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Health Care Reform HR 4872

The views expressed in this blog represent my personal opinions only and do not represent the views of Cottonwood nor it's administration.

I want to talk a little bit about health care reform and the two bills that were recently signed into law. I had previously said I would make no comments until the final bills were signed and I could read the texts. I was planning initially to discuss HR 3590 (the Senate version of the health care reform bill that President Obama signed into law March 23rd. This bill was passed as expected with tremendous media interest and there have been many com mentors on what this bill actually means for us. However HR 4872 was signed into law yesterday. It is the bill that has far more reaching consequences for our health care system but was not reported as anything more that a "fix it bill" amending the original health care bill. It was signed with little fanfare and the focus the Obama administration highlighted was the education component of the bill which alters the way college education is payed for in regard to student loans and federal grants.

Hr 3590, the Patient Protection and Affordable Health Care Act, is not a government takeover of the health care system. It basically amounts to a government takeover of the health insurance industry but has many features that most of us can probably agree with in the type of reforms outlined. It does have some problems which I will talk about later but it is not government run health care. HR 4872, the Health Care and Education Reconciliation Act, which is the amended bill is quite different though. HR 4872 runs to 2309 pages which is longer than the first bill passed. I have not read all 2309 pages yet but I have read the first 200 and can say that this bill is essentially a government takeover of the health care system. What I read surprised me. The first part of the bill reads word for word the previously proposed House bill which included a public run insurance plan as well as a new federal agency. For those of you who don't agree with me I welcome anyone to read the text of the bill itself and will be glad to discuss any aspect of what I am going to say here.

HR 4872 includes a government run public health care insurance option (page 12), (page 72), (pages 116- 125 Subtitle B -Public Health Insurance Option).

HR 4872 involves the creation of a brand new federal agency, the Health Choices Administration (page 41).

The Health Choices Administration will be headed by a Commissioner appointed by the president who has broad powers which include defining the terns used in health insurance coverage, determination what is accepted as a qualified health benefit plan and to, and determining to set the actual benefits that will be provided by a qualified health plan. In other words the Commissioner can determine what will and will not be covered. (pages 41-45)( page 84).

HR 4872 overrides any state required insurance mandates unless the state reimburses the federal government for the cost of the benefits mandated(page 87).

HR 4872 establishes a national health card which must be used prior to medical services to determine if one is eligible for those services (page 58-60). If the government does not want you to have certain medical services you cannot get them.

HR 4872 enables the federal government to debit your bank account for the cost of medical services 9page 58).

HR 4872 taxes individuals who do not obtain the type of health insurance that is qualified by the Commissioner and compliance must be reported to the IRS (pages 110, 167-168).

HR 4872 taxes small employers (businesses less $400,000 per year) who are not able to provide health care coverage a tax of 8% of the employer's payroll (page 184).

I have not seen much media coverage and have wondered, am I making a mistake? Was HR 4872 signed into law? An I reading the correct bill? Apparently. I hope that I am wrong.

These are some of the things that are in the first 200 pages of the bill. Again, we all are interested in this topic and I welcome any questions or discussions (write me!) :)

Thought for the day

May God grant me the serenity to accept the things I cannot change.

The Cottonwood Tucson Experience

The Breakfast Club

We all come to Cottonwood Tucson for various reasons, bringing along all shapes and sizes of baggage; with the common denominator being the desire to get well. It is understood that some have a greater desire than others do. At Cottonwood, we are stripped bare and completely exposed in an environment that is safe and nurturing. It is because of the caring and sharing that goes on that amazing bonds are built while on campus. We have taken those bonds beyond the campus.

For the past two years, since our mutual time at Cottonwood Tucson we have stayed in close contact. The "Breakfast Club" began as a group that had early breakfast together on the upper patio. We come from all over the world and are bound by common Cottonwood experience. Each breakfast began with going around the table one by one, giving your three core feelings for the day, and answering a ten-question self-evaluation. We could then move on to having breakfast.

We continue our experience via email, through the marvels of modern technology. We try to check in as often as possible and each email begins with your three core feelings. This is the safest place on earth. You can share any information that you choose and feel comfortable. Knowing that you are going to get responses that come from love and caring. If someone is not contributing for any length of time they are checked up on and reminded that whatever reason they are not communicating does not matter, we want to hear from you. You will never be reprimanded for not writing whatever the reason. This is all done out of love.

The Breakfast Club has become a family. We visit each other, hold reunions, meet each other's "real" families, and are as close as people can be. We owe this to Cottonwood and our own individual experience there. Cottonwood has introduced us, showed us how to open up and let in others with no judgment and develop the ability to share. Being able to share is a key force in each person's recovery.

With all this said, we want to thank Cottonwood Tucson for giving each of us the knowledge and tools that brought the Breakfast Club together.

Ellen S., Cottonwood Tucson Alumni

Psychiatry Public Trust Influence

Thomas Insel, MD, the director of the National Institute of Mental Health (NIMH) wrote an editorial in the most recent Journal of the American Medical Association discussing the relationship between psychiatry and pharmaceutical companies that have contributed to the increasing erosion of public trust in psychiatry. Now psychiatry has never had a positive image. I have often noted that in TV or film portrayals the psychiatrist is either a bumbling fool, a narcissistic jackass, or downright evil. There are some exceptions to this but they are few. Why might this be?

I think there are several reasons. First psychiatrists deal with mental illness that is still widely stigmatized, is poorly understood and often feared by those who don't understand. Secondly psychiatrists are the physicians who are associated with the whole ethical conundrum of involuntary treatment. Due to the nature of the illnesses involuntary treatment is occasionally necessary but is subject to great risk of abuse or misuse of power. Psychiatrists are the physicians who participate in forced hospitalizations and occasionally forced medication treatment. We also are associated with ill conceived barbaric treatments in the past such as unmodified and safely provided Electroconvulsive Therapy (ECT) and lobotomies. Safety of patients require occasional seclusion and restraint which are dangerous procedures fraught with ethical and practical difficulty, and have been overused. In addition I have often found that in social settings people often think that I am analysing them or can read their minds. But as Dr. Insel points out there is an additional problem that has eroded public trust in our profession and that is the relationship between psychiatry and pharmaceutical companies.

Psychopharmaceuticals are big money. Antidepressants and antipsychotics represent two of the top five drug classes sold in the United States today with sales of over $25 billion dollars per year. Although more prescriptions for these drugs are written by non psychiatrists than psychiatrists we are naturally associated with their use and have a large responsibility to see that these medications are used appropriately. There have been a few recent scandals in which it became apparent that data were falsified by well known and well respected academic researchers who were found to have close financial ties with the industry. A recent study indicated that 60% of all medical school department chairs have received personal income from the industry and 80% of all faculty reported such a relationship. A similar study showed much the same rates in non psychiatric medical disciplines but that does not excuse psychiatry. "Everyone is doing it" is not an acceptable rationalization.
Of 20 work group members who authored the American Psychiatric Association guidelines for the treatment of schizophrenia, bipolar disorder, and major depressive disorder 90% had pharmaceutical industry ties but none of this was disclosed.

What is especially sad to me is that the majority of psychiatrists that I know and have dealt with are good ethical people. Most are struggling with few societal resources to decrease the suffering of individuals with these devastating diseases and are doing the best they can with our limited state of knowledge. But that is not the public perception and the close ties with pharmaceutical companies has only made the situation worse.

Thought for the day

It is time to clean house.

Depression Alcohol Dependence Combination Therapy

There was an interesting stucdy in the March isssue of the American Journal of Pysychiatry that looked at combining medication treatment for those alcohol dependent patients who also suffered from co-occurring major depression. This study is important for one conclusion but as I have noted before with various studies the researchers often come to other conclusions that are not necessarily supported by their own evidence.

170 depressed alcohol dependent patients (mean 43.4 years of age) were randomly assigned to 14 weeks of the antidepressant sertraline (Zoloft) at 200 mg/day (the maximum dose), to the alcohol dependence drug naltrexone(Revia), to both drugs, or to double placebo groups and studied for a period of 14 weeks. All patients received weekly cognitive-behavioral therapy. The important finding was that at the end of 14 weeks 53% in the sertraline-naltrexone group maintained abstinence compared with an average of 23.8% for the other three treatments. This is very striking and may have significant implications for how we treat depressed alcoholics. Limitations of the study are the relatively small number of participants and the time frame of the study (3 1/2 months). But this is an important finding and one in which I hope there will be more follow-up for a longer period of time, enroll more patients, and separate out differences between men and women as well as those who received inpatient treatment compared with those were did not.

The other point they try to make in this study is that those receiving both treatments were less depressed than those with sertraline alone. They try to make the the point that there was a trend in that direction but the trend did not reach statistical significance. Reporting and highlighting trends that are not statistically significant is often a problem in that these results get reported in the media as important findings as well as the main findings and people come to conclusions that are not really supported by the evidence.

So in this case the improved abstinence rates at 3 1/2 months for the combined group is extremely important but we cannot say at this time that the combined treatment actually helps the depression.

Thought for the day

53% abstinence in a population with a co -occurring and serious psychiatric disorder is encouraging.

Health Care Reform Bill House

The views expressed in this blog are my personal views and do not reflect the views of Cottonwood nor it's administration.

I haven't written in awhile. I don't exactly know why but felt it was time to do so again. By now everyone is probably aware that the House passed a health care reform bill. I have been very interested in this area and have commented on it a number of times. It is no secret that I have disliked the proposed House bill in it's original form. After reading the proposed bill I had a lot to say but made no comment on the Senate's deliberations as there was never a final form reconciled with the House. I probably will have a lot to say on this bill but I will make no comments until I read the final version after reconciliation with the Senate.

Thought for the day

Compassion. compassion, compassion

Tobacco Effects Fetal Brain

A study recently published in the Journal of Pediatrics provides more evidence of the adverse effects of tobacco use during pregnancy. There is already evidence showing that prenatal tobacco exposure is associated with neuro-cognitive effects in the first 3 years of life, including problems with attention and regulation of emotions. We also know that maternal smoking is linked with intrauterine growth restriction and decreased neonatal birth weight. Now, a study from Finland has shown a link to actual brain development.

The researchers looked at 232 infants from a single hospital from 2001-2006 who were either very low birth weight or below 32 weeks gestational age. The developing fetuses were evaluated with head ultrasounds at different points and brain magnetic resonance imaging at term. 42 of the mothers smoked during their pregnancy (18.1%) and averaged 10 cigarettes per day. This smoking rate of 18% is very similar to what is found in the United States. Mothers who smoked during pregnancy were twice as likely to drink than those who did not smoke. The findings were that infants exposed to prenatal smoking had smaller frontal lobe and cerebellar volumes. The investigators did not report on developing functioning of the children as they aged so no clear clinical implications can be drawn from lower frontal lobe and cerebellar volumes but this study is one more piece of evidence that prenatal exposure to tobacco is clearly harmful.

Thought for the day

" So come what may, I'll not upset my cheerful happiness of mind. Dejection never brings me what I want; my virtue will be warped and marred by it".

The Way of the Bodhisattva