top 10 health rights gains
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Top 10 Health Care Rights Gainsof the Past 50 Years
Mount Holyoke College 50 th Reunion
Fran Miller
Visiting Professor of Law
University of Hawaii at ManoaProfessor Emerita, Boston University
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Defining Health Rights What is a health care right?
Lawyers answer: it depends . . . Answdepends . .
Different people
Different purposes Different contexts Different definitions
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Defining Health Rights The lawyers method of analyzing rights:
Constitutional? Judicially enforced? Legislatively created? Ethically mandated? Aspirational?
Lawyers tend to focus on enforcementpotential
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State of Patient Health Rights 50
Years Ago Institutional responsibility
& accountability for public
health comparatively slight
Significant % of the
elderly & poor lackedhealth insurance
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The good news is thatits not my problem.
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Research subjects(almost) literallyhuman guinea pigs
Not so much doctorscould do for patients,comparatively
50 Years Ago, cont.
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So What Have the Top 10 Patient HealthRights Gains Over Past 50 Years Been?
Constitutional, judicial, legislative,
ethical, or aspirational? Earliest to latest, or vice versa?
Most important to least?
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The Letterman Approach
My choices for top 10patient health rightsgains of the past half
century follow, inascending order of
importance:
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# 10 The Rise of Corporate
Responsibility
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# 10 - Rise of Corporate Responsibility
The WorkplaceSafety rules
Anti-pollution measures
Superfund clean-upresponsibilities
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# 10 (cont.) The Rise of CorporateResponsibility
The Board Visits the Lab, circa 1970
The Health Sector
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# 10 (cont.) The Rise of Direct
Corporate Responsibility Hospitals & Other Institutional Providers
Held Directly Accountable for Quality of Care
Managed Care Organizations directlyaccountable too
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# 9 Required Nutrition Information
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Congress &
theFDA joinforces toempower
consumers
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# 9 Required NutritionInformation (cont.)
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# 8 Vaccines Eliminate Many
Childhood Diseases
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Polio cases declined from 58,000 in 52 to161 in 61, eliminated in the Americas by 94
(vaccination tied to school attendance)
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#7 - Patient Autonomy Enhanced:(a) Pt-centered Standards of Disclosure
Adopted for Informed Consent toMedical Treatment
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# 7 (b) Autonomy Rights of
Incompetent Patients Protected
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Cruzan v. Director, MissouriDepartment of Health , 497 U.S. 261
(1990)
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# 7 (c) - Human Rights in Medical
Experimentation Protected
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Research subjects protectedvia OHRP common rule if
federally funded, or resultsdestined for FDA
Doctor seeking patient consent
has fiduciary duty to disclosepersonal interests unrelated topatient health
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Jesse Gelsinger Case:Dr. James Wilson, ConflictedPenn Researcher
"To suggest that I acted or was influenced bymoney is really offensive to me. I don't think about how my doing this work is going to makeme rich. It's about leadership and notoriety andaccomplishment. Publishing in first-rate journals.That's what turns us on. You've got to be on thecutting edge and take risks if you're going to stayon top.
Deborah Nelson, and Rick Weiss, Hasty Decisions in the Race to a Cure?: Gene Therapy StudyProceeded Despite Safety, Ethics Concerns , The Washington Post, November 21, 1999, at A01;Robin Fretwell Wilson, Estate of Gelsinger v. Trustees of University of Pennsylvania: Mone y,Prestige, and Influence in Human Subjects Research , Cases In Context: Health Law and Bioethics(Sandra Johnson, Joan Krause, Richard SSaver, & Robin F. Wilson eds., Aspen Publishing 2008).
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# 6 -The US Got Serious About
Smoking Hazards
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1965: Smokers = 42.5%of US population
Males: 51.9%Females: 33.9%
Whites: 42.1%Blacks: 45.8%
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#6 (cont.) Smoking Hazards
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1965 - Congresspassed legislationrequiring SurgeonGenls warning oncigarette packages
2006 Only 20.8% ofUS adults smoke30 years later (rate cut in )
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#6 (cont.) Smoking Hazards 1969 Cigarette advertising
prohibited on all TV & radio
1990 Smoking banned oninterstate buses & domesticflights of < 6 hours
90s & 00s State & local bans on smokingin workplaces, restaurants, schools,hospitals, etc. 21
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#5 (a) Womens Reproductive RightsEnhanced
FDA Approved Enovid OralContraceptive (1960)
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#5 (b) - Womens Reproductive
Rights Protected
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Roe v. W ade , 410 U.S. 113 (1973)
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#4 - Patient Safety Movement
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Institute of Medicines1998 study galvanized
the patient safetymovement with:
Medical care is the8 th leading cause ofdeath in the U.S.
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#4 - Patient Safety Movement Focused attention
on inherent dangersof health care Surgery Medication errors Infection Systems Errors 25
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WATERSHED MOMENT:
Social Security Act of1965 establishedMedicare & Medicaid
# 3
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# 3 (cont.) - Medicare & Medicaid
Revolutionized US Health Care Only 56% of elderly
had hospital insurancein 65 just 45 yrs ago
Uninsured elderly and poor got onlysporadic care
Medicare & Medicaid nowinsure > 1/4 of US population
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#3 -Medicare/Medicaid
Revolution (cont.) US spent $2.5 trillion on
health care in 2009 More than we spend on food, or housing,
or education, or defense
Health care = (+/) 17% of GDP Medicare/Medicaid (& other govt.
programs) now finance of all US care29
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#2 - The Patient Protection & Affordable Care Act of 2010
Comprehensive reform withan incremental soul
- Ezra Klein, Washington Post 30
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Fundamental Focus of Reforms
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1.
Improve dysfunctional & costlyinsurance markets for individuals &small businesses
2. Expand Medicaid coverage for the poor
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Re Federal ComprehensivenessIndividual mandate will add 34million new US insureds by 2014
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Fundamental Culture Shift at
the Federal Level
Purchase of affordable health ins =individual responsibility & obligation
(with employer & govt contributions )
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Uwe Reinharts 3-legged stool1. Universal mandate2. Subsidies for those who cant
afford ins3. Insurers must accept all comers
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The Basics Re Expanded
Coverage U.S. Citizens & Legal Residents MustHave Qualifying Coverage by 2014
Medicaid expansion for 17M new insured New ins exchanges to enroll 17M more
94-95% of US population to be insured
by 2014 (up from current 84%)
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Insured - 2014 Insured - 2010
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Medicaid Expansion Medicaid expanded to all individuals under
65 with incomes
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New State Health Benefit Exchanges &Small Business Health Options
Programs Link individuals lacking access to
employer-sponsored insurance, & Firms w
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Premium & Cost-Sharing Subsidies
to Purchase Health Insurance Individuals & families w incomes between
133-400% federal poverty level getrefundable & advanceable premium creditsto buy insurance thru state ins exchanges
Cost-sharing premium subsidiesfor eligible individuals & families
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Individual Mandate Enforced
Through Internal Revenue Code
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Starting in 2014,Individuals faceincreasing taxpenalties if no
health insurance
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Tax Penalty
$695/year up to max of 3x that amt($2,085)/family, or 2.5% of household
income (by 2016) Annual cost-of-living adjustmentspost-2016
Exemptions for financial hardship,religious objections, those w incomesbelow tax filing threshold,* etc.
* $9,350 for singles, $18,700 for couples in 09 40
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No Prior AuthorizationRequirements for Women To See
Ob-Gyns
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No Co-insurance or Deductibles for
Certain Preventive Services for Women
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Pre-existing Conditions Insurers can no longer reject applicants
with pre-existing conditions Or charge them exorbitant rates
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No Rescission of Existing
Policies for Illness
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Lifetime Caps on Insurance
Benefits Eliminated after 2014
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Insurers Must Permit Children to
Remain on Family Policies Thru Age 26
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Medicare Prescription Drug
Changes Part D donut hole* will be filled by 50%
prescription drug discount in 2011 By 2020, cost-sharing obligations within
gap reduce to 25%
* Donut hole eliminates Medicare coverage of prescription drugexpenditures between $2830 and $6440 (in 2010)
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Comparative Clinical
Effectiveness Research Establish non-profit Patient-Centered
Outcomes Research Institute tocompare clinical effectiveness of medical treatments
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Who Benefits from Reforms? Patients: almost everyone insured Doctors: more insureds = more
reimbursement Hospitals: more insureds = less
uncompensated care Ins. Companies: more insureds = bigger
market Pharmaceutical Manufacturers:
more insureds = bigger markets50
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#1 - The Internet
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Knowledge = Power The Internet Devolves Power Down to End Users
John Perry Barlows famous 1996declaration of Internet freedom:Governments of the Industrial World, youweary giants of flesh and steel, I come
from cyberspace, the new home of Mind . . . . You are not welcome among us. You have no sovereignty where wegather." 52
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Public Health Harnesses the Power of the Internet for
Patients Providers Researchers Government Public Health
Officials Payors
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Why Did We Have Such TroubleGetting The Patient Protection & Affordable Care Act Enacted?
Follow the money!
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Uh-oh . . . .
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Big Time Uh-oh!
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The Elephant in the Room
That Everyone Sees: Costs
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Costs of Federal Reform Will cost govt about $938 billion over
10 years, acc. to nonpartisan Cong.Budget Office (we spend $2.5+ trillionannually now)
Should reduce federal deficit by $138billion over decade
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Medicare Payment &
Service Delivery Reforms Value-based purchasing
programs
Quality reporting
Pilot programs onpayment bundling
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Limits on Insurance Adm. Costs
& Executive Compensation New limits on adminstrative costs & executive
compensation*
Violations will trigger subscriber rebates
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Insurance Costs of enrollees in nongroup plans
will qualify for federal subsidies
Average costs lowered for middle- and moderate-incomefamilies by about 60 percent
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Cost Controls: Individual
Incentives Excise tax on Cadillac Plans starting in
2020
Threshold for itemized medical expensededuction increased from 7.5% of adjustedgross income to 10% of AGI 62
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Watch out for the messagesit delivers
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What Will Be the Top 10 HealthRights Advances over the
Next Half Century? I Know Whats #1
on My Wish List`
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Single Payer Health Insurance