Issues Page

The presidential campaign is a little more than three weeks old and the indications are that health care has fallen off the radar screen. One measure is each candidates' acceptance speech at the convention. The speeches give a clear indication of their priorities and their sense of where they think the campaign and country are focused. As a Democrat and the "agent of change," the expectations that Barack Obama is committed to do something important on health care are fairly high. Furthermore, in a speech devoted to distinguishing his and John McCain's philosophies and priorities, health care would seem to be, well if not Exhibit A, then at least B or C. Thus, it was hard for a health policy wonk not to be disappointed. Mr. Obama spent less than a minute on health care, about 100 words out of 4,900. The expectations for Mr. McCain were much lower. He is not running as a leader on domestic policy, and his proposals on health care have been anemic. His proposals do not even aspire to actually fix the broken system. He spoke all of two sentences, less than 50 words of a 4,000 word speech, on health care.

Since 2001, the government has spent almost $50 billion for national biodefense at sites such as Fort Detrick and other specialty laboratories and universities, and this amount is likely to increase further with ambitious plans to build high-containment laboratories across the country. However, there is a largely unaddressed biological threat that does exist in America today - especially in places where poverty is concentrated, such as Baltimore. It is a hidden underbelly of poverty-related diseases that are ordinarily thought of as health problems in less-developed countries. The mainly Hispanic and African-American populations living in inner cities and rural areas are suffering from high rates of these ailments, known as the "neglected infections of poverty."

On few issues do Barack Obama and John McCain diverge as dramatically as they do on healthcare. Both say they want to reduce costs and expand coverage to the 47 million uninsured. But while Obama wants to build on the existing employer-based system with new coverage plans for families and businesses, McCain aims to move the country away from work-based insurance and toward a system in which all Americans cut their own deals with private insurers. If the national campaign ever gets past lipstick and the collapse of investment banks, these differences on healthcare may get the attention they deserve.

Chaplains are one of the newest methods used by the Department of Veterans Affairs to treat the nation's veterans. Their job: to assess the spiritual and emotional health of such veterans as Ratajczak and report back to nurses and doctors, in hopes of developing a more "holistic" course of treatment. Such "spiritual assessments" are now routinely conducted on entering patients, though they are not mandatory. Critics, however, say the program runs afoul of the separation of church and state, and say a patient's "spiritual" health should have no bearing on his or her physical treatment. Chaplains at the Baltimore VA hospital do not promote any particular religion, said Thomas, a Protestant, but add a "spiritual dimension" that patients often need.

The Catholic Church in Latin America is changing its approach to the continuing epidemic of HIV and AIDS, and many are welcoming the changes. "While moral double standards and stigma remain strong elements of the response to HIV and AIDS in many evangelical and Protestant churches, I've recently seen an enthusiastic willingness to deal openly with the epidemic from Catholic leaders," said Dr. Eduardo Campana, an Ecuadorean who heads an AIDS program for the Latin American Council of Methodist Churches. The bishops urged people to work together to fight discrimination against those with AIDS and to avoid judging them.

The pioneering Massachusetts program to provide health insurance for all citizens looks more and more successful with each passing month. The number of uninsured has dropped - Massachusetts now has the lowest rate in the nation - and so have the number of those who turn to costly emergency rooms for routine care. And while the state has had to seek additional sources of revenue - mainly because of the program's popularity - the gains in the first 21 months suggest that the plan could become a model for universal health coverage for other states or the nation. The plan requires everyone to take out health insurance or suffer a tax penalty and requires employers to offer coverage or pay a small assessment if they don't. Low-income residents can enroll in an expanded state-federal Medicaid program or receive subsidies to pay all or part of the premiums for private insurance. Those who earn more than 300 percent of the federal poverty level (about $63,000 for a family of four) receive no subsidy but can buy private policies through a new insurance exchange at much lower rates than before.

A s the presidential campaign goes into full swing, the American public is likely to be bombarded with the kind of misleading clichés and false dichotomies that distort serious discussion of health care reform in this country. One of these false dichotomies is "private market versus government" health care or "private market versus socialized medicine." Both terms mislead because their users seem not to understand precisely what the terms mean or, if they do, use them mischievously. The term "socialized medicine" in particular conveys to some an objectionably "un-American" form of government: socialism.

The two major presidential candidates agree on at least one thing: health care reform must be a high priority for the next administration. But when it comes to the details, much of the common ground between Republican Sen. John McCain and Democratic Sen. Barack Obama falls away. In their 2007 document on political responsibility, "Faithful Citizenship," the U.S. bishops said any efforts to reform the health care system must respect human dignity and protect human life; meet the needs of the poor and uninsured, including pregnant women, unborn children, immigrants and other vulnerable populations; protect the conscience rights of Catholics and Catholic institutions; and provide effective, compassionate care for those with HIV and AIDS.

The black church - traditionally a loud voice for social change - has been curiously silent on the crisis of AIDS in the African-American community, and some say, even negligent. Despite the fact that pastors across the south have offered small consolation to people infected with the virus, AIDS activists say they need black churches the help stem the growing tide of new HIV and AIDS cases. While African-Americans represent 19 percent of the south's population, Pinkston reports they're 56 percent of new AIDS cases in the region. It is an issue that the people of God must address, said Reverend Claude R. Alexander, Jr., of the University Park Baptist Church in Charlotte, N.C.

With prospects quite good for a Democratic Congress and administration in 2009, the United States is on the brink of joining all other industrialized nations in ensuring the provision of some form of basic health care for all Americans. Reforming American health care is the single most important public-policy issue on the Democratic agenda, and policy experts are weighing in from all sides. I will confine this article to offering some practical reflections on issues that may bear on the final shape of any approved plan.

The Sisters of St. Joseph, as the formal sponsor of a health-care system covering 14 hospitals and 20,000 workers in three states, were the target of an organizing effort by the Service Employees International Union. After five years of escalation, the union had brought its campaign literally to the doorstep of the sisterhood, holding rallies and worship services. In practical terms, the stakes are about 9,000 employees of eight of the nine St. Joseph hospitals in California, essentially all the workers except doctors, nurses and operating engineers. The impasse between the union and the hospital system involves the rules for holding an election on whether, and by whom, those employees want to be represented in collective bargaining.

Each year, many people make the journey to the small town of Wise to take advantage of a huge annual medical and dental expedition set up by Remote Area Medical, a nonprofit organization that provides basic medical and dental care to people in the world's most inaccessible regions. This year, more than 1,800 volunteer doctors, dentists, nurses and assistants descended on the small town near the Kentucky border, setting up enormous field-hospital-style tents in which they saw roughly 2,500 patients over the course of two and a half days in late July. The Wise operation is coordinated locally by a team of nurses with the Health Wagon, a tiny health-care outreach program. By the end of the weekend, the medical team, had extracted 3,857 painfully decayed teeth, administered 156 mammograms, screened hundreds of people for diabetes and heart disease, and given out 1,003 pairs of eyeglasses.

The death of the 23-year-old transgender Mexican immigrant is at the forefront of discussions at this week's international AIDS conference in Mexico City. Rights activists say it shows the failure of immigration officials to deal humanely with HIV-positive inmates among the 30,000 migrants held in detention centers across the United States. New York-based Human Rights Watch surveyed detention center officials and inmates after Arellano's death and found 14 cases in which it said HIV-infected immigrants were not given proper care while in custody of U.S. Immigration and Customs Enforcement.

Federal law requires hospitals to provide emergency care regardless of immigration status or ability to pay. St. Joseph's Catholic hospital in Phoenix, AZ now sends an average of seven uninsured immigrants a month back to their native countries for treatment, often against the wishes of family members, hospital officials say. Before 2000, the hospital rarely transferred any patients out of the country, perhaps only two or three times a year, the officials said. Not all patients who are sent back are undocumented immigrants. The hospital also is sending back legal immigrants who don't qualify for long-term Medicaid. Hospital officials attribute the practice to stricter laws and tighter controls at the state and federal levels that have made it harder for immigrants to obtain non-emergency Medicaid care, for which U.S. citizens are eligible. The hospital says the changes have forced it to transfer more immigrants to their native countries when they require long-term care and lack insurance.

The Bush Administration is reviewing the draft of a regulation that would require hospitals receiving federal funds to respect the religious freedom of health care workers by ensuring that workers do not have to participate in medical procedures that they consider morally objectionable. The regulation is especially concerned with the performance of abortion and the administration of "Plan B" morning after pills, which are considered emergency contraception by some but an abortifacient by others.

A Bush administration proposal aimed at protecting health-care workers who object to abortion, and to birth-control methods they consider tantamount to abortion, has escalated a bitter debate over the balance between religious freedom and patients' rights. The Department of Health and Human Services is reviewing a draft regulation that would deny federal funding to any hospital, clinic, health plan or other entity that does not accommodate employees who want to opt out of participating in care that runs counter to their personal convictions, including providing birth-control pills, IUDs and the Plan B emergency contraceptive. Conservative groups, abortion opponents and some members of Congress are welcoming the initiative as necessary to safeguard doctors, nurses and other health workers who, they say, are increasingly facing discrimination because of their beliefs or are being coerced into delivering services they find repugnant.

Slowly but surely the long-held article of faith that the United States has the world's finest healthcare is eroding in the face of mounting evidence. A fresh report from the prestigious Commonwealth Fund concludes that "despite spending more on healthcare than any other industrialized nation, the US overall continues to fall far short on key indicators of health outcomes and quality." Dig deeper into the report - and look around at other indicators, as well - and it becomes clear that there are important trends in healthcare today which bode well for a future of improved quality.

If black America were a country, it would rank 16th in the world in the number of people living with the AIDS virus, the Black AIDS Institute, an advocacy group, reported yesterday. The report, financed in part by the Ford Foundation and the Elton John AIDS Foundation, provides a startling new perspective on an epidemic that was first recognized in 1981. Nearly 600,000 blacks are living with HIV, the virus that causes AIDS, and up to 30,000 are becoming infected each year. When adjusted for age, their death rate is 2 1/2 times that of infected whites, the report said. Partly as a result, the hypothetical nation of black America would rank below 104 other countries in life expectancy.

U.S. bishops and the aid organization Catholic Relief Services welcomed the passage of the President's Emergency Plan for AIDS Relief. Congress passed PEPFAR last week and President George Bush said Saturday he is eager to sign it. Both the bishops' conference and the aid organization expressed appreciation at the retention of the "conscience clause," which will help assure that Catholic and other faith-based organizations are not discriminated against as HIV/AIDS service providers.

Most health insurance companies exist to make a profit for their shareholders. Profit motives are great when applied to commodities, but health care is not a commodity, and the health insurance market is not good for the health and well-being of Americans. Medicare was established as our taxpayer-supported health care financing system for senior citizens, and it has been a resounding success. The establishment of Medicare HMOs was a perfect experiment to test the hypothesis that the private market could do better. The results are clear: Medicare HMOs cost more and deliver less care than traditional Medicare. It is time to start expanding rather than assaulting Medicare.