We’re all in this together! … or are we?

Implementing reform of the Affordable Care Act has been a major point of interest in the media recently.  There have some discrepancies between the different enrollment systems.  Implementation on state level through state based exchanges has been going well since the opening on Oct 1.  However at the federal level there have been many different issues with implementing the new reform and enrollment processes.  At the state level there is better outreach, better functioning of the websites, more accessibility, and more direct help for coverage sign up.  For example in Connecticut (my home state woohoo!) has had 4,418 enrolled in Connecticut as of a week ago, outpacing other states and the national enrollment.

This does not fair well for those living in states that have not opened exchanges.  Altogether, 106,000 people have enrolled in health coverage nationwide last month, a figure far below administration projections.[1]

Check out CT’s user friendly site! http://learn.accesshealthct.com/events/

Obamacare-healthcare-exchange-website-please-wait-AFP<— The dreaded healthcare.gov!

What does this mean for the US? Although the Affordable Care Act is a federal program and reform for the whole country, there are many pitfalls to this system including the fragmentation of having state by state exchanges.  It is still early in the reform implementation process to fully see how this all will unfold. However looking to other countries that have implemented reform successfully can be somewhat of an indicator.  Health insurance design has a major impact on access, cost and the health of a country.  Countries such as the UK and Canada which have no cost sharing have high rates of equitable access to care throughout the country no matter age or income level.  Due to cost sharing the burden of cost is reduced and creates more access for low income patients to seek care without worry of the cost.  With no limits on deductibles and complex insurance systems, the US has very low accessibility and high costs.  The US is a unique country in that it creates disparities through both Medicare and Medicaid and poses a major challenge for equity promotion in the country.[2]  This inequality is further exacerbated through the decision to implement state by state exchanges.  There needs to be action at the state and federal level to better implement the reforms so that all Americans can gain the access they need to health care.  The country is still at the inauguration of implementing the reform here in the US, hopefully the federal enrollment system will be able to distribute access to health care in a more equitable manner than we are currently seeing (for optimism sake!).

For more information and to follow the implementation timeline of the ACA check out http://kff.org/interactive/implementation-timeline/

[1] Levey, N. (2013) Healthcare plan enrollment surges in some states after rocky rollout.

[2] Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson and Sandra Applebaum
(2010) “How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries” Health Affairs, 29.


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Decentralization to improve health delivery not merely a byproduct of political changes

Decentralizing the health service delivery provides a unique opportunity to improve health performance at the district level. Decentralization approach includes transferring financial, administrative, ownership, and political authorities for alternate institutions in the peripheral. The rationale for transferring such power is; local decision makers have access to better information on local circumstances than central authorities, thus they have all the legitimacy to modify services, operation, spending pattern as it suits to the local needs and preferences.

In the past, various forms of decentralization have been instituted in many developing nations and the results have not always resulted in an improvement of the health of the national population for many reasons. For instant, in Chile and Mexico, when decentralization of the health sector was implemented, municipal authorities were given decision making power with respect to health including employing health professionals. However, the central government retained economic power over the national health budget, thus the local authorities were unable to address health needs of the their people because they were not able to pay salaries of their workers.[1] On the other hand, when China implemented decentralization in the 1980s, the local public health authorities
 were given full control of health services delivery, however the central government decreased the national provided health budget and imposed user fees and taxes on families for health services.[2] In contrast to the above examples, Cameroon and Brazil’s implementation of decentralization proved to be the best models not only in controlling specific disease, but also in improving health services delivery nationally.[3] One of the noticeable benefits of the decentralization approach was enabling of efficient distribution of antiretroviral treatments to control HIV/AIDS. For example, Cameroon provided medical access to 58% of all eligible HIV/AIDS patients; this is one of the highest treatment rates in Africa.[4]  Brazil once had very high prevalence of HIV/ADIS similar to South Africa, however through the decentralization approach, it was able to stabilize the HIV epidemic to levels resembling those of the United States and Western Europe[5]. The secret to their successful implementation of decentralization was attributed the central government that fully decentralized its national health planning, health financing and community participation programs.

The above examples demonstrate how difficult the implementation of decentralization can get and how easily the system can be manipulated to pursue other political aims. When implementing decentralization, additional reforms such as allocation of financial and qualified personnel must be followed. The focus for decentralization is to make the operation of health facilities efficient, thus routine regional supervision of the health facilities and standardization of drugs and treatment plans should continue until the peripheral administrative are fully capable of handling all the tasks. The national government should continue investing on peripheral health systems and not to pursue other political aims with name of decentralization. If decentralization is implemented correctly, the positive outcomes will include equitable resource allocation between urban and rural areas, improved health service delivery in rural areas, and increase in access to essential medicines.

[1] Khan, S.& Willis, K. (2009) Health Reform in Latin America and Africa: decentralization, participation and inequalities. Third World Quarterly, 30 (5), 991-1005.

[2] Blumenthal, D. & Hsiao, W. (2005). Privatization and its Discontents – The Evolving Chinese Health Care system. New England Journal of Medicine, 353(11), 1165- 1170.

[3] Berman, P.A. & Bossert, T.J. (2000). A Decade of Health Sector Reform in Developing Countries: What Have We Learned? DDM Symposium. DPE-5991-1-A-00-1052-00

[4] Loubiere, S., Boyer, S., Protopopescua, C., Bononod, C.R., Abegad, S., Spirea, B. & Moattia, J.(2009). Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers. Health Policy, 92(2/3), 165-173.

[5]  Case in global health delivery (2011) “HIV/AIDS in Brazil delivering Prevention in Decentralization Health System” Harvard Medical School.

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50 Shades of Greyjing: China’s Air Pollution Crisis


            If you’ve read the news the past few weeks, you’ve noticed an increase in articles with phrases such as “face-mask nation,” “air-pocalypse,” and “Greyjing,” the city of Beijing’s not-so-illustrious nickname.  It’s no surprise that China has been facing worsening smog conditions in their urban areas, but public concern is growing. Last month, the city of Harbin was all but shut down after the PM2.5 rating reached an index of 1,000.[1] For reference, levels above 300 are considered dangerous to public health and the WHO advises a daily level not exceeding 20. PM2.5, meaning particulate matter with a 2.5micrometer diameter, is a dangerous particle found in the air that enters the blood stream and lungs. [2]  Harbin was forced to shut down airports, limit bus routes, and close schools due to the dangerous conditions and limited visibility. Sixteen of the twenty most polluted cities in the world are in China, making this air pollution crisis increasingly infamous.[3] All eyes are on China as, amid public outcry, the government finally takes action.

            As the saying goes, one must hit rock bottom before realizing a problem is so bad that it needs drastic treatment. One might say China hit rock bottom last week, when a young Chinese girl was diagnosed with lung cancer at the age of 8, making her the youngest lung cancer patient in China. Her cancer, her doctor confirmed, was due to exposure to PM2.5. [4]  In China, lung cancer is a growing problem as more of the Chinese population die of lung cancer each year than from any other cancer.[5] Over the last 30 years, lung cancer rates have increased by 465 percent, despite no reported increase in Chinese smoking habits.[6]

            With air pollution in China contributing to 1.2 million premature deaths in 2010 and an estimated reduction in life expectancy by 5.5 years in northern China, poor air quality has become a problem that the government can no longer ignore.[7],[8] China has proposed a five-year study to monitor the long-term impact of air pollution on human health.[9] In addition to increased monitoring tactics, the government also plans to spend approximately $817 billion on a plan to cut pollution drastically by 2017.[10] But with air quality reaching crisis states and public opinions growing more and more dissatisfied, will the plan be enough? And what obstacles will the Chinese face as they seek to implement reform?

[1] Blanchard, Ben. Huffington Post. Health Effects of Air Pollution to be Monitored in China as Smog Raises Safety Concerns, Oct. 28th, 2013. <http://www.huffingtonpost.com/2013/10/28/health-effects-of-air-pollution-china_n_4169696.html&gt;

[2] Ibid.

[3] The Week. November 15th, 2013. Pg.9

[4] Duggan, Jennifer. The Guardian. November 7th, 2013. China’s Air Pollution Blamed for 8 Year Old’s Lung Cancer. < http://www.theguardian.com/environment/chinas-choice/2013/nov/07/china-air-pollution-eight-year-old-cancer&gt;

[5] Ibid.

[6] The Week. November 15th, 2013. Pg.9

[7] Ibid.

[8] Blanchard, Ben. Huffington Post. Health Effects of Air Pollution to be Monitored in China as Smog Raises Safety Concerns, Oct. 28th, 2013. <http://www.huffingtonpost.com/2013/10/28/health-effects-of-air-pollution-china_n_4169696.html&gt;

[9] Ibid.

[10] The Week. November 15th, 2013. Pg.9

Photo: Philippe Lopez Getty Images. As seen in Huffington Post, September 3rd, 2013. Fake Hong Kong Skyline Gives Tourists a Better Backdrop, Ignores Pollution Problems. 

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He Said This, and She Said That; but … How About We Ask Them?


With the Millennium Development Goals in place many people have focused on what William Easterly calls a Planner approach on top-down method. This has been challenged recently due to shortcomings in achieving the MDGs. Still many of our policies on a national and international level still do not focus on a grassroots approach. This however is not solely an issue of the implementation method but also with the reform itself. Most often, measurements are based of WHO data or other mathematical models. I agree that quantitative analysis is best, but contest that often the monitoring methods remain stagnant as reform ideas change.  An example of this is a spatial decay formula[1], which would accurately reflect an individual’s proximity to medically trained personnel[2]. This would better reflect physician use because people do not place an arbitrary borders on distance, but operate more on the law of cost/benefit or distance/treatment.

Additionally, when setting up these facilities the systems can take into larger account the views of the local populations. Monitoring and standards are still held at a federal or international level, but daily activities can be better managed from a community-based system. This is seen in developing countries and even in ‘modernized’ countries such as the United Kingdom. When this reform is implemented in a top-down structure instead of a bottom-up system, often it is aligned to failure and protest as seen in Colombia with its current reform. Therefore, the question arises of how to mitigate government monitoring to prevent corruption and malpractice v. identifying local needs and demands.

A perfect example of this debate is in the Mental Health Act law in Ghana in March of 2012. Local demands on the system for better mental health reform issued the change from a previous law (created in the 1960’s) to the new MHA law. This desire showed great promise for use on the local level; however, national structural problems are creating issues in its implementation[3]. This shows that even with a strong local demand for a service, there needs to be an adequate national supply of infrastructure. At some level, just as the MDGs have failed to be completed due to low, local demand. Other systems are fledgling due to low, national supply. This intersection between the two populations must be mitigated and viewed from a more economic perspective if any reform is to be truly effective.

[1]Luo, W., & Qi, Y. (2009). An enhanced two-step floating catchment areamethod for measuring spatial accessibility to primary care physicians. Health & Place , 15 (4), 1100-1107.

[2] Dewulf, B., et al. (2013). Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas. BMC Family Practice, 14 (122), 2296-2310

[3] Doku, V., Wusu-Takyi, A., & Awakame, J. (2012). Implementing the mental health act in Ghana: Any challenges ahead? Ghana Medical Journal, 46 (4) 241-250

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Grounding Frequent Fliers

As an ER nurse, one of the toughest things about working in such a high demand and high flow environment is prioritizing patients and seeing the most critical patients in a timely manner. I come across many different personalities and situations. One of which is the most frustrating, as an ER nurse is the type of patient that we lovingly refer to as a “frequent flier”. These patients (aka frequent fliers) are the patients who come in several times in a day/week/month/year with or without emergent health needs. Sometimes the problems stem from social or economic factors, lack of knowledge on their disease process, lack of access to timely primary care doctors, or lack of affordable care other than an ER visit. Often times, these patients are faced with tough situations because they are known throughout the hospital and providers have compassion fatigue from treating them for the same issue each day/week/month. On top of that issue is the concern of cost, many of these patients are on Medicaid or Medicare and are in situations that could have been preventable with better outpatient/primary care. This issue is one that every hospital faces in the United States and the long-standing question has been how or if the hospital can even tackle the issue.  

Recently I stumbled across an article on NPR about these types of patients, also known as “hot spotters”, who cost the hospital, Medicaid & Medicare, and the health care system large amounts of money each year. It highlights a special initiative, the Comprehensive Primary Care Initiative, which allows primary care practices more resources in order to invest in their workforce. With the right approach, like Dr. Brenner’s clinic in New Jersey, the practices can hire an extra nurse or social worker in order to follow patients or make house calls in order to decrease the social, economic, or other barriers in their care. The general idea is that if there are people who can intercept these patients’ problems before they have to go to the Emergency Department and become admitted to the hospital than they will be making a significant impact on costs. In the fall of 2012 the Center for Medicaid and Medicare services launched this initiative in 500 primary care practices to gauge the affect. Already there are similar programs that have shown promising results.

If the results from the initial Primary Care Initiative prove successful I think then the real work will begin. It will be an uphill battle to then go to hospitals and convince them to invest in these types of initiatives in order to reduce their costs. Although, I am confident that it would provide better, safer patient centered care I think there will need to be significant and dramatic decreases in order to convince more investors that it is a good financial investment for the future.


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Comparative Health Systems – Mo’ money, mo’ problems

The recent passing of President Obama’s Health Care reform law – The Patient Protection and Affordable Care Act, in the United States has led to a flutter of multifarious emotions with those from the opposing side expressing scathing opinions as to what the reform will lead to.  A difficult objective to perfect, health care systems seem to be of constant debate between political parties – and one of the most debated points is that of cost.  It can be of fair assumption that as one of the wealthiest countries in the world we would spend more to have a superior health care system – in 2012 alone we earmarked nearly 20% of our GDP for healthcare[1], more than that of 12 other industrialized countries.[2] There are numerous reasons as to why healthcare in general is such a costly endeavor in any country – such as providing coverage to an entire population and the inelastic price of treatment.  However, if these are cost that virtually every developed country encounters, why is so much more for the same services in the United States – why is our more money, just leading us to more problems? 

One of the primary cost generating issues with the United States health care system verses comparative countries that offer socialized health care schemes is the inefficiency in our preventive health care services.  Those who are able to obtain health insurance either privately or via their employer are afforded the luxury of regular doctors’ visits for very little co-pays – making it easier to stay healthy.  However, despite being uninsured the remaining Americans are still entitled to receive treatment, though they must bear the entire cost of service.  Their inability to access affordable and regular services often forces them when in dire straits to utilize the most expensive options available – such as emergency rooms.  The costs associated with such visits are often too much for these individuals which leads to non-payment or bankruptcy filings, which then leaves the exorbitant cost of that of the taxpayer.  The United States also doesn’t have a centralized negotiation system when it comes to bringing the cost of things down.  Health care providers have no incentive to mitigate cost and simply charge whatever it is that they are able to get away with – which brings us to the final point of services in
America simply just cost more than they do in other countries-substantially more.  In some instances, Americans will pay virtually double for a service than that of our developed country counterparts.[3] 

Despite spending more money on health care, an estimated 34% more than comparable countries[4], our overall health still ranks several notches lower than regions that spend significantly less; and our life expectancy is no better despite our expenditures as we rank 51st globally.[5]  It just goes to show, money cannot buy you everything-and the best things in life (such as socialized health care) are free.    






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I Pledge Allegiance to the Healthcare of the United States of America

Being an American, one gets to experience the melting pot of cultures prevalent in almost every city.  We also get freedoms and human rights just for being born on US soil.  One of these rights is that of health care, but America falls victim to dramatic health disparities seen between upper and middle-class Americans, and everyone else.


I understand that health is influenced by many complex factors like genetics, but the best predictor of population health is the outcomes of our lower socioeconomic citizens. When examining the determinants of premature death, be it smoking, environmental exposures, and other social circumstances or assessing health outcomes by measuring amenable mortality, which is “deaths that should not occur in the presence of timely and effective health care,”[1] America should do better.


The United States is the only industrialized country without a comprehensive national health system to cover our residents, yet we spend the most on healthcare – roughly double the average per capita than Western European countries, but do not see better health outcomes as the return for our investment.


Don’t get me wrong; by in large our citizens have one of the longest life expectancies, but compared to France, Germany, and the United Kingdom, there is room for improvement in our health care system. In 2010 a survey was administered that asked adults “how confidant they were in their ability to afford health care if they became seriously ill?  US adults were the most negative about affordability.”[1]  So where to begin?  Well, healthcare reform for universal healthcare that includes: vision, dental, and prescriptions, increases access to primary care, minimizes insurance claim wait times, and ensures equity across all points of access.


I give kudos to the government for Medicare, which has been around since 1966, and is the closest thing to universal access to healthcare for persons 65 and older and younger people with disabilities.  What about everyone else? 


America is in the grips of what will be a glorious, much needed health reform that initiates universal health coverage for ALL Americans and for the first time addresses “health disparities resulting from differences in socioeconomic status.”2 If participants can successfully sign up, we can expect to see improved access to primary care through affordable, preventative measures, and better outcomes for population health.


Long and short, we have to do better, and we will; our Affordable Care Act is a step in the right direction, but we still have a long way to go…starting with fixing the website.



1. C. Schoen, R. Osborn, D. Squires, M. Doty, R. Pierson, S. Applebaum.  (2010) “How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries” Health Affairs, 29.

2. S. Schroeder.  (2007) “we Can Do Better – Improving the Health of the American People” New England Journal of Medicine, 357 

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