Health Insurance

Human Rights Day, December 10: Access to Medical Care as a Human Right

I was shocked that I had never read the Universal Declaration of Human Rights (UDHR). Surely I must have learned about it at some point? As I scanned my memory back at world history, US history, and government classes, I couldn’t remember studying it in high school or during my years in university. Certainly it was mentioned at some point. But compared to my familiarity with the Declaration of Independence, the U.S. Constitution, and other historic U.S. documents, somehow the UDHR wasn’t on my radar. I believe that we as pediatricians can help change our culture by familiarizing ourselves with the UDHR and referencing it in our conversations with our family members, friends and those with whom we work.

When I discovered and read the UDHR recently, Article 25 in particular stood out to me. “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.” (emphasis added) 

If achieving these rights outlined in the UDHR, namely access to affordable and accessible medical care as a human right, were part of our culture in the United States, how would conversations about child health, public health insurance, and our culture of health in general, change? Where could our actions as a nation collectively, driven by our legislation and system, go with this sort of culture? More can and ought to be done to use this important declaration as a tool to foster a culture and, ultimately, a society that values equal access to healthcare and public health insurance, especially for the most vulnerable children our country. 

The UDHR was drafted by the United Nations Human Rights Commission in 1948 as an important part of an effort to promote peace and prevent further catastrophe that occurred during World War II. In the preamble of the UDHR, it states “Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,… Now, therefore, The General Assembly, Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations…” 

Following its preamble, the Declaration outlines thirty articles that outline what are deemed as universal human rights. In studying these rights, I realized that many of the articles align with concepts familiar to most Americans. To the casual American reader, statements such as “Everyone has the right to life, liberty, and the security of person”, “No one shall be subjected to torture or to cruel, inhuman or degrading treatment of punishment” sound familiar.  Rights such as “the right to freedom of thought, conscience and religion” or “the right to freedom of peaceful assembly and association” have their correlates in the U.S. Constitution. Other rights, such as “the right to marry and found a family” may not be canonized in writing, but are indeed part of our common values as Americans. In short, adopting the principles of the UDHR into our identity, culture and belief system does not require the sacrifice of existing values that we all hold dear. Rather, the UDHR adds to those beliefs some concrete and objective ways by which humans can live life to their fullest potential. Because the Declaration was new to me, I spent some time searching through the medical literature for references to this document. On the AAP website, the UDHR was referenced explicitly in only two articles within its database. On PubMed, searching for “Universal Declaration of Human Rights” yielded 229 results. Common topics of articles that cited the UDHR were articles regarding the rights of underserved, migrant or refugee populations, the rights of persons with speech and communication disorders, and, unsurprisingly, the overlap of  medical ethics and human rights. From this brief search, I concluded that while connections between human rights and access to medical care were being made, it has not been prominent within the culture of medicine or even medical humanities. It reaffirmed to me the need for pediatricians and physicians in general to champion the document and reference it more readily.

One article I found in my search, A Culture of Health and Human Rights, elaborated on the importance of human rights as a framework whereon a national culture of focus towards universal health and well-being could be built. Written in 2016 by two Boston University law professors, the article offers the following model:

 “Human rights offers a sustainable conceptual framework that supports the imperative of improving the social determinants; empowers the public to demand positive change; and offers common ground for initiatives, both public and private, that improve population health. Policies that protect and fulfill basic human rights are policies that address the social determinants of health, well-being, and equity. A culture of health can be most effectively deployed to improve population health when linked to a human rights agenda.” 

In tackling the current culture of health that exists in our country, authors Wendy Mariner and George Annas suggest:

“If a culture of health is intended to mean that Americans should prize health as a national social norm, it will be challenging to realize. In our pluralistic, multicultural country, attitudes about health and its causes vary, especially among different socioeconomic groups. While everyone might agree in principle that health, well-being, and equity are desirable, there is less consensus on where health ranks among life goals and values. Empirical observations of what people actually do—actual norms—suggest that there is no universally accepted—or practiced—culture of health in the United States. Many people might view health not as a primary good or an end in itself but as a means to attain other life goals, such as financial security, personal safety, respect in one’s community, and fulfilling relationships with family and friends. Those who are struggling to raise a family on minimum wages or in a violent neighborhood might be too preoccupied with survival to make health a high priority.”

Mariner and Annas go on to argue that given the plurality of opinions towards health, the best way to improve health culture in our country is to change policy. They astutely note that this endeavor will require decades-long efforts of focused coalitions with unified commitment towards human rights and improving the social determinants of health. 

If culture changes about children’s health can and should start with us as pediatricians, what can we do? More so than ever before, we can amplify our voice on online platforms. Arguably more effective and important are the day-to-day conversations we have with those in our immediate circles. If we individually internalize and embrace those rights that have been declared as universal, we can offer our voice from a place that is grounded in international support and consensus when divisive language about topics like healthcare and immigration arise, or during election seasons. 

Since 1950, December 10th has been dedicated as Human Rights Day and is recognized in many countries. We can use this day, and frankly any other day, to promote access to medical care as a basic human right. Nestled between Thanksgiving and the winter holidays, acknowledging Human Rights Day in our own personal way would lead to conversations about the UDHR.  That will give us opportunities to inform and discuss these principles and how they apply to the children in our communities.

Discussions, especially during the COVID-19 pandemic, have reflected a constant politicization of medical and healthcare issues which need not be political. By addressing the needs of children from a universal human rights framework, we can cast a wider, more inclusive net that catches the attention of those with whom we come in contact. Our efforts can slowly help others, including family, friends and neighbors, embrace health as a part of our culture, and more important, as a human right. As a generation of pediatricians more globally minded than perhaps any generation before, I hope we can help the world embrace the challenge of promoting a “standard of living adequate to the health and well-being” of all children.

David Oleson, MD

References:

Mariner WK, Annas GJ. A Culture Of Health And Human Rights. Health Aff (Millwood). 2016 Nov 1;35(11):1999-2004. doi: 10.1377/hlthaff.2016.0700. PMID: 27834239.

https://www.un.org/en/about-us/universal-declaration-of-human-rights

Children’s Hospitals Need More COVID-19 Emergency Relief Funding

Since the start of the COVID-19 pandemic, the financial losses of businesses and employees in the service, retail, and entertainment industries have been the subject of a large amount of media attention. What many Americans would not expect is that health systems are also under major financial strain during this difficult time.  Pediatricians can act now by writing their U.S. Representative or Senator to express the need for additional emergency funding for children’s health systems.

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New “Public Charge” Rule: How does it affect our patients’ families?

Texas is home to approximately 4.7 million immigrants (an estimated 17% of the state population), including approximately 317,000 immigrant children1. Of these immigrants, approximately 1.7 million are naturalized US citizens, nearly 1 million are eligible to become naturalized US citizens, and nearly 2 million are undocumented immigrants1,2. The number of US-born children in Texas who live with an undocumented family member is reported to be approximately 1 million, with approximately 500,000 children with an undocumented parent1,3. Obtaining permanent residency status is a lengthy process and a source of anxiety for many immigrants. Recent changes to the US Department of Homeland Security (DHS) rules regarding which public benefits count negatively towards obtaining permanent residency may impact these families and children. Pediatric healthcare providers should be prepared to help immigrant families understand how the use of public benefits could impact changing their immigration status.

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Is the rising cost of prescription drugs preventing patients from accessing life-saving medication?

Prices of prescription drugs in the United States are among the highest in the world. Most recently, the skyrocketing price of the epinephrine pen, EpiPen, has been the subject of major news headlines. Many have been enraged by the dramatic price increase of the EpiPen ($100 to over $600 in the span of a few years). Unfortunately, the EpiPen is one of many prescription drugs that has been affected by such dramatic inflation. Many fear that the rising cost of life-saving medication will limit access to those who need it. Healthcare providers cannot stand idly as these changes negatively impact patients. We need to have a better understanding of the prescription drug industry so that we can find reasonable solutions for our patients. (more…)

Telemedicine: establishing a secure connection for everyone

            Despite the large role that technology plays in our society, delivery of health care continues to mostly occur in a face-to-face setting between doctor and patient. Telemedicine offers the opportunity for providers and patients to communicate remotely via video interfacing and mobile technology while still allowing for accurate diagnosis, quality doctor-patient interactions, and monitoring for complex medical needs. As healthcare providers, we must acknowledge that this form of interaction allows physicians to easily follow a patient’s progress, and save time and resources for our patients.

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Addressing the violence in the news with children

Children are indirectly exposed to acts of violence and terrorism almost continuously via the media.  News media continually cycles global events onto screens in every household. The stress of witnessing a shooting is no longer limited to the bystanders and civilians caught on the scene, but is spread diffusely across state and national borders to viewers in their homes including children. Pediatricians can help children and their caretakers process these tragedies better.  

Exposure to such news stories can contribute to a stressful environment for the child. In recent years the AAP has focused on ‘toxic stress’ in a child’s life. Toxic stress has been defined as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (National Council of Science: Excessive stress disrupts the development of brain architecture). A growing body of evidence suggests that ecology and biology interact to effect development, i.e., the ecobiodevelopmental framework. In the case of toxic stress, a stressful ecology inculcates lasting detrimental effects in biology and behavior. It can lead to development of poor coping skills, unhealthy lifestyle choices, chronic cardiovascular diseases and serves to perpetuate health disparities to mention a few.

Opinions vary on the extent and significance of the effect of exposure to news media coverage of acts of terror and violence. Increasingly, after such an incident, many articles emerge suggesting how parents should talk to their children about violence. Unfortunately, many children do not have the “buffering protection afforded by stable, responsive relationships” with their parents. Parents themselves may face a difficult time coming to terms with the same tragedies. This gap can be bridged by the pediatrician, school and public policy.

Pediatricians can routinely screen for toxic stress. The AAP has put forward many helpful resources which advise parents on how to talk to their children regarding media violence, tragedies they may have witnessed, school shootings and disasters. Whenever such news is circulating, pediatricians can ask parents if they have trouble communicating with their children about it, expand on their anticipatory guidance using the pre-existing AAP guidelines and recommend appropriate resources to them.  Further, pediatricians in collaboration with mental health professionals can meet with parent-teacher associations to share how children are able to best process these events.

Schools can engage their own mental health services and counselors to have a discourse with children in an age-appropriate manner. In the absence of adequate resources, these sessions could be done in groups and limited to when the event is local.

Finally, state government officials can improve funding for mental health services for children and implement strategies to incentivize an increase in the mental health professionals catering to the pediatric population. Legislators can formulate guidelines for Social and Emotional Learning (SEL) curriculum for grades K-12 as exist for pre-kindergarten. As of December 2015, free-standing guidelines for Social and Emotional Learning exist only in the states of Illinois, West Virginia and Kansas. Bills proposing training of teachers and principals to address social and emotional development needs of students have been previously introduced in the U.S. House (H.R.850; H.R.497) and the U.S Senate (S.897) in 2015. In the same year, a bill (HB 3289) was also introduced in the Texas Legislature proposing formulation of a local school health advisory committee to address mental health concerns existing in school efforts and to make recommendations to the school district concerning the integration of social and emotional learning into the academic curriculum.

Adopting such a multi-pronged approach will better preserve the childhoods of the current generation and safeguard their adult lives as well.

References:

1.       National Scientific Council. Excessive stress disrupts the development of brain architecture. Journal of Children’s Services. 2014 Jun 10;9(2):143-53. Accessed July 11, 2016. URL: http://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf

2.       Shonkoff, J.P.; Garner, A.S. Technical Report: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012. doi:10.1542/peds.2011-2663

3.       Committee on psychosocial aspects of child and family health, committee on early childhood, adoption, and dependent care, and section on developmental and behavioral pediatrics. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012. doi:10.1542/peds.2011-2662

4.       Busso, D.S.; McLaughlin, K.A.; Sheridan, M.A. Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings. Depress Anxiety. 2014 July ; 31(7): 551–558. doi:10.1002/da.22282

5.       Marie Leiner, M.; Peinado, J.; Villanos, M.T.M.; Lopez, I.; Uribe, R.; Pathak, I. Mental and emotional health of children exposed to news media of threats and acts of terrorism: the cumulative and pervasive effects. Frontiers in Pediatrics. 2016. doi: 10.3389/fped.2016.00026

6.       Collaborative for Academic, Social and Emotional Learning. Identifying K-12 Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: https://pedsadvocacy.files.wordpress.com/2016/07/a46cb-state-scorecard-summary-table-for-k-12-12-16-15.pdf

7.       Collaborative for Academic, Social and Emotional Learning. Identifying Preschool Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: http://static1.squarespace.com/static/513f79f9e4b05ce7b70e9673/t/55df7c05e4b031d82f728c5d/1440709637809/preschool-table-8-27-15.pdf

8.       Texas Education Agency. Accessed July 9, 2016. URL: http://tea.texas.gov/index2.aspx?id=2147495508

 

Gohar Warraich, M.D.

 

Removing Barriers to Enrollment in Medicaid and CHIP

Recent figures show that approximately 31 million (or 42%) of U.S. children receive health insurance through Medicaid or CHIP.1,2 These programs have been critical in improving access to pediatric care, which studies show improves medical utilization and leads to better personal, educational, and societal health outcomes. Thus, as healthcare providers, it is critical that we understand how these systems function if we hope to advance our nation’s health. (more…)

Lack of Medicaid expansion in Texas continues to impact uninsured

Dr. Rachael Johnston posted a thoughtful piece about a year ago about the impacts of Texas’ refusal to accept additional funding for Medicaid that is available through the Affordable Care Act. This week, on the heels of the opening of a brand-new Parkland Hospital in Dallas, a hospital that provides care for thousands of low-income patients, the Dallas Morning News has published and editorial outlining the impact that this policy decision has had on the state.

UPDATE: Support the ACE Kids Act of 2015 for Children with Complex Medical Conditions

In January 2015, a bipartisan group of U.S. Senators and Representatives introduced the Advancing Care for Exceptional Kids Act of 2015 (ACE Kids Act), S. 298 and H.R. 546. If passed the Act will improve Medicaid care for the children with complex medical conditions. The legistation currently has 136 co-sponsors in the House of Representatives and 19 co-sponsors in the Senate. The bill has been referred to committees in both the House and Senate, but it has not progressed further. To move the legistlation forward for a vote, I encourage you to contact your Congressional Representative and the Texas Senators to express your support for this bill.

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The Pediatric Subspecialist Shortage

We often hear about the shortage of general practitioners when it comes to adult medicine. Our newly minted doctors are foregoing primary care and opting to pursue further fellowship training in preparation for careers as subspecialists following their residency training in internal medicine. Interestingly, pediatrics has the opposite problem. Adult medicine has 36 specialists for every 100,000 patients whereas pediatrics only has 13 specialists for every 100,000 pediatric patients. We have a gross shortage of pediatric subspecialists ready to take care of the complex medical problems which are beyond the scope of practice for the general pediatrician. (more…)