HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Thursday, January 27, 2011

Kaplan: The Impact of ObamaCare on Older Americans

Richard L. Kaplan (Illinois) has published Analyzing the Impact of the New Health Care Reform Legislation on Older Americans, 18 Elder L.J. 213 (2011).

Here is the abstract:

Rkaplan This Article analyzes the impact on older Americans of the major changes enacted in the Patient Protection and Affordable Care Act. It begins with Medicare’s treatment of prescription medications, explaining the origin of the coverage gap known colloquially as the "doughnut hole" and then examining how this gap will be filled over the coming decade. It also considers changes affecting employer-provided drug plans for retirees and the new income-based surcharges on higher-income enrollees. The Article next analyzes long-term care, addressing first the new voluntary entitlement program known as Community Living Assistance Services and Supports (CLASS) and then the newly mandated disclosures regarding nursing homes. It then considers the expansion of Medicare’s preventative services and the changes to Medicare’s managed care program. Finally, the Article addresses early retirees who are not yet age-eligible for Medicare.

January 27, 2011 | Permalink | Comments (0) | TrackBack (0)

Rates for Elective C-Sections Soar In Some Areas Ignoring Best Practices and Creating Surgical Signatures

A new study reports that the rates of elective c-section surgeries for no valid medical reason have soared to upwards of 40% in some hospitals in some areas, ignoring the risks associated with this choice to the mother and baby. According to the WSJ,

[s]ome 773 hospitals voluntarily provided the group with information on early elective deliveries. Rates varied widely, even within a single community — rates in Boston ranged from almost zero to 27%, Leapfrog says. (The group’s target rate this year is 5%, down from 12% last year.)

This pattern of early elective C-sections performed for no medical reason creates 'surgical signatures' indicating that the probability that a pregnant woman will undergo labor in the normal course or will have a C-section is not related to medical need but is related to geographic location or hospital choice.

These stats come courtesy of the Leapfrog Group — a coalition of health-benefit purchasers aiming to improve health-care safety, quality and affordability — which today put out a new report calling on expectant moms to request the rates of early elective delivery from hospitals in their area.

The group, along with Childbirth Connection (a not-for-profit focused on maternity-care quality) and the March of Dimes is trying to educate women about the importance of those last few weeks of pregnancy for the baby’s development, and about the risks to both moms and babies if delivery is induced or scheduled early without a valid medical reason. Those might include a mother developing hypertension or her water breaking without labor beginning. Here’s Childbirth Connection’s review of the evidence on labor induction.

Leapfrog says early elective deliveries cost the U.S. health-care system almost $1 billion a year.

“Some of these data will be quite disturbing,” said Leah Binder, Leapfrog’s CEO, on a phone call with reporters. “The hospitals that reported have at least committed themselves to transparency.” Many hospitals declined to report data.

As we wrote a while back, Utah’s Intermountain Health tapped its electronic medical records to show its physicians data on the health consequences of early elective deliveries, including higher rates of intensive care and ventilator use. Intermountain also developed guidelines to discourage early elective deliveries and tracked cases that didn’t adhere to the guidelines.

Within six months of starting the program, the rate of elective early delivery fell to less than 10% from 28%, and after six years “continues to be less than 3%,” according to a study published in 2009.

Maternity-care bonus: Will New Guidelines Let More Women Try Labor After a C-Section?

January 27, 2011 | Permalink | Comments (0) | TrackBack (0)

Tuesday, January 25, 2011

Global progress on clean water and sanitation

Improving access to safe drinking water and good sanitation is an international priority, and progress is unfolding due to cooperation sparked by the sustainable development movement.

In September 2000 United Nations Millennium Declaration was approved, committing signatories a new global partnership to reduce extreme poverty and setting out eight goals to be achieved by the year 2015. Known as the Millennium Development Goals, they range from achieving universal primary education to combating diseases like HIV/AIDS and malaria.

Millennium Goal #7 commits countries to “ensure environmental sustainability.” One of the major targets within this goal is to reduce by half “the proportion of people without sustainable access to safe drinking water and basic sanitation” by the year 2015. In the past, economic development often relied on resource depleting or polluting industries to expand economies and create jobs in developing countries. The result was often more income for workers, but declines in health and standards of living due to water pollution, poor sanitation and other environmental problems. Millennium Goal #7 was designed to change this trend, redirecting countries to economic development that is sustainable, and focuses more communities' quality of life.

With less than five years to go until the 2015 deadline, how far has the international community come in achieving the clean water goals of Goal #7?

According the U.N. Development Programme (UNDP), the agency charged with monitoring the progress on the goals, several countries have made major strides, due to commitment from their governments as part of millennium goal strategies, and grants made through funding sources like the World Bank’s Global Environmental Facility (GEF). Examples are numerous, as shown in a UNDP monitoring map: from 2000 to 2006, the proportion of the population with access to clean water increased from 93% to 97% in Turkey, 44% to 51% in Angola, 79% to 84% in El Salvador, 68% to 72% in Mongolia. In other places the improvements are minor; in Afghanistan this access increased from 21% to 22%, and in the Congo from 45% to 46%. Obviously, these values do not approach the “increase by 50%” goal, but clearly progress is occurring.

Today, partnerships and projects are focusing on rapidly developing countries. On January 11, the World Bank and the government of India announced its “green growth” strategy, which includes projects to make water supply and wastewater systems more efficient. On April 13, 2011, India will host a major international water conference. China, whose urban population is expected to grow by 350 million in the next 20 years, is working with the U.N. and has committed to a low-carbon, sustainable urban growth plan. On January 19, the World Trade Organization (WTO) met to discuss a WTO agreement that would include tariff reductions on waste management and water treatment products. Essentially, the strategies emerged from United Nations Conference on Environment and Development in 1992 where an “integrated water resources management (IWRM) framework” was highlighted based on the perception of water as an integral part of the ecosystem, a natural resource and a social and economic good. It was stressed that priority has to be given to the satisfying basic needs and safeguarding ecosystems. Subsequently, at the 2002 World Summit for Sustainable Development countries pledged to develop IWRM and water efficiency plans. These provide a backbone for new policies.

The improvements and initiatives demonstrate that the world can make progress when nations cooperate. Certainly, challenges continue. For example, on January 13, the IUCN issued a report on Eastern Himalaya freshwater systems, indicating that development of water resources in the region is expanding at a rapid rate, and ecosystems and communities are at risk. The Millennium Goal implementation provides one way to identify and take real steps to address these problems.

The United Nations is keeping this issue on the public agenda through by declaring the years 2005 - 2015 as the "Water for Life" decade. Information on the latest publications on water and sanitation from the UN agencies and programmes is available here.  On January 18, in a press release, the new President of the UN Economic and Social Council (ECOSOC) announced that one of his priorities would be accelerating the review, coordination and implementation of the Millennium Development Goals (MDGs). This is good news, because it helps keep world focused on these goals.

Posted by Mary Munson


January 25, 2011 | Permalink | Comments (0) | TrackBack (0)

Sunday, January 23, 2011

Why Don't Beer, Wine and Alcohol Have Nutrition Fact Labels?

A flurry of articles published this week highlighting a long-time movement to mandate nutrition labeling on alcohol (hat tip to Doug Ray) raises the question, 'why don't beer, wine and alcohol have nutrition fact labels?' This question appears to be particularly germane in light of alcohol's high liquid calorie count and the current obesity crisis.

A look back through history may help to answer this question. After the end of prohibition, the period from 1920 to 1933 when alcohol could not be made, transported or sold in the United States, Congress passed the Federal Alcohol Administration Act of 1935 which is still in force. Instead of delegating the regulation of alcohol to the Food & Drug Administration, which regulates most consumer food and beverages and requires nutrition labeling, Congress recognized the tax potential of alcoholic beverages and assigned to the Treasury's Alcohol and Tobacco Tax and Trade Bureau (TTB) the role of regulating alcohol, including its labels. As Marion Nestle over at SFGate points out, adding the TTB to the regulatory mix means that, "as absurd as it may seem, the labeling rules differ for wine, beer and distilled spirits:"

- Substances to which people might be sensitive, such as sulfites and yellow No. 5, must be labeled.

- Labels of distilled spirits must state percent alcohol. They may list calories (but usually don't). Wine label rules depend on percent alcohol.

- Wines from 7 to 14 percent must list alcohol and may list calories (but don't).

-  Wines with less than 7 percent alcohol are regulated by the Food and Drug Administration, not TTB. They must display Nutrition Facts labels with calories, nutrients and actual ingredients. They may disclose percent alcohol, and some do.

However, this all may be changing. According to the blog Food in America

[m]ost notably, the provision in the Obama health care reform law that will require menu nutrition labeling at chain restaurants will also include alcoholic beverages. Baylen Linnekin at Crispy on the Outside reports that by March 2011 the FDA will issue proposed regulations requiring chain restaurants to disclose on nutrition information about menu items including alcoholic beverages. The required info will include total calories, fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, fiber and total protein.

Beer label Another recent development with implications for alcohol nutrition labeling was the Alcohol and Tobacco Tax and Trade Bureau’s (TTB’s) determination in July 2008 that certain products commonly referred to as beer but produced without malted barley (e.g. beers made from sorghum, rice or wheat) do not qualify as malt beverages under the TTB’s enabling statute, and thus are not subject to TTB regulation. Per the terms of a memorandum of understanding between TTB and FDA, that means these products are instead subject to regulation by the FDA. What does that mean? Well, according to the FDA’s November 2010 guidance on the topic, that means these beers will be subject to the labeling requirements under the Federal Food, Drug, and Cosmetic Act (FFDCA) and the Fair Packaging and Labeling Act (FPLA). The specific guidelines are spelled out in the guidance document, but in brief the beers will be required to have nutrition facts and ingredients labels like those you already see on most hard cider. 


These recent developments may be a signal that the TTB will finally be taking action on its Notice of Proposed Rule 73, published back in 2007, which proposes amending labeling regulations to require on all alcohol beverage labels (1) a statement of alcohol content expressed as a percentage of alcohol by volume, and (2) a Serving Facts panel including a statement of calories, carbohydrates, fat and protein. The example in PR 73 is as follows:   

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The five previous attempts at similar rule making, in 1974, 1979, 1980, 1985, 2005, were all unsuccessful. One of the dubious grounds for these failures was an argument by industry that putting a "nutrition" label on alcohol would deceive consumers into believing that alcohol is part of a nutritious diet. It is hoped that this type of paternalistic argument, that keeping calorie information from consumers is somehow in their best interest, will no longer be seen as persuasive, especially in light of the current obesity crisis.

January 23, 2011 | Permalink | Comments (0) | TrackBack (0)