This is a guest blog by Jennifer Proctor, a metadata technician. Jennifer is working on the U.S. Reports project with Julie McVey and Quinn Smith. She is also working on the Statutes at Large project.
You’ve probably heard of the Red Baron (Manfred von Richthofen) – the most famous German fighter pilot in history – but it may be harder to recall the great U.S. pilots who fought against him in the skies over the trenches of the First World War. Though little known today, for much of the war the most famous American pilots – Norman Prince, William Thaw, Elliot Cowdin, Raoul Lufbery, and Kiffin Rockwell, among others – belonged to the Lafayette Escadrille and they fought for France.
When World War I broke out and the United States declared its intent to remain neutral, these pilots volunteered and formed a squadron of their own within the French Air Service, known first as the Escadrille Américaine (or American Aviation Corps), then later as the Lafayette Escadrille.
The United States maintained strict neutrality for the early years of the war. Maintaining that neutrality, however, was hard work. It required many resolutions by Congress, speeches and appeals by President Wilson, and volumes of diplomatic documents (1914-1917). These documents show the existence of hundreds of protests and incidents both by and against the United States about everything from whether tobacco was a strategic war supply to the risks faced by American merchant ships.
While many Americans fought for the French Foreign Legion at the time, the unprecedented celebrity of these American pilots caused special complications. In December 1915 during one of several stateside media tours by pilots from the unit, a pro-German newspaper editor wrote a scathing opinion (pg. 25) that ran in many prominent newspapers and attracted international attention. It condemned the American Escadrille as a violation of American neutrality and led to the German Ambassador lodging a protest with the U.S. State Department. Both the State Department and the French Ambassador were drawn into the controversy. While initially stalling until the pilots had returned to their unit, the State Department was eventually forced to determine that the pilots could keep flying but the “American Aviation Corps” would have to go. On December 6, 1916, the unit officially became the Escadrille Lafayette (or the Lafayette Escadrille to its English-speaking members), named after the Marquis de Lafayette, a French nobleman who served as a general for the Continental Army in the Revolutionary War.willing to bend the rules (pg. 173) on age, infirmity, eyesight, and balance to allow the other war-battered members of the unit to transfer, they would not bend the rules on segregation for Eugene Bullard. While the pilots that had formed the Lafayette Escadrille were dispersed to various units to train new American pilots with the benefit of their war experience, the Lafayette name carried on in the Lafayette Flying Corps, a U.S. Army Air Service unit made up of Americans who had transferred from other French units, including the ground forces of the Foreign Legion and the Ambulance Service. The name and neutrality controversy lasted nearly a full year, more than half of the life of the unit, because these pilots were celebrities whose popularity and personal positions on American involvement in the war influenced many.
Despite their popularity back home, aviation was new, aerial combat newer still, and life at war was often tragically cut short. Though being an excellent combat pilot, Rockwell was killed in action only months into his service. Prince died as the result of a devastating crash when returning from a combat mission. Lufbery too was killed in combat, but not before he had trained new pilots for the U.S. Army Air Service in aviation mechanics and the tactics of dog-fighting, many of which he pioneered. In time, their early achievements were surpassed by pilots who had the benefit of their training and tactics, who flew better machines, and who survived to fight longer. And while the unit, just like the man it was named after, still holds a special place in Franco-American relations, the grip it had on the popular imagination at the time has faded.
Several times a month, Jessica Wen, a pediatrician specializing in liver diseases, has a teenager show up at her clinic at the Children’s Hospital of Philadelphia with an unexpected diagnosis: hepatitis C.
Hepatitis C virus, or HCV, is the most common bloodborne infection in the U.S. and a leading cause of liver failure and cancer. Injection drug use is a common risk factor, as is receiving a blood transfusion before 1992. But some of the teens Wen sees picked up the illness another way: at birth, from their mothers.
“I have diagnosed moms after diagnosing the kids,” Wen said, referring to mothers who have hepatitis C, didn’t know it and then passed it to their babies during childbirth. Wen estimates that about 1 or 2 of every 1,000 young children have chronic hepatitis C.
A study by the Philadelphia Department of Health points to what Wen and others in the medical profession see as a worrisome trend: Children with hepatitis C may be unaware of their diagnosis and the potential need for treatments down the road in order to prevent long-term liver damage.This story is part of a partnership that includes WHYY, NPR and Kaiser Health News. It can be republished for free. (details)
Using city surveillance data, the study found that as many as 8 in 10 children at high risk for hepatitis C exposure in Philadelphia were never screened for the condition. More specifically, of the approximately 500 moms-to-be who were registered as having hepatitis C between 2011 and 2013, only 84 of their newborns, or about 16 percent, were tested for the virus by 20 months of age.
“Sixteen percent is really low,” said Danica Kuncio, lead author of the study. “When you think about children, you hope that the number would be 100 percent, that it should be in the interest of every provider to be doing the best they can to get information to the next provider.”
Kuncio, an epidemiologist with the city, worries that people who don’t know they contracted hepatitis C as babies won’t get the health care they need or realize they could spread the virus to others through blood-to-blood contact. It’s a concern intensified by a rise in both injection drug use and hepatitis C among women of childbearing age, she said.
“It’s a call to arms to figure out how we can do this better,” said Dr. Michael Narkewicz, who specializes in pediatric liver diseases and hepatitis C at the University of Colorado School of Medicine.
Not so long ago, the lack of drugs to cure hepatitis C made screening less of a priority. But in 2013, the Food and Drug Administration approved the first of several drugs that effectively eliminate the virus. Now, with access to these expensive medicines, the condition has gone from chronic and debilitating to curable.
Narkewicz and others say the next frontier is to prove these treatments are safe and effective in children. Clinical trials are underway, and he thinks the drugs could become available for children in the next year or two.
But unlike HIV, which has safe and effective treatments that can dramatically reduce transmission of the virus from mother to child, “for hepatitis C, there are no treatments to prevent transmission in a mom or in a newborn,” said Narkewicz.
Hepatitis C in children may be lacking attention for another reason: Perinatal transmission rates are a lot lower for hepatitis C compared to hepatitis B and HIV. For every 100 babies born to women with HCV, five to seven will contract the virus. Of those who do get it, 30 to 40 percent will clear it on their own before the age of two, said Narkewicz. That’s why the current protocols for children exposed to HCV call for monitoring and then screening them at 18 months with an antibody test.
But up to 15 percent of those born with HCV will develop a more aggressive form of the disease during adolescence, said Narkewicz, which can result in advanced fibrosis or liver scarring that can progress over time. “It’s a small percentage, but it’s still a real number,” he said.
The medical community really hasn’t done a good job of projecting the costs and benefits of early identification and treatment in children, according to Dr. Ravi Jhaveri, a pediatrician at UNC Children’s Hospital in Chapel Hill, N.C.
“A lot of these other issues related to mom-to-infant transmission, it really all fallen by the wayside,” Javeri said. “[The conversation] still falls on, we don’t have resources to treat patients that are the priority right now.”
Having new drugs to treat hepatitis C in children will be a game-changer, according to Dr. Regino Gonzalez-Peralta, a pediatrician at the University of Florida Health System in Gainesville.
“The old dogma was, why screen mothers if there’s nothing to be done?” said Gonzalez-Peralta, who has also been studying gaps in identifying children infected with HCV.
He said that while drugs to prevent transmission are not yet available, there are promising developments. “Now we’ve got drugs that potentially might be useful in preventing maternal-fetal transmission. This is going to become a hotter area,” he said.
Another issue under debate is universal screening for the virus. Dr. Damien Croft, an obstetrician at Hahnemann University Hospital in Philadelphia, doesn’t advocate it for everyone in the country. But he thinks it might be a good idea for his pool of patients. “There [are] enough women who are high risk for hepatitis C in Philadelphia that maybe we should consider doing that.”
Croft also thinks it’s important to improve communication between obstetricians and pediatricians so the pediatrician will know which children are at higher risk for having hepatitis C and can recommend screening.
In the meantime, Philadelphia’s health department has begun working with health care providers and at-risk mothers in the city to improve the testing of infants born to women with hepatitis C, and when necessary, linking mother or child to specialists.
This story is part of a reporting partnership with NPR, WHYY’s health show The Pulse and Kaiser Health News.
A 12-year-old boy named Strazh hangs from the monkey bars, staring at the ground. The other kids in the park aren’t interested in him. And he’s not interested in them.
“I just like to play by myself,” he says.
Strazh has autism. Today is a good day. But on most others, Strazh has meltdowns. Something frustrates him and he can’t control his emotions.
“I sometimes end up screaming,” he says. “And I end up yelling and screaming.”
And hitting and banging things, throwing things, adds Strazh’s mom, Natalie Dunnege. As a single parent, she says she bears the brunt of it.
“He told me that I disgusted him,” she says softly. “He tells me he hates me.”This story is part of a partnership that includes KQED, NPR and Kaiser Health News. It can be republished for free. (details)
Dunnege puts all her spare money into therapy for Strazh. She says it helps a lot. But Dunnege herself is struggling, feeling depressed and overwhelmed. She decided to look for her own therapist.
“One of the things that I’ve really had to wrap my head around is that I can’t change him. I can only change how I handle the situation,” she explains. “And not that I would want to change who he is. He’s a really good kid, but it’s a lot to handle, especially as a single parent.”
But when she logged onto her insurance website to find a therapist, she realized her copay for a mental health visit was going to be upwards of $75 — more than double her copay for other doctors’ appointments. Under a 2008 federal mental health law, those copays are supposed to be the same.
“There’s no way,” Dunnege says. “It’s out of my budget right now.”
Dunnege lives in a one-bedroom apartment with her son and her father in San Francisco’s Haight district. Grandfather and grandson sleep in twin beds side by side. It’s an awkward walk past those beds to the only bathroom. Dunnege says $75 a week for therapy is impossible.
“My income, I just made lower middle income. Just by the skin of my teeth,” she says. “So I just have to hold off until I’m actually middle class.”
More than 43 million Americans suffer from depression, anxiety and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care. Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.
Recent health laws, the 2008 Mental Health Parity Act and the Affordable Care Act, were supposed to fix this. They require health plans to provide benefits for mental health conditions on par with physical health conditions. Under the law, insurance companies can’t charge higher copays or set up separate deductibles for mental health care compared to other medical or surgical care. They can’t limit hospital stays or require preauthorization for mental health treatment if the same limits are not applied to treatment for physical health conditions.
But advocates say insurance companies are still finding ways to keep people who need care from getting it. Some are still not complying with the law. And some have found subtle, technically legally, ways to limit treatment.
Problems With Mental Health Provider Directories
Natalie Dunnege encountered some of these barriers when she tried again to find a therapist. In the last year, she got a promotion at work and moved into a larger apartment. Her employer switched to a better health plan, too. Now she has Blue Shield coverage, and her copay for mental health appointments is only $20.
“Which I was really excited about,” Dunnege says.
But when she looked for a therapist who took her insurance, she struck out.
“I contacted six or seven,” she says.
Only three called her back.
“One of them, they were completely booked,” she says. “And then the other two just didn’t accept the insurance anymore.”
Zero hits out of seven. Had to be a bad draw, right?
To find out, we decided to conduct our own survey and called all the psychologists — 100 in total — that were listed on the Blue Shield website for Natalie’s plan in San Francisco.
Here’s what happened:
The end result: 28 psychologists actually had appointments. And only eight of them had slots available outside regular work hours. Eight out of 100.
“Sorry, I wish you the best of luck,” was a common refrain in therapists’ voicemail messages.
For Natalie Dunnege, after seven rejections, she gave up looking.
“It’s hard when you’re feeling sad and you feel like you can barely keep things together,” she says. “It just seemed like way too much at the time.”
Mental health advocates say this is exactly what insurance companies are hoping.
“It’s a way to control cost,” says Keith Humphreys, a Stanford psychiatry professor who served as an advisor to Congress when it was developing the 2008 Mental Health Parity Act. He says while insurers are now required to keep an adequate number of clinicians listed in their directories, they still find ways to sidestep the rules.
“You know the law doesn’t say you can’t put people on there who are dead, or you can’t put people on there who are not taking new patients,” he says. “What that translates into, then, is people have to wait longer for care, which then cuts expenditures for the insurer and reduces access.”
California passed a law last year, SB 137, raising the standards for physician directories. Insurers will have to police their lists for providers who are booked or retired. But a lot of questions remain about how the law will be enforced, especially when it comes to mental health providers, who are largely self-employed, solo practitioners.
The insurance industry says it will be a challenge.
“When you have networks as large as ours and you have as many enrollees as we have here in California, you’re not going to be able to just have everything accurate every single second of every single day,” says Charles Bacchi, CEO of the California Association of Health Plans.
He said the industry is working to make it better.
“But we also need to be realistic,” he says. “We don’t run a mental health provider’s office. They do. And how they handle people calling their offices is their job.”
In a statement, Blue Shield said it tries to make it easy for providers to update changes in their contact information and schedule.
“We understand that there are a number of issues that impact a provider’s availability to take new patients, such as administrative limitations and fluctuating numbers of patients based on their individual needs. When those instances arise, the provider is required to notify us so that patients have access to the most up-to-date information about who is available in their area.”
The industry also says it’s facing another challenge: a nationwide shortage of mental health providers, further exacerbated by the millions of people who signed up for insurance under the Affordable Care Act.
In California, there are “around 4 to 5 million more people with coverage, just in the last two years,” Bacchi says. “And that’s creating a strain for everybody, plans and mental health providers.”
This story is part of a partnership that includes KQED, NPR and Kaiser Health News.
The federal government released its first overall hospital quality rating on Wednesday, slapping average or below average scores on many of the nation’s best-known hospitals while awarding top scores to many unheralded ones.
The Centers for Medicare & Medicaid Services rated 3,617 hospitals on a one- to five-star scale, angering the hospital industry, which has been pressing the Obama administration and Congress to block the ratings. Hospitals argue the ratings will make places that treat the toughest cases look bad, but Medicare has held firm, saying that consumers need a simple way to objectively gauge quality.
Just 102 hospitals received the top rating of five stars, and few are those considered as the nation’s best by private ratings sources such as U.S. News & World Report or viewed as the most elite within the medical profession.
Medicare awarded five stars to relatively obscure hospitals and a notable number of hospitals that specialized in just a few types of surgery, such as knee replacements. There were more five-star hospitals in Lincoln, Neb., and La Jolla, Calif., than in New York City or Boston. Memorial Hermann Hospital System in Houston and Mayo Clinic in Rochester, Minn., were two of the only nationally known hospitals getting five stars.Use Our Content This KHN story can be republished for free (details).
Medicare awarded the lowest rating of one star to 129 hospitals. Five hospitals in Washington, D.C., received just one star, including George Washington University Hospital and Georgetown University Hospital, both of which teach medical residents. Nine hospitals in Brooklyn, four hospitals in Las Vegas and three hospitals in Miami received only one star.
Some premiere medical centers received the second highest rating of four stars, including Stanford Health Care in California, Massachusetts General Hospital in Boston, Duke University Hospital in Durham, N.C., New York-Presbyterian Hospital and NYU Langone Medical Center in Manhattan, the Cleveland Clinic in Ohio, and Penn Presbyterian Medical Center in Philadelphia. In total, 927 hospitals received four stars.
Medicare gave its below average score of two-star ratings to 707 hospitals. They included the University of Virginia Medical Center in Charlottesville, Beth Israel Medical Center in Manhattan, North Shore University Hospital (now known as Northwell Health) in Manhasset, N.Y., Barnes-Jewish Hospital in St. Louis, Tufts Medical Center in Boston and Washington Hospital Center in D.C. Geisinger Medical Center in Danville, which is a favorite example for national health policy experts of a quality hospital, also received two stars.
Nearly half the hospitals — 1,752 — received an average rating of three stars. Another 1,042 hospitals were not rated, including all hospitals in Maryland.
Medicare based the star ratings on 64 individual measures that are published on its Hospital Compare website, including death and infection rates and patient reviews. Medicare noted that specialized and “cutting-edge care,” such as the latest techniques to battle cancer, are not reflected in the ratings.
The government said in a statement that it has been using the same type of rating system for other medical facilities, such as nursing homes and dialysis centers, and found them useful to consumers and patients. Those ratings have shown, Medicare said, “that publicly available data drives improvement, better reporting, and more open access to quality information for our Medicare beneficiaries.”
In a statement, Rick Pollack, president of the American Hospital Association, called the new ratings confusing for patients and families. “Health care consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers,” he said. “We are especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor.”
A preliminary analysis Medicare released last week found hospitals that treated large numbers of low-income patients tended to do worse, as did teaching hospitals.
This is the next in our “Medicaid Works” blog series, which aims to inform the debate over Medicaid’s future by providing the latest facts and figures on this essential and popular part of the nation’s health care system.