If you or someone you are close to has ever tried to get more than a doctor’s appointment for deep depression, alcoholism or a drug addiction, you already know that figuring out where to get care and who will help cover the cost is messy.
Now that struggle is spelled out in the first health care cost trends report from Attorney General Maura Healey. It takes stock of behavioral health benefits and the low health insurance pay rate for these services in Massachusetts. Healey is shifting the focus of her office’s health care cost report after several, under former Attorney General Martha Coakley, that highlighted the wide gaps between payments made to high and low cost hospitals.
Healey says she’s changing gears because “it’s really important to look at the whole health of the patient.”
“We need to get to a place where we treat people who’ve got mental health, substance abuse issues in the same way we treat patients with diabetes or with cancer or with broken bones,” Healey says.
Seventy-nine percent of Massachusetts residents enrolled in MassHealth or ConnectorCare have coverage that separates general medical care from mental health and substance abuse. For members of commercial health plans that number is much lower but still significant: 31 percent. Healey’s report does not say that the separation is necessarily bad, but that the state needs a better system of sharing patient information between medical and behavioral health providers, and more coordination of care.
That call, for better coordination of care, is not new. The problem is supposed to be getting better with the shift to global payments. If you have diabetes and you aren’t taking care of yourself because you are depressed, under global payments both your counselor and your primary care doctor will lose money if they don’t help relieve your depression.
But some global payments separate physical and behavioral health, eliminating the incentive for doctors from those separate worlds to work together. The AG’s report says the state needs “meaningful financial incentives” that will encourage insurers, hospitals, physicians and nurses to “integrate the delivery of medical and behavioral services.”
But Health and Human Services Secretary Marylou Sudders says the state needs to prioritize fixing the payment gaps between high and low cost hospitals.
“We have to continue to ensure that we have equity of behavioral health with physical health care before we get to global payments,” Sudders says.
But thousands of doctors and nurses have already moved into this payment system. Can the state make adjustments now?
“We have pockets of global payments,” Sudders says, “but we’re still very much paying behavioral health on fee-for-service structures, so we still have a ways to go.”
The AG’s report reinforces the need to address another long-standing problem: many doctors and hospitals lose money on behavioral health care. The report says hospitals that admit patients for mental health or substance abuse treatment lost 28 cents for every dollar spent on those services between 2010 and 2013. The loss for outpatient care was 45 cents on the dollar.
Staff in the AG’s office said they tried to get more information about who is paid what for behavioral health care in the state, but that it was difficult because providers have different names for the same services and payers don’t use a standards methods.
In the meantime, the report says patients are suffering. Healey highlights the opioid epidemic and points out that “behavioral health is the top primary diagnostic category for most age groups 44 and under” at Massachusetts acute care hospitals. Not treating addiction or depression is expensive. The report finds patients who have asthma and anxiety, or some other combination of a medical and behavioral health problem, spend between two and two-and-a-half times more on health care than do patients with just a medical condition.
The Massachusetts Association of Health Plans says it shares the AG’s concerns about making sure patients can get mental health services. MAHP points out that its plans receive good ratings and follow national guidelines for care.
“We look forward to working with the Attorney General on measures to improve care coordination of behavioral health services, while also being mindful of our collective goal of containing costs as established under the state’s 2012 Payment Reform Law,” Lora Pellegrini, MAHP president and CEO, said in a statement.
By Marina Renton
Wondering whether you should forgo your Starbucks run in favor of a cross-country run before work? According to a study just out in the June issue of the journal Medicine & Science in Sports & Exercise, no need to give up your morning cup (or two) of coffee for a trip to the gym. In fact, the caffeine could enhance your performance — particularly your legwork.
The study is titled “Caffeine’s Ergogenic Effects on Cycling: Neuromuscular and Perceptual Factors.” (Vocabulary note: “Ergogenic” means “enhancing physical performance.”) It consisted of two experiments in which young adults consumed caffeine — equivalent to between two and three cups of coffee — and then cycled using their legs and arms.
The researchers found that caffeine improved leg muscle performance but not arm muscle performance, and it decreased sensations of pain and perceived effort in both legs and arms when the exercise was at a moderate intensity level.
The takeaway? Barring any special circumstances — like being adversely affected by caffeine or having heart trouble — you needn’t hesitate to caffeinate before you exercise.
I spoke with Christopher Black, assistant professor of Health and Exercise Science at the University of Oklahoma and lead author of the study. Our conversation, lightly edited:
Could you summarize the study’s results?
There are multiple parts to the study but, in general, here’s what we found: Consumption of a 5-milligram-per-kilogram body weight dose of caffeine — which is the equivalent of maybe two to three cups of coffee depending upon how much you weigh and what kind of coffee it is — improves cycling performance if you ride the bike with your legs. But, that same dose does not improve cycling performance if you ride the bike with your arms. And that’s the big, real-world performance measure of things.
We ascribe that difference of effect to the fact that caffeine improved people’s strength in their legs but not in their arms. And it improved that strength by allowing them to turn on more of their muscle.
In what form were people given the caffeine?
It’s powdered caffeine; we mixed it up into little tablets, and they swallowed it with some water.
Is it possible to suggest that people drink caffeine before exercising?
Absolutely, they should drink caffeine. They should take caffeine in any possible form before exercising. There are 20 or 30 or 40 studies that have demonstrated a very similar thing to what we found in the legs. For endurance-type performance, caffeine is absolutely going to improve your performance.
Are there any caveats? For example, an excess of caffeine makes some people jittery, so could that wind up inhibiting muscle performance?
I don’t know that we have a lot of scientific data supporting the fact that it can in some people actually decrease performance. But, there is scientific data that in certain people, let’s say you’re a high-anxiety person, consuming large amounts of caffeine may exacerbate your anxiety. And it may make you more jittery.
There does seem to be — and this is, again, somewhat anecdotally — kind of a tipping point where, if the dose gets to be too high, you can’t concentrate and you’re fidgety. So it’s plausible to me that, at some high levels, caffeine could actually make performance worse. But, in these typically-tested doses, as long as you don’t have some sort of adverse reaction to the caffeine — which could be jittery, potentially in some people it might upset their stomach, although there’s really very limited data that suggests that’s going to be the case.
Then there are potentially some people that caffeine just does not affect. There are some people that we would term to be non-responders. It doesn’t really matter how much they have, they just do not exhibit the typical response.
And if people are not responsive to caffeine, would they not experience the improved exercise performance?
That’s a tricky needle to thread as a scientist. I’m unaware that there are data that support that conclusion, but that again seems very plausible to me.
Is there a risk for people with certain heart conditions because of the combined increased heart rate from exertion and caffeine consumption?
The general response is: not necessarily. I don’t know that caffeine plus exercise is necessarily riskier than exercise all by itself from that standpoint. Now that would be with the great caveat of: If you’re an at-risk population, then you should get physician’s clearance. I am unaware of any studies that have been done to say that caffeine makes exercising more dangerous, although exercise is inherently dangerous, especially if you’re a cardiac person.
We do tend to see a bit of an exaggerated heart rate response during exercise for the people that consumed caffeine. Heart rate is up a little bit, so there is theoretically greater stress being placed on the heart. So that could potentially be somewhat more dangerous.
It seems kind of counterintuitive, but there is some data suggesting that, if you have a cup of coffee and you sit and you rest, caffeine actually lowers heart rate. You would think, caffeine is a stimulant, so it should make my heart rate go up. And there are several studies that find that is actually not true.
What made you interested in embarking on this study?
It was well-known in our field that caffeine improves exercise performance. One of the questions that was out there, though, was: Why? How does it work? By doing arm and leg exercise, we thought that this would be a unique way to try and manipulate the effects of caffeine on muscular strength and the activation of those muscles.
Study participants also experienced less pain and less perceived effort, right?
If the exercise is done in a certain way, then they did actually experience less perceived exertion and less muscle pain. And again, that’s also a finding that is similar to several previous studies. But it only works that way in very controlled circumstances.
We prescribed an intensity of exercise to our folks; they rode either with their arms or their legs for 30 minutes. When we asked them to do that at about 60% of their maximal ability — that’s fairly similar to what a lot of people would train at, that’s kind of a jog to a somewhat brisk jog to a lot of people — it did reduce pain, and it did reduce perception of effort. When we increased that to a heavier exercise intensity, then it didn’t lower perception of effort, and it did not lower pain levels.
Is there anything else about the study you would like to share?
Caffeine does seem to improve muscle performance, and the reduced sensations of pain and effort are also potentially very useful for a general population.
If you have a cup of coffee or something before you go to your exercise bout, then you are likely to feel a little bit better during that particular exercise bout. A lot of people have probably anecdotally experienced that, especially if you tend to be a coffee drinker or someone who consumes a lot of caffeine.
Readers, thoughts? Experiences?
This report contains information on provisions in constitutions and other founding documents specifying an ethnic or religious identity for an Asian or European country. Section I covers twenty countries and includes those indicating an ethnic identity and in some cases also a religious one. Section II covers four countries for whom those documents mention only a religious identity, not an ethnic one, and whose constitutions indicate that the specified religion is the basis for legislation. Section III covers thirteen countries that specify a religion, without necessarily indicating that religion is the basis of legislation and without any single ethnic identity.
Visit http://www.loc.gov/law/help/national-religious-identity/constitutional-provisions.php to read the entire report.
This report is one of many prepared by the Law Library of Congress available at http://loc.gov/law/help/legal-reports.php and one of the new reports highlighted at http://www.loc.gov/law/help/current-topics.php. The Law Library of Congress produces reports for members of Congress and others. Learn more at http://blogs.loc.gov/law/2013/05/law-library-provides-global-legal-research/.
The following is a guest post by Tariq Ahmad, a legal analyst in the Global Legal Research Directorate of the Law Library of Congress. Tariq has previously blogged about Islamic Law in Pakistan – Global Legal Collection Highlights, the Law Library’s 2013 Panel Discussion on Islamic Law, Sedition Law in India, and Physician-Assisted Suicide in Canada.
On May 27, 2015, a Pakistani English newspaper, the Express Tribune, reported that the government of Pakistan had finalized a draft bill that would introduce certain amendments to the country’s blasphemy laws. Though the details and full extent of the bill have yet to be made fully public, the article did mention that the proposed changes would include the necessity to prove mens rea, or “guilty” intent, in order to convict a person of blasphemy under section 295-C of Pakistan’s Penal Code, and would provide stiffer penalties for false accusations of blasphemy. The report highlighted that the proposals are aimed at preventing abuse of the law and ensuring that “no one takes the law into their own hands, as only the state (police and courts) are responsible for punishing anyone found guilty” of the crime.
In this post, I take a look at the proposed changes, the issues that they seek to address, and previous attempts to reform the laws.
1. What is the current law?
Pakistan inherited its substantive criminal law, including certain blasphemy provisions, from the British colonial government through the Indian Penal Code, 1860. Historians maintain that the British colonial administrators enacted these provisions in order to preserve order and harmony in British India’s religiously heterogeneous society. In 1927, section 295-A was added to the Penal Code through the Criminal Law Amendment Act, No. 25, to criminalize “insults or attempts to insult the religious beliefs” of any class of “His Majesty’s subjects….” This amendment was made in response to severe communal tensions and riots, particularly resulting from the acquittal by the Lahore High Court of a publisher of a pamphlet meant to insult the founder of the religion of Islam.
In the 1980s, these provisions in Pakistan’s Penal Code were revised as part of then General Zia-ul-Haq’s Islamization process. While the original provisions were religion-neutral, new sections were added to mainly protect against insults to the religion of Islam, including defiling or desecrating the Holy Quran and using derogatory remarks in regards to Muslim holy personages. These changes also included the addition of section 295-C, made pursuant to Criminal Law (Amendment) Act, 1986, which criminalized insults to the Prophet Muhammad.
2. What is the mens rea issue?
The first proposal in the bill, as mentioned in news reports, appears to be in response to criticism that section 295-C is easily exploitable since the crime lacks a mens rea requirement. The section stipulates that: “Whoever by words, either spoken or written, or by visible representation or by any imputation, innuendo, or insinuation, directly or indirectly, defiles the sacred name of the Holy Prophet Muhammad (peace be upon him) shall be punished …” This is in contrast to section 295-A which includes the need to prove “deliberate and malicious intention” with respect to the crime of outraging “the religious feelings of any class by insulting its religion or religious beliefs.”
The lack of a mental element makes section 295-C a strict liability crime, making it a far easier offense to prove despite the fact that it stipulates a far more severe punishment. This has been particularly problematic in the sizable number of blasphemy cases involving mental illness, with critics noting that lower trial courts have convicted mentally ill persons and have even ignored insanity defenses. Dr. Osama Siddique and Zahra Hayat observe that, although there is no guarantee that unfair convictions “would be eliminated if a mens rea requirement were inserted into the blasphemy laws, it is arguable that the chances of such convictions would be lowered.”(pg. 348)
Interestingly enough, the news report also mentions that “as per a Federal Shariat Court judgment of 1990 ‘bad intention’ was a necessary element to establish any offense under section 295-C .” In 1991, the Federal Shariat Court of Pakistan, which is subject to certain jurisdictional limits has the power to “examine and decide the question, whether or not any law or provision of law is repugnant to the injunctions of Islam,” went into some detail on the mens rea issue. It observed that the crime of “contemner of the Holy Prophet” under Shari’a is a hadd, a crime that has a fixed (as opposed to a discretionary) punishment, and that Shari’a “recognizes an offence liable to Hadd only if it is accompanied by an express intention.” (Muhammad Ismail Quereshi vs. Pakistan Through Secretary, Law, and Parliamentary Affairs, PLD 1991 FSC 10, para. 48)
In its final order, the Court held that section 295-C is repugnant to the injunctions of Islam to the extent that it provides life imprisonment as a punishment; however, it did not appear to explicitly direct the Government to add a mental element to the crime. (Id. paras. 67-69.) Moreover, as noted by Dr. Osama Siddique and Zahra Hayat (p. 349), although Pakistan’s appellate courts have read in or imputed an intention requirement in a different section of the blasphemy provisions, or have occasionally done so for section 295-C in the context of bail applications, “this particular provision [295-C] has not received any meaningful judicial attention in terms of mandating an intent requirement through judicial interpretation” during actual trial proceedings.
3. How prevalent are false accusations of blasphemy?
The second proposal in the draft bill appears to be in response to criticism that most cases or police reports are filed on false or frivolous grounds, motivated by persecution of minority groups, rivalry between religious sects, or property or economic disputes. Though exact official figures are hard to come by, human rights organizations and scholars have noted a significant increase in the number of blasphemy cases since the provisions were amended in the 1980s. An oft-quoted 2012 report by the Centre for Research and Security Studies (CRSS) states that:
From 1851 to 1947… there were only seven blasphemy-related incidents but during Zia’s rule along [sic] (1977-1988) alone, as many as 80 blasphemy cases were reported to courts. As a whole, between 1987 and Aug. 2012 we have seen almost 247 blasphemy cases registered or raised, directly affecting lives of 435 persons approximately. (p. 5.)
A 2012 article indicates that estimates for the number of cases filed or police reports made since the amendments vary from 1,200 to 4,000.
In 2010, the chairperson of the Human Rights Commission of Pakistan (HRCP), a Pakistani human rights organization, stated that approximately 80 percent of those accused of blasphemy are “falsely implicated.” Under Pakistan’s Penal Code, filing a false report is punishable by up to six months of imprisonment. However, legal action for a false complaint is seldom taken due to fear of the accused being victimized. It is unclear, therefore, the extent to which providing a stiffer penalty for false accusations of blasphemy will be a sufficient deterrent.
4. How do the courts treat blasphemy cases?
Judicial treatment of blasphemy has varied. Pakistan’s lower courts, which are reported to “often face threats, intimidation and pressure, specifically while dealing with blasphemy cases,” tend to convict while higher courts typically overturn these convictions. For example, in August 2002, the Supreme Court of Pakistan overturned the conviction of Ayub Masih, a Christian who was accused of making “certain derogatory remarks” about the Prophet Muhammad and for recommending that the complainant read Sulman Rushdie’s book Satanic Verses. (Ayub Masih vs. The State, 2002 PLD 1048 SC, para. 10.) The Court questioned the veracity of the evidence put forth by the prosecution, the possible malafide motivation of the complainant, who was involved in a land dispute with Masih, and the possibility that the alleged events were fabricated due to the unwarranted and unexplained delay in filing the police report. Also, in another important case in 2002, the Lahore High Court noted the increased number of blasphemy cases and how “an element of mischief” is involved in them being filed while providing guidelines on how such cases should be investigated by police. (Muhammad Mahbood alias booba vs. The State, PLD 2002 Lahore 587, para. 30.)
Dr. Osama Siddique and Zahra Hayat state that most blasphemy convictions are overturned by provincial high courts on appeal typically (as in the case above) on the basis of “weakness, inconsistency, and lack of veracity of evidence,” procedural issues with respect to investigations, prosecutions, or trial processes, or malafide motives on the part of the accusers. (p. 325-26)
Although most blasphemy convictions are overturned by provincial high courts on appeal, there has been concern that even Pakistan’s superior judiciary can come under pressure or influence from hardline religious groups. In a relatively recent example, in 2014, the Lahore High Court upheld the death penalty conviction in the high profile case of Aasia bibi, a decision that has come under considerable international criticism.
5. Have there been previous attempts at reform?
Relatively recent efforts to reform or repeal the blasphemy laws have faced strong opposition from religious organizations, political parties, and clerics, and have not been enacted. In 2011, certain procedural and substantive amendments aimed at preventing abuse of the law were proposed in a private member’s bill. However, the bill was dropped after receiving strong opposition from religious clerics. One of the proposed changes was to reduce the punishments in certain sections of the blasphemy laws, including removing the mandatory death penalty and replacing it with imprisonment for a term of up to 10 years for committing the crime contained in section 295-C. Other proposed changes would have required a judicial warrant for an arrest to be made and removed the jurisdiction of the lower Session courts to try blasphemy cases. In addition, the bill would have required that “anyone making false or frivolous accusation under any of the sections of 295 A, 295 B and 295 C . . . shall be punished in accordance with similar punishments prescribed in the section under which the false or frivolous accusation was made.”
Voices on reform, even among official religious bodies, can also come under pressure to reverse their positions. For example, as I’ve previously written, “on September 18, 2013, the Council of Islamic Ideology (CII), a constitutional advisory body on Shari’a issues, proposed the application of the death penalty for those making false accusations of blasphemy, in order to prevent abuse of the law. However, a few days later the Council dropped the proposal and stated that the existing law against false registration of cases is sufficient.”
One amendment did successfully pass in 2004, adding a section to Pakistan’s Code of Criminal Procedure that prohibits police officers below the rank of superintendent from investigating cases involving derogatory remarks in respect to the Holy Prophet. However, according to human rights groups, the procedural rule has not been “uniformly applied” or is “rarely used.”
At the provincial level, recent minor reforms and initiatives have been taken to attempt to alleviate problems of abuse. According to a news report, on April 11, 2015, the Sindh provincial assembly passed an amendment to the Sindh Mental Health Act, which now requires those accused of blasphemy to undergo a mandatory psychiatric evaluation and accords courts discretionary authority to decide whether or not to reduce the sentence of those found to be suffering from mental illness. In February 2015, it was reported that the Punjab provincial government had instituted “fast track” trials to “speedily decide the fate of alleged blasphemers” who may have been victimized by complainants and who are “languishing in jails and are not being convicted because of lack of evidence, poor evidence, and non-availability of their counsel.”
A report of the Immigration Refugee Board of Canada states that the main challenge for activists, politicians, and officials to reform Pakistan’s blasphemy laws is the threats they face from extremist and sectarian groups who consider that “even to advocate for legislative reform” is a blasphemous act.
Tuesday would have been the last day of operation for 10 Texas clinics that provide abortion. But on Monday the U.S. Supreme Court, in one of its final actions this session, said the clinics can remain open while clinic lawyers ask the Court for a full review of a strict abortion law. Two dozen states have passed regulations similar to the ones being fought over in Texas.
Two years ago, when Texas passed one of the toughest laws in the country regarding abortion, the number of clinics offering the procedure dropped from 41 to 19. Amy Hagstrom Miller, chief executive of Whole Woman’s Health, has already closed two clinics in Texas because of the law and was about to close two more.
“Honestly I just can’t stop smiling,” Hagstrom Miller said. “It’s been so much up and down … so much uncertainty for my team and the women that we serve.”
The Texas law says doctors who perform abortions must have admitting privileges at a nearby hospital. But some hospitals are reluctant to grant those privileges because of religious reasons or because abortion is so controversial.
The law also requires that clinics meet the same standards as outpatient surgery centers. Those upgrades can cost $1 million or more.
“It’s an example of the rash of laws … that have taken a sneaky approach by enacting regulations that pretend to be about health and safety but are actually designed to close down clinics,” said Nancy Northrup, chief executive of the Center for Reproductive Rights, which is representing clinics in their fight to overturn the Texas law.This story is part of a partnership that includes Houston Public Radio, NPR and Kaiser Health News. It can be republished for free. (details)
Supporters of the law say every woman deserves good medical care whatever the procedure.
“While we hope that she would not be compelled to choose abortion, we hope that her life would of course not be at risk should she choose to do that,” said Emily Horne of Texas Right to Life. “Pro-life does not just mean care for the life of the unborn child, it’s care for the life of the woman undergoing the abortion as well.”
The law has had a drastic effect in Texas, the country’s second most populous state, leaving most of the remaining clinics in major cities.
There’s just one clinic left along the Mexican border and one in far west El Paso – they were among the nine about to shut down.
If they had closed, the women there faced roundtrips of 300 miles or more to get an abortion.
Hagstrom Miller says all these clinic rules and the doctor restrictions are a deliberate strategy waged by anti-abortion groups. “They’re going state by state by state,” she said. “They can’t make it illegal, so they’re basically making it completely inaccessible.”
Other states that have passed similar laws are also facing legal challenges.
Emily Horne, of Texas Right to Life, says her group would welcome a legal review by the U.S. Supreme Court.
“With this case, issuing some more guidance on that could be very helpful for the pro-life movement in determining what courses to pursue, which laws they might pass in other states in the future.”
The clinics in Texas can stay open at least until the fall. If the court decides to take the case, it would hear arguments in its next term that starts in October.