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© 2011 Sanford Journal of Public Policy
By Emily Tiry, Staff Editor
A new Associated Press analysis reports that sales of prescription painkillers are rapidly increasing in new areas. Traditionally, sales of these painkillers have been highest in affluent suburbs and in Appalachia, where there is a high prevalence of chronic pain from coal mining and other manual labor. Over the past decade, however, increased sales have started to spread to new areas. Between 2000 and 2010, sales of oxycodone and hydrocodone increased over 500 percent in New York, Delaware, Tennessee, and Florida.
This rapid increase is being driven by a combination of the aging of the U.S. population, doctors’ greater willingness to treat pain with these medications, and addiction. Part of the problem, especially with regard to addiction, stems from a lack of effective monitoring systems for controlled substances. Forty states now have monitoring systems that track individual patient usage, but most do not link to one another. Buyers can easily cross state borders to fill prescriptions if their own state begins strengthening their monitoring systems, a problem Tennessee is currently facing.
Painkillers such as oxycodone and hydrocodone cause over 12,000 deaths per year—more than heroin and cocaine combined. However, painkillers can also provide a meaningful increase in the quality of life for those who suffer from chronic pain. As prescription painkiller abuse becomes a growing problem, policymakers need to develop strategies that reduce the harm these drugs can cause while also preserving the benefits they provide.
Graph via Wikimedia Commons
By Jeff Bartelli, Staff Editor
The Baby Boom generation is beginning to retire, and communities around the country have not begun to prepare. As this generation grays, it will need better public transit, walkable cities and neighborhoods, better health care, and active workers to support them. The United States is continuously bickering over policies that would provide for the boomers and the generations that follow them. Boomers themselves are struggling to survive, even returning to school in the hopes of getting jobs to replace everything they lost in the last recession. Forward-thinking policies should be implemented now to serve all Americans. Solutions to health care challenges, Social Security’s long-term solvency, and inadequate transportation infrastructure are critical for serving Baby Boomers and everybody else. The longer politicians delay, the more it will cost the country in the long run, and the more U.S. citizens will struggle.
By Emily Tiry, Staff Editor
Maryland Lieutenant Governor Anthony G. Brown recently announced a plan to address the state’s persistent health disparities and to improve outcomes and quality of care. The plan, which comes from recommendations from the Maryland Health Quality and Cost Council Health Disparities Workgroup, revolves around health enterprise zones (HEZ). These zones would be created in areas that are underserved and have documented health disparities. Several types of incentives would encourage primary care physicians to practice in HEZs, including loan repayment assistance, tax credits, and help in installing electronic medical record technology.
Additionally, the plan would create the Maryland Health Innovation Prize to reward new programs or interventions that successfully reduce health disparities. The plan would also require the two commissions that measure health care performance data in Maryland to track performance by race and ethnicity.
Stuart Butler, the director of the Center for Policy Innovation at the Heritage Foundation and the creator of the urban enterprise zones on which HEZs are modeled, noted some issues that need to be addressed if HEZs are to be successful. For example, he suggests suspending the Certificate of Need requirement, adjusting land-use rules, and modifying state Medicaid rules to reward health providers for innovative services.
While this program might increase access to health services in underserved areas, it may not drastically reduce or eliminate health disparities without complementary measures also being pursued. This is not to say that improving access is not an important component of reducing health disparities, but doing so is also not the only component. The causes of health disparities are extremely complex and one program will not solve every problem—but it’s a start.
Images via alaska.sierraclub.org and localizedusa.com
By Kris FitzPatrick, Staff Editor
It was revealed last month in the New York Times that the Sierra Club secretly accepted $26 million in donations prior to 2010 from Chesapeake Energy, the second largest producer of natural gas in the U.S. (Natural Gas Supply Association). The revelation spurred criticism of the Sierra Club for not disclosing the donation, particularly as the group spoke positively of natural gas as a “bridge fuel” to a clean energy future.
The incident reflects uncertainty among environmental groups over how to handle the resurgence of U.S. natural gas production in the last several years. Exhibit A, as explained by the Wall Street Journal (subscription required), is the unusual alliance between the Sierra Club and the American Chemistry Council to oppose the export of U.S.-produced natural gas.
For environmental groups, keeping natural gas in the U.S. market offers some huge benefits, in the form of lower carbon and particulate emissions resulting from electric companies using more natural gas and less coal. The groups also have concerns that exports will spur more drilling and hydraulic fracturing, a method they worry contributes to emissions from escaping methane at wells and from pipelines.
On the other hand, low domestic natural gas prices are hindering renewable energy penetration in the U.S. Exporting more natural gas could increase natural gas prices domestically and be a boon to struggling renewables.
Image by Ken Hammond (USDA) (http://www.usda.gov/oc/photo/02cs2059.htm), via Wikimedia Commons
By Sharita Thomas, Staff Editor
The United States has a higher incidence of premature birth than any developed nation, a factor that contributes to its abysmal ranking in the infant mortality rate. 12.2% of births in the U.S. are preterm, while only 5% to 7% of births in other developed nations are preterm. The U.S. health care system clearly has a lot of ‘splainin’ to do.’ Additionally, preterm births and newborn deaths in the United States disproportionately affect Non-Hispanic Blacks and Hispanics. Non-Hispanic Blacks, Non-Hispanic Whites, and Hispanics have infant mortality rates of 15.2, 6.4, and 6.3 respectively. This problem is even more pronounced in North Carolina: Non-Hispanic Blacks account for 17.6% and Hispanics account for 12.1% of preterm births in the state. Only seven states and the District of Columbia fare worse than North Carolina in the overall number of preterm births and number of infant deaths.
To combat this problem, the Director of North Carolina’s Division of Medical Assistance, Craigan Gray, launched a program over a year ago that brings together community leaders, the Division of Public Health, and Community Care North Carolina to provide a pregnancy medical home (PMH) for recipients of Medicaid. PMHs may particularly help Non-Hispanic Blacks and Hispanics because they make up 48% of the state’s Medicaid recipients.
North Carolina is the first to implement a statewide comprehensive managed care pregnancy model of this kind. A goal of PMHs is to reduce Medicaid spending through the achievement of improved perinatal care, which should result in improved birth outcomes. Medicaid is a primary payer for perinatal care in North Carolina, covering 56% of the 126,785 live births in 2009 alone. The focus on outcomes as an indicator for success makes the PMH a “value-added” model. Traditionally, the main purpose of medical homes has been to provide patient-centered, comprehensive, and coordinated care with increased access and a systems-based approach to quality. This program will be fee-for-service with additional monetary incentives to increase provider participation and streamline the outcomes.
The list of possible contributors to the poor infant outcomes for Non-Hispanic Blacks and Hispanics is long and may include inadequate care, lack of education, poverty, and stress. Instead of focusing on how to reduce the cost of care directly, the PMH model aims to reduce the inadequacies in care that lead to pregnancy-related medical problems and higher Medicaid costs. The promise of reducing adverse outcomes and costs will lie in the ability of the program to identify high risk pregnancies and sufficiently coordinate and manage care up to and through delivery. Providers will be tasked with early outreach, as some incentives are based on the number of patients enrolled.
The question remains as to whether the significant cause of the disparities in pregnancy outcomes among racial and ethnic minorities is quality and access of care. Dr. Jennifer Culhane has noted that some studies have shown that common interventions, such as prenatal care, risk screening, and nutrition training have not been successful in preventing preterm births among racial and ethnic groups, specifically among Non-Hispanic Blacks.
It will be interesting to study the results of North Carolina’s PMH program when they become available next month to see just how much of an impact comprehensive care can have on reducing health outcome disparities. So far, 80 percent of North Carolina’s obstetricians have joined the program and have screened 60 percent of all pregnant women enrolled in Medicaid.
Image source: http://blogs.cas.suffolk.edu/cyberdad/2012/01/30/fukushima-daiichi-and-japans-nuclear-history/
By Kris FitzPatrick, Staff Editor
The impacts of Japan moving rapidly away from nuclear power after the Fukushima Daiichi disaster are now being felt globally. As the Wall Street Journal explains in video and written form this past week (subscription required for written), Japan is the world’s third largest economy and relied on nuclear power for roughly a third of its electricity in 2010. Suddenly, most of that nuclear power is offline and may not return any time soon, given Japanese domestic opposition.
To make up for the loss, Japan is hurriedly attempting to secure natural gas to fire its alternate power plants. Japan is investing in increased Australian gas production and aggressively seeking liquid natural gas (LNG) imports. This sudden increase in demand coincides with exploding natural gas production in the U.S. and a growing call for the U.S. to begin exporting its new glut of gas. And with European and Asian natural gas prices as much as six times higher than those in the U.S., look for domestic gas producers to continue this export push.
Image Via TheRawStory.com
By Dan Jasper, Staff Editor
For nearly a year, Syria has been in a state of unrest that has caused upwards of 5,000 deaths and an immeasurable amount of destruction. For nearly a year, the United Nations, the Arab League, and the world has watched as the regime of Bashar al-Assad has decimated the lives of its citizens and desecrated the principles that the Universal Declaration of Human Rights was built upon. For nearly a year, nothing has been done about it.
In the wake of Rwanda, the world declared “never again,” as it had many times before. But this time, it was supposed to be different. The world would wake up and live by a new set of standards, a new set of responsibilities, a new honor code of sorts. The Responsibility to Protect doctrine was supposed to change the way the state viewed its citizens, states viewed each other, and the way the international community viewed conflict. It was supposed to make the world care. But the image above illustrates the failure of the doctrine in Syria.
The inaction of the UN Security Council has cast doubt on the role of the R2P principles in international affairs. Moreover, the Security Council is losing credibility as it fails, again, to take action, and is once again highjacked by the oppressive domestic agenda of Russia and China. What does this mean for the future of international relations? It’s difficult to say. But what is clear is that the structure of the Security Council is inherently flawed, and the functionality of the UN will continue to be impaired by these structural flaws.
But the future of international relations is not what we should focus on at the moment. We should focus on the lives being lost and the freedom of the Syrian people. In a series of youtube videos (some images may be disturbing) a brave Syrian man named Danny Dayem captures the ongoing violence in Homs (the epicenter of the violence in the past weeks) and makes a heartfelt plea for help. I think Danny captures the frustrations of many Syrians in six simple words: “Where the f*** is the UN?” And given the gap between rhetoric and action, that anger is seeming more and more understandable.
By Emily Tiry, Staff Editor
San Francisco’s new homeless czar, Bevan Dufty, is pushing for an unconventional solution to the city’s homeless alcoholics: wet houses. These facilities would serve as shelters for the chronically homeless, but unlike many current shelters, they would also allow alcoholics to continue drinking while living there. The conventional wisdom is that these types of programs would actually enable addiction. However, wet house advocates promote a “harm reduction” strategy, which argues that if people are going to engage in self-destructive behavior anyway, it is better that they do it in a supervised environment where the harmful effects can be limited.
Many of these limited harmful effects would come in the form of reduced emergency room, ambulance, and detox costs. San Francisco spent more than $20 million in emergency medical services on 477 homeless individuals from July 2009 through June 2010. In contrast, a 2009 study of a wet house program in Seattle found that the median cost reduction was $2,249 per person per month relative to a control group. Additionally, participants reported fewer drinks per day over the course of the year.
Still, the study does not provide unconditional evidence in favor of wet houses. The Seattle study was not randomized due to ethical concerns, so the researchers cannot definitively claim that the wet house program caused the reduction in costs. Also, the study may have overstated the medical costs saved because it used billing charges rather than the actual cost of service. It would be helpful to see a careful randomized study and cost-benefit analysis of wet house programs compared both to no program as well as to traditional abstinence shelters before implementing such policies in San Francisco or elsewhere across the country.
By Eric Nakano, Staff Editor
In what is expected to be a competitive primary and presidential election (not to mention the first elections since redistricting), it’s baffling that the U.S. is not considering bills to reform voter registration and create a centralized system. On Tuesday, the New York Times highlighted a report by the Pew Center on the States that found that twelve years after Bush v. Gore, no meaningful election reform has taken place despite advances in technology and best practices in voter registration management from other countries. The report also noted that Canada spends 35 cents per voter to process its registrations and 93 percent of its voters are eligible. In contrast, Oregon spent $4.11 per voter, and nationwide, there were 2.2 million votes lost because of voter registration problems in 2008. While creating a centralized system is likely years away (and may never happen), allowing online registration and using data-matching technologies to ensure voter registration roll accuracy offer a sensible start and something that both Democrats and Republicans should be able to agree on.
By Zarak Khan, Staff Editor
New York Times columnist David Brooks recently lamented the lack of big ideas in President Obama’s State of the Union speech. “It’s sad to compare that era of bigness to the medium-sized policy morsels that President Obama put in his State of the Union address,” he writes, “He had some big themes in the speech, but the policies were mere appetizers.” It just goes to show: you can’t please everybody.
Brooks downplays the enormous amount of political capital spent on “big ideas” over the past three years (see: Obamacare) and skims over the graveyard for transformational legislation that is the United States Congress (climate change legislation, immigration reform, changes to the tax code, etc.). He comments, “It’s odd that an administration that once wanted to do everything all at once now should be so gradualist.” Is it?
Not according to Ryan Lizza’s recent New Yorker article, in which he reviews memos from the early days of the Obama White House. Though not the tell-all scoop some people were hoping for (he does have a book deal, after all), Lizza’s insider account maps the transformation of Obama’s policy agenda from one of big ideas based on post-partisan unity to a more pragmatic one that is less reliant on political grand bargains. “He had hoped to use a model of consensus politics in which factions in the middle form an alliance against the two extremes,” writes Lizza. “But he found few players in the center of the field.”
Lizza’s critique helps explain Obama’s policy proposals in this year’s SOTU and his reticence to do “big ideas.” If Congress remains paralyzed, the president has to use the tools at his disposal to chip away at larger issues. The most prominent of those tools are executive orders and the bully pulpit. At several points during the speech, he scolded Congress for its immobility, going so far as to say, “With or without this Congress, I will keep taking actions that help the economy grow.” It remains to be seen if Obama will be punished or rewarded in November for proposing “appetizer” policies in the face of a Congress that has no stomach for the entrées that American voters (and David Brooks) want.
