Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Learning the Moral Economy of Commodified Health Care: “Community Education,” Failed Consumers,and the Shaping of Ethical Clinician-Citizens

Leaders of health professional schools often support community-based education as a means of promoting emerging practitioners’ awareness of health disparities and commitment to serving the poor. Yet, most programs do not teach about the causes of health disparities, raising questions regarding what social and political lessons students learn from these experiences. This article examines the ways in which community-based clinical education programs help shape the subjectivities of new dentists as ethical clinician-citizens within the US commodified health care system. Drawing on ethnographic research during volunteer and required community-based programs and interviews with participants, I demonstrate three implicit logics that students learned: (1) dialectical ideologies of volunteer entitlement and recipient debt; (2) forms of justification for the often inferior care provided to “failed” consumers (patients with Medicaid or uninsured); and (3) specific forms of obligations characterizing the ethical clinician-citizen. I explore the ways these messages reflected the structured relations of both student encounters and the overarching health care system, and examine the strategies faculty supervisors undertook to challenge these messages and relations. Finally, I argue that promoting commitments to social justice in health care should not rely on cultivating altruism, but should instead be pursued through educating new practitioners about the lives of poor people, the causal relationships between poverty and poor health, and attention to the structure of health care and provider–patient interactions. This approach involves shining a critical light on America’s commodified health care system as an arena based in relations of power and inequality.     

Evaluating the risks of public health programs: Rational antibiotic use and antimicrobial resistance

Existing ethical frameworks for public health provide insufficient guidance on how to evaluate the risks of public health programs that compromise the best clinical interests of present patients for the benefit of others. Given the relevant similarity of such programs to clinical research, we suggest that insights from the long‐standing debate about acceptable risk in clinical research can helpfully inform and guide the evaluation of risks posed by public health programs that compromise patients’ best clinical interests. We discuss how lessons learned regarding the ethics of risk in one context can be fruitfully transferred to the other, using the example of a so‐called ‘rational antibiotic use’ guideline that limits antimicrobial prescribing in order to curb antimicrobial resistance.     

Ethnic politics and labour market closure: Shipbuilding and industrial decline in Northern Ireland

This article examines the interplay of ethnic conflict and economic interests in Northern Ireland, specifically for the case of the shipbuilding industry, which received massive state aid despite its terminal decline. Parkin's theory of dual social closure by members of the subordinate class but dominant status group to monopolize resources and opportunities is employed to examine the interests and actions of Protestant workers. The contribution of local institutions including Extended Internal Labor Markets to the salience of Protestant group solidarity is examined from a political economy perspective. Political accommodation between Protestant labour and the Northern Ireland government, and later British government political fears of antagonizing Loyalist workers, facilitated huge aid to a failing industry.     

Rethinking the Response to Emerging Microbes: Vaccines and Therapeutics in the Ebola Era—a Conference at Harvard Medical School

Harvard Medical School convened a meeting of biomedical and clinical experts on 5 March 2015 on the topic of “Rethinking the Response to Emerging Microbes: Vaccines and Therapeutics in the Ebola Era,” with the goals of discussing the lessons from the recent Ebola outbreak and using those lessons as a case study to aid preparations for future emerging infections. The speakers and audience discussed the special challenges in combatting an infectious agent that causes sporadic outbreaks in resource-poor countries. The meeting led to a call for improved basic medical care for all and continued support of basic discovery research to provide the foundation for preparedness for future outbreaks in addition to the targeted emergency response to outbreaks and targeted research programs against Ebola virus and other specific emerging pathogens.     

State- and payer-specific estimates of annual medical expenditures attributable to obesity

The goal of this study is to expand prior analyses by presenting current state-level estimates of the costs of obesity in total and separately for Medicare and Medicaid. Quantifying current Medicare and Medicaid expenditures attributable to obesity is important because high public sector costs of obesity have been a primary motivation for publicly funded obesity prevention efforts at the state level. We also present estimates of the obesity-attributable fraction (OAF) of total, Medicare, and Medicaid expenditures and the percentage of total obesity costs within each state that is funded by the public sector. We used the 2006 Medical Expenditure Panel Survey, nationally representative data that include information on obesity and medical expenditures, to generate an equation that predicts annual medical expenditures as a function of obesity status. We used the 2006 Behavioral Risk Factor Surveillance System, state representative data, and the equation generated from the national model to predict state (and payer within state) expenditures and the fraction of expenditures attributable to obesity for each state. Across states, annual medical expenditures would be between 6.7 and 10.7% lower in the absence of obesity. Between 22% (Virginia) and 55% (Rhode Island) of the state-level costs of obesity are financed by the public sector via Medicare and Medicaid. The high costs of obesity at the state level emphasize the need to prevent and control obesity as a way to manage state medical costs.     

Poverty in the United States as Defined by Federal Standards—Report of the Bureau of Research and Planning

The subject of this Socio-Economic Report is of tremendous importance to the medical profession because physicians should be aware that future programs for the expansion of health care services will be based and, in fact, are being based upon information which this Report contains. The relationship between poverty and accessibility of health care services is therefore quite direct. So, too, will be the impact upon the profession and the organization of medical practice.The 1966 amendments to the Poverty Act are concerned with neighborhood health centers and a vast array of other programs which will touch every physician and every community which can be identified by the standards indicated in this Report as low income, poor, or near poor. For this reason the California Medical Association Committee on Welfare Medical Programs, among several others concerned with aspects of this problem, is trying to alert every county medical society of developments as well as of the responsibilities they should assume in working with the Office of Economic Opportunity and other community organizations in providing guidance and leadership in structuring programs compatible with the interests of the public and the health care professions.This Report on poverty presents a current and prospective view of the problems and issues to be faced. Unless physicians see the relationship and join in a community effort to aid in resolving an issue which underlies public policy, we shall be looking back five or ten years from now to point out that we failed to take advantage of opportunities to assist in the development of a rational system of medical care for low-income groups.Individual physicians, component medical societies on a grass-roots level and CMA as a state organization should all be concerned with and aware of the facts.     

The return on investment of a Medicaid tobacco cessation program in Massachusetts

Background and Objective

A high proportion of low-income people insured by the Medicaid program smoke. Earlier research concerning a comprehensive tobacco cessation program implemented by the state of Massachusetts indicated that it was successful in reducing smoking prevalence and those who received tobacco cessation benefits had lower rates of in-patient admissions for cardiovascular conditions, including acute myocardial infarction, coronary atherosclerosis and non-specific chest pain. This study estimates the costs of the tobacco cessation benefit and the short-term Medicaid savings attributable to the aversion of inpatient hospitalization for cardiovascular conditions.

Methods

A cost-benefit analysis approach was used to estimate the program''s return on investment. Administrative data were used to compute annual cost per participant. Data from the 2002–2008 Medical Expenditure Panel Survey and from the Behavioral Risk Factor Surveillance Surveys were used to estimate the costs of hospital inpatient admissions by Medicaid smokers. These were combined with earlier estimates of the rate of reduction in cardiovascular hospital admissions attributable to the tobacco cessation program to calculate the return on investment.

Findings

Administrative data indicated that program costs including pharmacotherapy, counseling and outreach costs about $183 per program participant (2010 $). We estimated inpatient savings per participant of $571 (range $549 to $583). Every $1 in program costs was associated with $3.12 (range $3.00 to $3.25) in medical savings, for a $2.12 (range $2.00 to $2.25) return on investment to the Medicaid program for every dollar spent.

Conclusions

These results suggest that an investment in comprehensive tobacco cessation services may result in substantial savings for Medicaid programs. Further federal and state policy actions to promote and cover comprehensive tobacco cessation services in Medicaid may be a cost-effective approach to improve health outcomes for low-income populations.     

Effects of parental public health insurance eligibility on parent and child health outcomes

Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents’ self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children’s use of routine doctor visits or parents’ assessment of their children’s health status. We observed modest decreases in children’s body mass index (BMI) of about 2% (p < 0.05), especially for girls.     

Twenty-first century brain banking: practical prerequisites and lessons from the past: the experience of New York Brain Bank,Taub Institute,Columbia University

Generally accepted methods for processing postmortem brains are lacking, despite the efforts of pioneers in the field, and the growing awareness of the importance of brain banking for investigating the pathogenesis of illnesses unique to humans. Standardizing methods requires compromises, institutional or departmental mindset promoting collaboration, and the willingness to share ideas, information, and samples. A sound balance between competition and institutional interests is needed to best fulfill the tasks entrusted to health care institutions. Thus, a potentially widely accepted protocol design involves tradeoffs. We successfully integrated brain banking within the operation of the department of pathology. We reached a consensus whereby a brain can be utilized for diagnosis, research, and teaching. Thus, routing brains away from residency programs is avoided. The best diagnostic categorization possible is being secured and the yield of samples for research maximized. Thorough technical details pertaining to the actual processing of brains donated for research were recently published. Briefly, one-half of each brain is immersed in formalin for performing the neuropathologic evaluation, which is combined with the teaching task. The contralateral half is extensively dissected at the fresh state to obtain samples ready for immediate disbursement once categorized diagnostically. The samples are tracked electronically, which is crucial. This important tracking system is described separately in this issue. This report focuses on key lessons learned over the past 25 years of brain banking including successful solutions to originally unforeseen problems.     

The Impact of Changing Medicaid Enrollments on New Mexico's Immunization Program

Background

Immunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico''s immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices.

Methods and Findings

This study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment.

Conclusions

New Mexico''s improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state''s efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.     

The route to a national health policy lies through the states.

National health program legislation has been becalmed in the Congress for almost 80 years. Despite periodic cries of "crisis," legislation never emerges from committee. Periodically, campaigns have been mounted without success. Tactical efforts to circumvent direct action by legislating bits and pieces of related programs, Medicare and Medicaid, health maintenance organization support, and pre-budgeting, have complicated operation of the medical care system and stimulated intractable cost inflation. For the first 150 years of American history, responsibility for public health and welfare legislation rested with the states. Most public health policies originated in a state or a few states and then later became national legislation. The state efforts were, in effect, natural experiments. After the Depression and the flood of funding from the federal government in subsequent years, the states faded as innovators. It is proposed that funding a few state models to restimulate state initiative in this regard will provide a more effective route to a national health program.     

Impact of CDMA wireless phone power output and puncture rate on hearing aid interference levels

Interference between digital wireless phones and hearing aids occurs when the radiofrequency bursts from the phone transmission are demodulated by the hearing aid amplifier. The amplified interference signal is heard as a "buzz" or "static" by the hearing aid wearer. Most research and standards development activity has focused on worst-case scenarios with the phone operating at its maximum power. Since this power level is often not typical in urban and suburban settings, it is of value to determine the impact of lower power levels on the overall level of audible interference. Using a frequency analyzer, and several hearings aids and code division multiple access (CDMA) phones, the audio frequency spectrum of interference was recorded for each phone-aid combination and for a range of power levels producing from no interference to maximum interference. As phone power is increased, the interference signal becomes distinguishable from the ambient noise level and a linear response region is observed in which a specified increase in power output results in a proportional increase in the overall input referenced interference level (OIRIL). As power is increased beyond the linear region, the hearing aid enters a saturation region where an additional power increase results in a reduction or no increase in the OIRIL. The numeric differences in interference documented in this study were used in conjunction with the results of a previous study by the authors to determine the impact of reduced power on speech intelligibility and annoyance. The amount of improvement for a given power reduction depends on the radiofrequency immunity of the hearing aid and is substantial for hearing aids with poor immunity. For high-immunity aids, the level of audible interference remains low even at high phone power levels.     

Structure of tightly membrane-bound mastoparan-X, a G-protein-activating peptide, determined by solid-state NMR

The structure of mastoparan-X (MP-X), a G-protein activating peptide from wasp venom, in the state tightly bound to anionic phospholipid bilayers was determined by solid-state NMR spectroscopy. Carbon-13 and nitrogen-15 NMR signals of uniformly labeled MP-X were completely assigned by multidimensional intraresidue C-C, N-CalphaCbeta, and N-Calpha-C', and interresidue Calpha-CalphaCbeta, N-CalphaCbeta, and N-C'-Calpha correlation experiments. The backbone torsion angles were predicted from the chemical shifts of 13C', 13Calpha, 13Cbeta, and 15N signals with the aid of protein NMR database programs. In addition, two 13C-13C and three 13C-15N distances between backbone nuclei were precisely measured by rotational resonance and REDOR experiments, respectively. The backbone structure of MP-X was determined from the 26 dihedral angle restraints and five distances with an average root-mean-square deviation of 0.6 A. Peptide MP-X in the bilayer-bound state formed an amphiphilic alpha-helix for residues Trp3-Leu14 and adopted an extended conformation for Asn2. This membrane-bound conformation is discussed in relation to the peptide's activities to form pores in membranes and to activate G-proteins. This study demonstrates the power of multidimensional solid-state NMR of uniformly isotope-labeled molecules and distance measurements for determining the structures of peptides bound to lipid membranes.     

A longitudinal study of medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease

Background

Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period.

Methods and Findings

Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%–70%) and 49% (95% confidence interval 6%–72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated.

Conclusions

Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services. Please see later in the article for the Editors'' Summary     

‘An island of socialism in a capitalist country’: Postsocialist Russian science and the culture of the state

Through a comparison of privatization programs in two physics institutes, this article explores the ways in which scientists in the Siberian science city of Akademgorodok adapted to the low levels of state funding available to them in the 1990s. Scientists transformed structures that were available under socialism into hybrid state-private ventures. Rather than ‘freeing’ Russian science from its former dependence on the state, however, these changes have reconfigured, and in some cases even strengthened, the relationship between state power and the production of knowledge. Seeing ‘the state’ as it is constituted in Russian scientists' discourse challenges Western models of the autonomy of science.     

Failed promises: economic integration, bureaucratic encounters, and the EU-Turkey Customs Union

European integration is based upon the promise to bring prosperity by creating economic and social equilibrium among member states and its regions via integrationist policies jointly managed by states and the institutions of the EU. As one common market initiative for greater economic integration in the wider region, goods circulate without tariff and customs duty barriers in the EU’s common customs area. Turkey, not an EU member, has been in this common market since 1996. The EU-Turkey Customs Union, which promised to bring deeper economic and political integration through eventual Turkish membership, represents Turkey’s aspirations to move from the periphery of Europe into its core. As an anthropological contribution to investigations of advanced European capitalism, this paper examines fundamental conflicts of interest between the EU and Turkey and locates them in their unequal power relations and in the disjuncture of each side’s overall objectives from economic integration. Most importantly, it shows that these interest conflicts have ramifications at the individual bureaucratic level and in daily bureaucratic practice. Dramatic expressions of Turkish state power, which are initially geared toward balancing out power inequities, exacerbate Turkish and EU officials’ failures to maintain at least a facade of mutually sustainable interests. Interpreted by EU officials as Turkish bureaucratic inertia, such disintegration of interests has implications for ongoing economic integration and membership negotiations between the two parties, with Turkish officials experiencing loss of control. The paper calls for a critical political economy that pays due attention to the cultural settings in which the former is embedded.     

Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S

The United States ranks first among developed nations in rates of both teenage pregnancy and sexually transmitted diseases. In an effort to reduce these rates, the U.S. government has funded abstinence-only sex education programs for more than a decade. However, a public controversy remains over whether this investment has been successful and whether these programs should be continued. Using the most recent national data (2005) from all U.S. states with information on sex education laws or policies (N = 48), we show that increasing emphasis on abstinence education is positively correlated with teenage pregnancy and birth rates. This trend remains significant after accounting for socioeconomic status, teen educational attainment, ethnic composition of the teen population, and availability of Medicaid waivers for family planning services in each state. These data show clearly that abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the U.S. In alignment with the new evidence-based Teen Pregnancy Prevention Initiative and the Precaution Adoption Process Model advocated by the National Institutes of Health, we propose the integration of comprehensive sex and STD education into the biology curriculum in middle and high school science classes and a parallel social studies curriculum that addresses risk-aversion behaviors and planning for the future.     

Meeting the Health Care Challenge: Improved Program Management

The Health Care Financing Administration (HCFA) is the government agency that administers Medicaid and Medicare, and is responsible for standards and certification programs, and for Professional Standards Review Organizations. HCFA is attempting to improve program management, while securing the very best health care for the 47 million Medicare and Medicaid beneficiaries. Better management would allow resources to be focused where the greatest need exists and would thereby increase program effectiveness.