing swelling. In this case, eye exams would be needed more often, as it becomes more severe. People with more severe cases may need a dilated eye exam as often as every 2 to 4 months. It is important to know that early detection and treatment can reduce the risk of blindness on a global scale.