Today is the anniversary of Justice Thurgood Marshalls swearing-in as an associate justice of the Supreme Court on October 2, 1967. He was the Court’s 96th justice and the first African American to hold a seat on the Supreme Court.
President Lyndon Johnson nominated the then-Solicitor General Marshall on June 13, 1967 to fill the post vacated by Justice Tom Clark. When Johnson nominated Marshall, he said it was the right thing to do, the right time to do it, the right man, and the right place. Attorney General Ramsey Clark said that Justice Marshall had a wealth of legal experience rarely equalled in the history of the court. He has been a distinguished leader of the American Bar since finishing at the top of his class at Howard Law School in 1933as one of the few attorneys in history to appear before the Court more than 50 times, as a member of the nations second highest court, and as Solicitor General of the United States. I have no doubt that his future contributions will add even more prominence to his already well-established place in American history.
President Johnson was confident in his choice, and the Senate had few dissenting opinions, nearly all from Senators from the Deep South. After spending nearly half of July debating his nomination, the Senate confirmed Marshall as an associate justice by a vote of 6911 on August 30, 1967.
Justice Marshall was sworn in by Chief Justice Earl Warren, with Marshalls wife Cecelia and sons Thurgood Jr. and John attending. Although Johnson could not be present at Marshalls ceremony, the remarks Johnson made a few years earlier at Justice Marshalls swearing-in as Solicitor General are equally apt for Marshalls swearing-in as Justice. Johnson observed, Thurgood Marshall symbolizes what is best about our American society: the belief that human rights must be satisfied through the orderly processes of law. it is a cause of profound satisfaction to me that in [then-] Judge Marshall we shall have an advocate whose lifelong concern has been the pursuit of justice for his fellow man. Johnson also noted, Marshall is already in the front ranks of the great lawyers of this generation. He has argued 32 cases before the Supreme Court; he has won 29 of them. And that is a batting average of .900.retiring in 1991 due to ill health. During his tenure at the Court, he was known as the Great Dissenter due to the large number of dissenting opinions that he wrote and his strong stance for civil rights, minorities, the poor, and privacy, and against the death penalty. He also had a reputation for biting humor. (About one public official, Marshall observed: “It’s said that if you can’t say something good about a dead person, don’t say it. Well, I consider him dead.”) The year he retired from the Court, he donated his papers, including his correspondence, case files, dockets, and other papers from the Court, to the Library of Congress. He died of heart failure in 1993.
Marshalls legacy was such that many governments and institutions have honored him by erecting statues and naming buildings after him. In Marshalls native Maryland, the city of Baltimore put up a statue in his honor in front of the federal courthouse, and there is a statue of him in front of the Maryland State House; the State of Maryland has named their international airport after him. Near Union Station in Washington, D.C., the Federal Judiciary Building is named for him. He was a posthumous recipient of the Presidential Medal of Freedom in 1993.
What are the childhood origins of adult disease? Might there be certain developmental periods in a child’s life when he or she is particularly vulnerable to stress? And might psychological distress early in life lead to heart and other health problems later in adulthood, even after that stress is gone?
A recent study on early childhood stress published this week in the Journal of the American College of Cardiology doesn’t definitively answer these questions. But it does suggest that a high level of psychological distress in childhood may lead to a heightened risk of disease in adults, even if the stress doesn’t linger on.
The study, led by researchers at the Harvard School of Pubic Health, concludes:
Psychological distress at any point in the life course is associated with higher [cardiovascular and metabolic disease] risk. This is the first study to suggest that even if distress appears to remit by adulthood, heightened risk of cardiometabolic disease remains.
An editorial accompanying the study notes “the possibility that there are sensitive periods in childhood during which some seemingly irreversible physiological, emotional, or behavioral processes are established that affect [cardiometabolic risk]. That is, perhaps there are critical windows of risk linking childhood distress and [cardiometabolic risk] that point to windows of opportunity for intervention.”
The new study was based on an analysis of data from the 1958 British Birth Cohort Study, a longitudinal look at people born in Great Britain during a single week in March 1958. Individuals completed measures of psychological distress and a biomedical survey when they were 45 years old after repeated assessments over the course of their lives, from age 7 to 42.
I asked the new study’s lead researcher, Ashley Winning, a postdoctoral research fellow in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health, some followup questions. Here, edited, are her answers:
RZ: In this study were you able to determine what, exactly, constituted “stress” for these children? Trauma, illness, abuse? If not, might you speculate on what types of stressors might be linked to later heart problems?
AW: High levels of distress in childhood may be the result of early life adversity (such as trauma, illness, abuse, neglect, poverty) and this may be one reason children in these environments are at heightened risk of poor health. However, symptoms of distress may be in response to less dire exposures too – chaotic environments, parental discord, stressful circumstances – normative responses to difficulties that may become chronic in the absence of appropriate adult capacity to help the child learn to navigate these challenges.
It’s also possible symptoms of distress are early signs of an underlying mental disorder in childhood (which may or may not have a hereditary component). We suspect that distress occurs in response to a range of difficult circumstances but what other research has suggested is that ongoing distress is less likely to occur when there is a nurturing adult or supportive environment available.
In this study we did not look at what leads to symptoms of psychological distress, but rather the distress symptoms themselves. We used the term “distress” to imply a reaction to potential stressors (stressful experiences or events), as opposed to the stressors themselves.
Psychological distress in childhood was captured by symptoms of internalizing (e.g., depression, anxiety) and externalizing (e.g., conduct disorder, hyperactivity) disorders, which were reported by the children’s teachers. In adulthood, adults reported on their own symptoms and levels of distress.
Can you explain more about the possible mechanisms that might be contributing here?
Psychological distress may impact risk of heart disease, stroke, and diabetes in a number or ways, primarily through behavioral and biological pathways. For example, distress may motivate harmful behaviors such as cigarette smoking and physical inactivity, or reduce educational and occupational achievement. Given there are sensitive periods for establishing behavior patterns (e.g., smoking is typically initiated in adolescence), childhood and adolescent distress may be especially influential. So for example, kids who are highly distressed may be more likely to begin smoking cigarettes, and that habit, once begun can be difficult to change.
Psychological distress may also have a more direct biological impact on health by causing increased activation of stress-related biological systems (for example more sympathetic nervous system activation). Chronic activation of stress-related biological responses, triggered by repeated or sustained exposure to stressful experiences, can lead to a cascade of deleterious effects on processes related to heart health, including, for example, blood pressure and cholesterol.
If stress response systems are altered in childhood it may make people more reactive to stress and more prone to its cumulative effects over time. This is consistent with the concept of biological embedding, whereby early experiences are thought to “get under the skin” to influence human biological and developmental processes. Alterations in biological stress-regulatory systems that emerge early in life may become more difficult to rewire in adolescence or adulthood.
In our study, both behavioral and biological pathways appear to be relevant. Though we did not test this, it is also possible that social attitudes and stigma against those with mental disorders or a lack of empathy for individuals who are struggling, as well as insufficient resources to address their needs, contribute to these effects.
Are any of the findings surprising to you?
The most striking finding in our study was that high levels of childhood distress predicted heightened adult disease risk, even when it did not appear that these high levels of distress persisted into adulthood. This is the first study to suggest that even if distress appears to remit by adulthood, some heightened risk for diseases such as heart disease, stroke, and diabetes remains. We were surprised to see that severity of distress in childhood seemed even more important than severity of distress in adulthood in predicting adult disease risk.
What are the key implications of the study, and where do you go from here?
Our findings have several implications:
•Greater attention must be paid to psychological distress in childhood. It is an important issue on its own right and may also set up a trajectory of risk for more rapid development of adverse physical health outcomes as people age.
•Focusing on early emotional development and helping children learn to regulate emotions effectively may be an important target for disease prevention and health promotion efforts.
•Physicians should be aware of the impact of mental health on physical health. In considering disease risks, health professionals should look beyond health behaviors and inquire about current distress symptoms as well as history of psychological distress across the lifespan.
•Overall, our findings point to childhood distress as relevant for both screening and intervention related to adult heart disease prevention, and provide support for the importance of attending to early emotional development as an early prevention strategy.
We’re starting to look at disease risk biomarkers earlier in the life course (in childhood and adolescence) to see how early the association between distress and heart disease risk may become evident, and whether those effects are sustained over time.
We also want to explore positive and protective factors that might reduce risk, and to help inform the development of good prevention and intervention practices for improving psychological wellbeing (particularly in childhood, but also all across the lifespan).
What does all this mean for parents today thinking about stress in their children’s lives?
While many experiences or circumstances are not directly within a parent’s control, parents and caregivers can work to limit children’s exposure to highly distressing experiences and can also focus on teaching children healthy ways to manage and cope with stress, and on providing them with support in difficult circumstances. They can also be aware of and monitor children’s mental health (including symptoms of depression, anxiety, hyperactivity and conduct disorder) and be aware that seeking help earlier rather than later is important.
One note: Having a difficult childhood in no way guarantees higher disease risk as an adult. In our study we looked at the presence or absence of high distress but we did not look at positive or protective factors. Thus, it is possible that people who had a difficult childhood but who had positive resources available as they grew up, got into more a more positive supportive environment later on, had strong social support, or other positive experiences in adulthood or perhaps even obtained therapy, may not in fact experience excessive disease risk. As noted earlier, this is something we would like to look at more directly in future work.
It’s common knowledge that consumers have to pay more money if they choose doctors or hospitals outside of their insurance plan’s network. But a new analysis prepared by the insurance industry seeks to show just how much more in each of the 50 states.
Out-of-network providers charged patients on average 300 percent more than the Medicare rate for certain treatments or procedures, according to the analysis of 2013 and 2014 claims data released Thursday by the America’s Health Insurance Plans. The industry group, which supports limiting out-of-network charges, found that some treatments were even more exorbitant — with out-of-network providers charging nearly 1,400 percent more than what is reimbursed by Medicare.
Charges for an MRI of the brain, for example, cost on average $2,929 with an out-of-network provider, compared to the Medicare rate of $405, according to the report. And patients who needed a one-hour chemotherapy infusion paid on average $437 while Medicare reimbursed $136, the group found.
The study found significant differences among providers for the same treatments and wide geographic differences. California had some of the largest gaps between out-of-network charges and Medicare rates. For example, out-of-network providers billed an average of 626 percent higher than Medicare for a brain MRI.
Other states also saw out-of-network charges that far exceeded the Medicare rates, the study found. In New York, providers charged on average 1,100 percent more than the Medicare fee for low back disc surgery. And emergency care in Florida cost about 700 percent higher for out-of-network care.
“This is the blueprint to show that there is more work to be done and that we have to fix this problem for patients,” said Clare Krusing, spokeswoman for America’s Health Insurance Plans. “There needs to be much more disclosure from hospitals and doctors and specialists.”
Krusing said limits should be set on charges that out-of-network providers can bill. The report is based on 18 billion claims covering about 100 medical procedures performed in 2013 and 2014 in all of the states.Use Our Content This KHN story can be republished for free (details).
A spokesman for the American Medical Association said he had not yet reviewed the report. The association’s president has in the past blamed insurers for failing to negotiate and provide fair rates.
Betsy Imholz, director of special projects for Consumers Union, said she wasn’t surprised that out-of-network providers are charging excessive amounts.
“Some providers will take whatever they can get,” she said. “If there is no limitation … they will ask for the most they can.”
The bigger problem, Imholz said, is when patients get stuck with surprise bills. That happens when they go to an in-network hospital but are unknowingly treated by anesthesiologists or other specialists not in the plan’s network.
“The rude awakening is that when they get home … there are these huge other bills that come filing in,” she said. “The Affordable Care Act was aimed at making care affordable, and we want it to remain that way.”
A few states, including New York, have passed laws to protect patients from higher surprise bills. Proposed legislation that would have done so in California recently died in the legislature.
Imholz said consumer advocates would try again. “We are not giving up on this,” she said.
Blue Shield of California Foundation helps fund KHN coverage in California.
I was reading my colleague Elin Hofverberg‘s interesting blog post on Icelandic names, and found we have posted several times on foreign laws banning unacceptable baby names. Not long ago, I noticed Taiwanese law also regulatesunflattering names in its Name Act. The Act does not ban such names, but rather recognizes that having an unflattering name is an acceptable reason to change one’s legal name.
According to article 9 of the Name Act, one can change his or her first name if the name is unflattering, is an unreasonably long transliteration of a name in another language, or if there are other special reasons. The Act restricts the times one may change his/her name in a lifetime based on these reasons. Prior to an amendment to the Name Act enacted on June 1, 2001, the Act allowed only one opportunity in a persons lifetime to change an unflattering name, which was increased to twice by the 2001 amendment and further to three times by a recent amendment enacted on May 20, 2015. Also included in the 2001 amendment was the removal of the governments authority to decide whether a name was unflattering or other special reasons before the name could be changed. (Fatiao Yange, the Legislative Yuan Law Database.)
Parents must note that they get only one chance to change their babys unflattering name out of the total three chances in the baby’s lifetime. This is because the Name Act requires that the second name change be done after the person comes of age. (Id. art. 9).
Even adults are not able to change their names arbitrarily. One can only change his/her name (first, last, or full name) if conditions set forth in the Name Act are satisfied. For example, after marriage either a husband or a wife may add the spouses last name to his/her own last name, and those who had the spouses last name added may also apply to remove it and to reinstate his/her original last name. The Act limits such a reinstatement of the original name to only once in a marriage, so if one got a chance to reinstate his/her original last name and then chose to add the spouses name again, the name could not be changed back to the original for a second time. (Id. art. 8.) If a person has the exact same first and last names as those of a criminal at large, the person may apply to change his/her name, but only the first and not the last name. (Id. art. 9.) A criminal at large, however, cannot apply to change his/her legal name. (Id. art. 15.)
Under the Name Act, a legal name in Taiwan must be Chinese and use characters found in major Chinese dictionaries including Ci Yuan, Ci Hai, Kangxi Dictionary, and Guoyu Cidian compiled by the Ministry of Education. (Id. art. 2.)
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