HealthLawProf Blog

In Defense of Vaccines

Pandagon's Amanda Marcotte supports vaccines and has a spirited defense of them.  She writes,

Anti-vaccination cranks make me see red, in no small part because there’s no excuse for the levels of ignorance they demonstrate about the real value of vaccines. It would be more understandable if the invention of the polio vaccination, for instance, was so far in the past that there were no survivors of the disease hanging around being reminders of how terrible it really is. But there are plenty of people who had the disease that are around, suffering the lifelong effects of even the minor cases that would have allowed you to reach middle age after suffering that disease in your youth. I for one am incredibly grateful to have never known anyone with small pox, tetanus or even the . . . mumps my whole life. . . . .

Maybe what bothers me the most is that the opposition to vaccinations tends to play into this knee-jerk Luddite mentality. Not that I don’t think new technologies shouldn’t be carefully examined to see if they do more good than harm, and that things that prove to be problems like cars should be seriously reconsidered. But a lot of people don’t want to do the hard work of taking each new technology and its issues and problems on for itself, and instead just want this general “new is bad/old ways were better” rule that they can apply indiscriminately. . . .  Anti-vaccination crankery doesn’t make much sense outside of this knee-jerk hostility to innovation and science.

The irony here is that scientists really aren’t trying to conquer the imperfect body at all. Vaccination technology actually makes more sense if you realize it came from a place of great respect for the the complexity of life, and the careful study of defenses that had evolved in the body. Which is why I love vaccinations. They work with the pre-existing environment. The real wow factor is that the body responds so well and so predictably to the vaccination. In one sense, it’s a bit alarming that I extended my arm the other day to be shot up with a syringe-full of dead bacteria that would, if alive, kill me pretty . . . dead, but it was no big deal at all, because I trusted my body’s immune system to kick into action and do its job. So who’s the one that’s really trusting nature to do what it does best?

Oregon's Autism Cases

Reuters's Maggie Fox reports on the autism cases argued in federal court in Oregon.  She writes,

The parents of two 10-year-old boys who believe vaccines caused their sons to develop autism brought their case to U.S. federal court on Monday, arguing a mercury preservative in the shots caused a rare reaction.  Their case is the second of three being heard by a special court trying to determine if autism might sometimes be caused by vaccines. Although most medical experts say there is no link, the court can rule there is a plausible association and allow parents of children with autism to get federal compensation from a special vaccine fund. . .

"The debate is over. There is no controversy," government attorney Lynn Ricciardella retorted in her opening arguments.  "The credible scientific community has already spoken on this issue and has rejected it."  Some autism activists have seized on the case of Hannah Poling, a girl from Georgia who won a case claiming a vaccine caused autism-like complications from a rare disorder.  The activists say it proves the federal courts gave in on the argument, but the government says Poling's case, which was removed from the special process and heard separately, was an exception and cannot be used as a precedent.

The court is hearing three different theories on how vaccines might cause autism. One is that a combination vaccine for measles, mumps and rubella, or MMR, plus a mercury-containing preservative called thimerosal, can cause autism. The court heard those arguments last year and has not ruled.  On Monday, the court began hearing arguments that thimerosal in various vaccines might have caused autism in William Mead and Jordan King, both 10 and both from Portland, Oregon.

INTERACTION WITH GENES

"What we will conclude ... is that thimerosal-containing vaccines belong on the list of environmental factors ... when one is evaluating what might have caused autism in a child when all of the other theories have been ruled out," attorney Tom Powers told the court in opening arguments.  He said the boys had conditions that made them especially vulnerable to the mercury in thimerosal.  "The evidence is indirect and it is circumstantial but it is supportive of the general theory of causation," he said.  No one knows what causes autism, which can severely disable a child with symptoms ranging from severe social avoidance to repetitive behaviors and sometimes profound mental retardation.  The U.S. Centers for Disease Control and Prevention estimates that about one in every 150 children has autism or a related disorder such as Asperger's syndrome.

Doctors agree there is a genetic link, and probably that something in the environment, possibly even conditions in the womb, can cause the brain effects that lead to symptoms.  While many studies have shown the thimerosal in vaccines has not caused autism, a vocal group argues the government and other experts are ignoring or covering up the evidence. Thimerosal has now been removed from most childhood vaccines. . . .

Oral Cancer and HPV: Gardasil for Boys?

The New York Times reports today on a study concerning a link between oral cancers and human papillomavirus.  Nicholas Bakar writes,

The sexually transmitted virus called HPV, for human papillomavirus, is well known to lead to cervical cancer in women — which is why the federal government recommends that all girls be vaccinated for HPV at 11 or 12, before they become sexually active.  Now researchers are finding that many oral cancers in men are also associated with the virus.

A clinical trial testing therapies for advanced tongue and tonsil cancers has found that more than 40 percent of the tumors in men were infected with HPV. If there is good news in the finding, it is that these HPV-associated tumors were among the most responsive to treatment.  Of an estimated 28,900 cases of oral cancer a year, 18,550 are in men.

“The high risk of HPV-associated cancers in men suggests that vaccinating all adolescents is something that should strongly be considered,” said the lead researcher, Dr. Francis P. Worden, a clinical assistant professor of medicine at the University of Michigan.

HPV can enter the mouth during oral sex. A study published in February by researchers at Johns Hopkins estimated that 38 percent of oral squamous-cell cancers are HPV related, and suggested that their increasing number might be a result of changing sexual behaviors.

The new study, published in two papers in The Journal of Clinical Oncology, included 51 men and 15 women with cancers of the tonsils or the base of tongue. The researchers were able to examine biopsies of 42 of the subjects before treatment. After tests for HPV, the researchers found that 27 tumors, nearly two-thirds, were positive for the virus. Of the 51 men, researchers found 22 with HPV. . . .

“Clearly,” Dr. Gillison added, “it should give people optimism that the vaccine that was approved largely for women and for cervical cancer could have broader implications, and also for other cancers that occur in both men and women. All of our clinical trials now will be designed for either HPV-positive or HPV-negative patients. Right now, these patients are treated the same way.” . . .

“Patients who have HPV infections are at higher risk for these cancers,” Dr. Worden said. “But the good news is that if that’s the cause of their cancer, they’re more likely to survive treatment. We still don’t know what the ideal treatment regimens are. For example, these patients may benefit from less intense chemotherapy and radiation.”  Although the researchers acknowledge that the number of patients in their study was small, they conclude that especially in patients with HPV-positive tumors, chemotherapy followed by combined chemotherapy and radiation appears to be an effective treatment.

An author of the papers has an interest in a company that is developing an HPV detection method.

I wonder how people will respond to recommendations or mandates for boys to be prescribed Gardasil.

Detained Immigrant Health Care

The Diane Rehm Show focuses on the health care, or lack of it, provided to detained immigrants in the United States.  The overview of the show states,

The number of immigrants detained in the United States each year has tripled since the September eleventh attacks, but medical spending has not kept pace. A Washington Post investigation raises questions about dozens of deaths and the treatment of sick immigrants in custody.

Guests

Dana Priest, investigative reporter for "The Washington Post" and author of "The Mission: Waging War and Keeping Peace with America's Military"

Amy Goldstein, national social policy reporter for "The Washington Post"

Gary Mead, acting director of detention and removal operations for U.S. Immigration and Customs Enforcement.

Tom Jawetz, immigration detention staff attorney at the American Civil Liberties Union's National Prison Project

Employee Health Incentive Plans and Cheating

The Chicago Tribune has been following the recent development of monitoring employee incentive plans and punishing those employees who cheat.  The Tribune's Barbara Rose reports on the troubles at Whirlpool and writes,

Whirlpool Corp.'s suspension of 39 production workers at an Indiana plant who were seen smoking after declaring themselves eligible for a $500 annual tobacco-free insurance discount may signal the end of the honor system that rules most corporate wellness programs, experts said Tuesday. The action also underscores the difficulty of enforcing so-called voluntary programs when fines or incentives grow big enough to encourage cheating and snitching, they said.

"Employers have been using the honor system ever since wellness programs started, and you have to be a little naive to think that people are going to admit they smoke when they know they're going to be penalized," said Lewis Maltby, president of the non-profit National Workrights Institute in Princeton, N.J. "Sooner or later, employers are bound to start checking up. This may be the beginning of the trend."

The workers were suspended after they continued to smoke in designated locations outside the Evansville plant despite enrolling for health insurance in October as non-smokers, 
avoiding the penalty.  The company routinely asks employees to confirm their status as a tobacco user or a non-tobacco user as part of the annual benefits-enrollment process," Whirlpool said in a statement. The company added that it "investigates" employees when there appears to be a discrepancy in their enrollment status and their behavior.

"Falsifying company documents is a serious offense," Whirlpool said. "Those found to have done so are subject to disciplinary action, which could include suspension and termination."
The statement added, "The investigation into this situation is ongoing. Out of respect for the process and Whirlpool employees, the company has no further comment at this time." . . .

Get-tough regimes raise a host of legal as well as ethical issues. Employers are allowed to offer incentives or fines as part of voluntary wellness programs as long as the amount is not more than 20 percent of employees' total cost of insurance, according to federal guidelines that went into effect in January for calendar-year plans. . . .   "This is the first instance I've seen where people said they didn't smoke so they wouldn't get hit with the penalty and then got caught and punished," Maltby said. "My sense is, most employers are still using the honor system" and not checking up. . . .

But, he added, "employers didn't set up the penalty just for the fun of it. They set up penalties because they intend to enforce it. This is a very heavy-handed way to help people get healthy and cut medical costs."  Maltby questions the net savings of having smokers pay more, after employers factor in the cost of enforcement and hidden costs such as the impact on morale.  Jerry Filipiak, a senior vice president in Chicago at consulting firm Hays Benefits, said the Whirlpool action underscores the pressure employers face to control health expenses.  "To me it's a sign of how serious health-care costs are to an employer," he said. . . .

Reporter Barbara Rose further writes about the use of smoking policies in general -Smoking is a lightning rod for controversy, as is the question of whether workers who smoke should have to pay more for their health insurance.

It's no wonder then that Whirlpool Corp. made headlines last week for suspending 39 workers who were seen smoking outside their Evansville, Ind., factory despite enrolling for insurance as non-smokers.  Whirlpool's smokers pay $500 a year more for their employer-provided health insurance—a penalty big enough to increase the likelihood of cheating—but how would the company find out? Internet message boards buzzed last week with speculation about spy cameras and company snitches.   

But truth sometimes is stranger than fiction. It wasn't management surveillance or finger-pointing co-workers that outed the smokers. It was the employees themselves.  A little history is in order.

The workers' union challenged the smoker fees in 2006, citing a state law, and an arbiter ruled the company had to pay back the surcharges collected during a 28-month period through June 2006. The amount was expected to be about $1,000 per employee, according to the Evansville Courier & Press.  Last month, Whirlpool's suit to overturn the ruling was dismissed in a sealed settlement, setting the stage for rebates.  The suspended workers drew attention to their smoking when they asked for the rebates, prompting the company to check to see whether they had paid the fees. Apparently they hadn't.

Whirlpool declined to comment about what happened. Last week's statement confirming the suspensions said "falsifying company documents is a serious offense" punishable by suspension or termination. Workers are represented by Local 808 of the International Union of Electronic, Electrical, Salaried, Machine and Furniture Workers-Communication Workers of America, but the union also declined to comment. . . .

Nobody anticipated the trouble that would ensue from the union's 2007 grievance over the fees. The sheer number of employees suspended last week was unusual. Managers were forced to call back laid-off workers to keep the plant running.  . . .

Some no doubt will say the workers deserve to be punished if they lied on their enrollment forms. I'm tempted to say that companies ought not to ask questions about employees' health-related habits in the first place. Don't ask, don't tell.  On the other hand, I know that some companies help workers lead longer, healthier and more productive lives by offering programs that include questions about smoking and rewards for those who don't. The best of the corporate wellness programs that have been around for more than a decade include incentives for healthy behaviors. . .

The pendulum may be swinging toward the notion that employees who smoke ought to pay more for employer-provided insurance because their health-care costs are higher. Still, a minority of companies have adopted the practice.  A survey by consulting firm Mercer found that only 5 percent of employers with 500 or more workers varied health-care premiums based on smoker status in 2007. Among large employers, those with 20,000 or more employees, the number was 16 percent.  Charging smokers more inevitably raises issues of testing and enforcement. Most companies rely on the honor system. At Whirlpool's Evansville plant, that system seems to have failed.

Health of U.S. Hospitals

Firedoglake posts an interesting piece on the state of our nation's hospitals and it isn't pretty.   hospitals.  Isaiah Poole writes,

What I don't get is how all of McCain's free-market fundamentalism on health care is supposed to help make sure my neighborhood hospital is up and running when I need it.

McCain didn't address the health of our nation's hospitals when he rolled out his health care plan last week. Perhaps that's because the issues are complex and many of the proposed solutions don't fit neatly into ideological lines. Perhaps it's because if he started delving into our health care infrastructure, he'd have to admit that the conservative mantra that we have "the best health care system in the world" is false.

A report this week by the House Government Reform and Oversight Committee looked at just one consequence of the dysfunction in our health care delivery system.

Committee staff members surveyed hospital emergency rooms in seven major cities on one Tuesday afternoon to get a snapshot of emergency room capacity, with the goal of determining if emergency rooms in these cities were capable of handling a disaster of the scale of the March 2004 terrorist train bombing in Madrid, Spain. In that attack, 15 Madrid hospitals handled a surge of nearly 1,000 injured people.

The bottom line:

The results of the survey show that none of the hospitals surveyed in the seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid. The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, D.C.

Almost 60 percent of the hospital emergency rooms surveyed were operating above capacity at the time of the survey. The closest hospital to my home, Washington Hospital Center, happened to be "the single most overcrowded hospital surveyed." Its emergency room was already operating at 286 percent of capacity at the time of the survey.

In essence, this survey doesn't tell us anything that especially those of us who live in big cities don't already know: Our hospital system is badly strained on a calm day. And if that's the case, God help us if any sort of major disaster hits. . . .

Elizabeth Edwards on Lack of Health Insurance in America

Thinkprogress has a great story on Elizabeth Edwards and her continued attempt to educate everyone about the need for health reform and greater access to health care for all Americans.   The story includes testimony from her recent appearance before the Senate Health Committee and states the following,

. . . Center for American Progress Senior Fellow Elizabeth Edwards told the Senate Health Committee today, “It doesn’t matter what kind of services we have if we don’t have access to them”:

Health insurance matters. The quality of coverage, of course, matters, but health insurance itself is really crucial part of this. Probably the most preventable cause of unnecessary suffering in our health care system is the lack of adequate health insurance. … We know how to lengthen and improve the lives of people with cancer. But we’ve chosen as a nation to turn our backs on some of us who have the disease. I urge you to reform health care responsibly, morally, and aggressively. . . .

Edwards also mentioned the disturbing disparities in access faced by minorities. FamiliesUSA writes, “Although racial and ethnic minorities constitute one third of the total U.S. population, they comprise more than one half (52 percent) of the uninsured population. In fact, in 2003, 23 million of the 45 million uninsured were racial and ethnic minority Americans.” Rather than cover these people, McCain’s plan could result in 158 million more Americans losing their health insurance.

 

Politics of Health Reform

Ezra Klein has a great piece entitled, "The Elusive Politics of Reform," and writes about the various options to reform our health care system.  He starts with a brief statement on why the United States should be focused on reforming health care and then describes the plans currently set forth.  He writes,

If health insurance were cheap, we could all buy it. If universal health care could get 60 votes in the Senate, we'd all have it. But these two imperatives -- the need to control costs and the need to attract the 60 Senate votes required to overcome a filibuster -- point in opposite directions. This is the central paradox of health reform.

The most intractable policy problem is not, fundamentally, the 47 million uninsured or the fact that insurers have a business model right out of Dickens. It's cost. In 2006, the average family policy cost $13,600. This is why one out of six Americans are uninsured; they can't afford the premiums. An October 2007 Kaiser Family Foundation poll found that more Americans were "very worried" about being priced out of their health insurance than feared losing their job, their house, or being in a terrorist attack. And with good reason: Premiums have gone up 98 percent since 2000. Wages have not.

Corporate America's outlook is similarly grim. Better Health Care Together, a health-reform coalition that includes Intel, Wal-Mart, and General Mills, recently issued a report, Health-Cost Crossroad: Why American Businesses Urgently Need Health Care Reform. The paper warns that "health care cost growth threatens businesses, workers, and the overall health of the American economy," and frets that "if trends continue, health benefit costs will exceed profits in Fortune 500 companies in 2008."

Likewise government. Absent reform, government health spending would be 37 percent of gross domestic product by 2050. (The entire federal government now consumes about 20 percent of GDP.) David Walker, the U.S comptroller general, warns that "we have been diagnosed with fiscal cancer, and we need to start treating it." At the Congressional Budget Office, the normally staid Peter Orszag gives an Al Gore-esque slideshow on the looming threat of health costs that risk bankrupting government finances.

The question, then, is how to limit heath-care costs while still surviving the legislative process. A single-payer system would increase efficiencies, but critics fear that it would control costs excessively, limiting care. Politically, single-payer would mean restructuring about 17 percent of our economy and eliminating multibillion-dollar industries that provide tens of thousands of jobs. It would have to be legislated over the fierce objections of the Republican Party and all conservative Democrats. Conversely, many Republicans, John McCain included, advocate a radical shift of costs onto individuals, controlling spending by pricing care out of reach for tens of millions. Few Democrats or moderate Republicans -- or voters -- favor this course. . . .

Who Uses the ER?

The New York Times reports today on a study showing that the overcrowding that occurs in emergency rooms does not result from an increasing number of insured patients.   

It is often said that emergency rooms are crowded because of the disproportionate number of uninsured people using them. But data based on telephone surveys and in-person interviews, published on April 14 in The Annals of Emergency Medicine, tell a different story. The number of uninsured people nationwide rose to 15.7 percent in 2004 from 15.4 percent in 1995. Yet in that period, the proportion of uninsured people using emergency rooms declined.

The 26 percent increase in the number of visits in the period was largely caused by an increase in the number of people with private doctors who sought emergency room care. The authors suggest several reasons, among them an aging population, a growing number of time-sensitive medical treatments that can be performed only in an E.R., complications from medical and surgical treatments and the difficulty of obtaining a timely appointment with a private physician. . . .

McCain's Rhetoric on Health Care

The New York Times reports and critiques on McCain's discussion of the two Democratic presidential candidates. MIchael Cooper and Julie Bosman write,

Senator John McCain has been repeatedly suggesting that his Democratic rivals are proposing a single-payer, or even a nationalized health care system along the lines of those in countries like Canada and Britain.  The suggestion is incorrect. While both Senator Barack Obama of Illinois and Senator Hillary Rodham Clinton of New York are calling for universal health care and an expanded role for government, they stop well short of calling for a single-payer plan.

Mr. McCain has made the assertion several times in recent days, even as he and the Republicans have made repeated calls for accuracy on the campaign trail. They have been complaining indignantly that the Democrats were grossly distorting his position by suggesting that he favors a “100-year war” in Iraq, when he has simply said that he would be fine with stationing troops there for 100 years as long as there were no more American casualties.

Yet on repeated occasions, Mr. McCain, of Arizona, has inaccurately described the Democrats’ health care proposals, using language that evokes the specter of socialized medicine . . . .

“But before you decide to sign on to that kind of a program, go to Canada, or go to European countries that have government-run health care systems,” he continued. “My friends, they don’t work, they’re inefficient, and they end up in a two-tiered system where the wealthiest can afford to pay for their own health care and those with low income sometimes wait six or eight months for a routine kind of treatment. And that’s what I’m not going to let happen to the United States of America.” . . .

Language, of course, is a potent weapon in the battle to shape policy. And Mr. McCain’s effort to cast the Democrats’ plans as a government takeover is just the latest example in a long tradition of using similar language to characterize proposals to change the health care system, said Robert J. Blendon, a professor of health policy and political analysis at Harvard.

“In the campaign, what Senator McCain tries to appeal to is a general antigovernment feeling, a sense that we shouldn’t be doing things too big,” Professor Blendon said. “In a sense he’s appealing to a value that may or may not relate to the policies being discussed by either of the candidates.”

The only Democratic presidential candidate to propose a true single-payer, Medicare-for-all type of health plan in this election cycle was Representative Dennis J. Kucinich of Ohio. Mr. Obama’s and Mrs. Clinton’s plans do not call for a single-payer system like Canadians have, or a government-run national health system like the British have.  Both candidates have called for universal health coverage, with Mrs. Clinton saying she would require everyone to have insurance and Mr. Obama saying he would mandate coverage for children. Both would maintain the existing private insurance system, providing government subsidies or tax credits to help the low-income uninsured afford premiums. And they would give consumers a new option to buy insurance from the federal government, with policies along the lines of Medicare. . . . 

Mr. Bounds said that Mr. McCain’s characterization of the Democrats’ plans was completely reasonable. “While their proposals may not outline one to the finite extent, they clearly suggest that the movement toward a single-payer system is in their overall interests,” he said.

Democrats and Republicans view health care differently, polls suggest. Surveys have found that the most significant health concern voiced by Democrats is expanding coverage for the uninsured, while Republicans and independents are more focused on bringing down health care’s cost.

Even the phrase “socialized medicine” means different things to members of each party. A telephone survey conducted earlier this year by the Harvard School of Public Health and Harris Interactive found that 70 percent of Republicans thought that “socialized medicine” would be worse than the current system, while 70 percent of Democrats thought that it would be better.