The following is an article written by Mark Hartsell, writer-editor for The Gazette, the Library of Congress staff newsletter.
The court’s decision in Bush v. Gore, 531 U.S. 98 (2000), brought an end to the contested presidential election of 2000, and in the aftermath, Breyer noted, there were no riots, no acts of violence, no guns, no deaths.
“We have decided to decide our major disagreements under a system of law,” he said Tuesday in the Coolidge Auditorium. “That is a remarkable thing, that people actually follow that. It has a long history, and that history does begin 800 years ago with [Magna Carta].”
Philanthropist David Rubenstein interviewed Breyer in the Coolidge as part of a Library of Congress symposium marking Magna Carta’s 800th anniversary and exploring how the charter’s political and legal traditions carried into modern times.
The program, sponsored by the Law Library, featured four panel discussions: “Drafting Modern Constitutions,” Proportionality Under the 8th Amendment,” “The Enduring Value of Magna Carta” and “Rule of Law in the Contemporary World: Civil Liberties and Surveillance,” a panel that included Reps. Jerrold Nadler (D-N.Y.) and F. James Sensenbrenner Jr. (R-Wis.).
Sir Robert Worcester, chairman of the Magna Carta 800th anniversary commemoration committee, also provided an international perspective on the Great Charter’s legacy.
Since, Rubenstein said, one rarely gets an opportunity to interview a Supreme Court justice, he asked Breyer about a wide range of subjects – Magna Carta, his experiences as a special counsel in the Senate, the inner workings of the court, cameras in the courtroom (“too many uncertainties”) and his beginnings as a lawyer.
“You may not remember this – you’re not old enough – but there was a time when you tended to do what your parents said,” Breyer said to laughter, noting that his own father was a lawyer. “It’s completely foreign to this entire audience, such an idea.”
Breyer served as a law clerk to Supreme Court Associate Justice Arthur Goldberg, a special assistant in the Justice Department, an assistant special prosecutor on the Watergate Special Prosecution Force and, in the late 1970s, as counsel to the Senate Judiciary Committee, working for Sen. Ted Kennedy – an experience he called “fabulous.”
“I learned a lot from him,” Breyer said. “He was wonderful to work for. … It was fun. It was interesting. You wanted to accomplish something good. Every minute, though, there are things that pop up. It’s a wonderful place to work.”
“For any lawyer to become a federal judge, lightning has to strike. It really does,” he said. “To be on the Supreme Court, it has to strike twice in the same place.”
Breyer said he often is asked about the way in which the high court makes its decisions: People will ask, Aren’t you just “junior-league politicians”? Don’t you just decide cases however you like?
“I never do what I like,” Breyer quipped. “Are you kidding? It’s like being married.”
About half the court’s cases are decided unanimously, he said, and only a very small minority are decided according to what media would think is a liberal-conservative breakdown.
But those decisions, he said, are informed less by ideology than simply by a lifetime of professional and personal experiences that shape each justice’s views and the way he or she grapples with difficult, complicated constitutional questions.
“You cannot jump out of your own skin, and you shouldn’t,” he said. “Therefore, on that basis, you will find differences and you will find a coalescing around certain basic things. …
“It’s not such a terrible thing to go on the Supreme Court of the United States. Over long periods of time, you have people who think quite different basic views about how this document should be interpreted. It’s OK.”
Breyer also discussed the most basic principles American law derived from Magna Carta: No person shall be deprived of life, liberty or property without due process of law.
“It’s such a simple idea,” he said. “But that’s what people are all over the world today trying to see if they cannot embody in institutions.”
The charter’s influence, he said, clearly can be found in contemporary issues. Supreme Court Associate Justice Anthony M. Kennedy, Breyer said, cited Magna Carta in a decision that determined prisoners at the Guantanamo Bay military detention camp have the right to come into civilian courts.
“We have a constitution that doesn’t just guarantee democracy,” Breyer said. “It guarantees democracy, basic human rights a degree of equality, separation of powers, and it guarantees a rule of law.”
Breyer and his law clerks toured the “Magna Carta: Muse and Mentor” exhibition in the Jefferson Building in late November and, on Tuesday, he urged the audience to visit as well.
“It’s fabulous, partly because you see the document. … Partly because as you go through that exhibition it will force you to think about the time that has passed, the people who have been involved, a few of the ups and downs,” Breyer said. “Think of this country. We lived in a period of slavery. We had a terrible Civil War. We had 80 years of government-backed racial segregation.
“We’ve had all kinds of ups and downs, and it’s taken a very long time before those words in the Magna Carta have come to be accepted in the customs and habits of the people.”
[We will provide a link to the symposium webcast soon.]
The Library of Congress is commemorating the 800th anniversary of Magna Carta with an exhibition – Magna Carta: Muse and Mentor, a symposium, and a series of talks starting this year. Through January 19, 2015, the Lincoln Cathedral Magna Carta, one of four remaining originals from 1215 is on display along with other rare materials from the Library’s rich collections to tell the story of 800 years of its influence on the history of political liberty.
That kiss last night? You may have left with more than butterflies. According to Dutch researchers, the average 10-second french kiss can result in the exchange of around 80 million pieces of bacteria.
And they have the data to prove it.
Twenty-one couples recently volunteered to kiss for science. This all went down at the Amsterdam Royal Artis Zoo in 2012. The Dutch researchers studying bacteria surveyed the kissing habits of each partner in each couple with questions like, “How often do you kiss? and “When did you last kiss?” Researchers then swabbed each partner’s tongues for “salivary microbiota,” before and after a “controlled kissing experiment” (read: a tightly timed 10 seconds).
Then there was a second kiss. One member of the couple was asked to swig some probiotic yogurt beforehand. This made it easier to look at the bacteria from the yogurt both on the tongue of the person who drank it — and the tongue of the person who didn’t.
So what do we learn?
Turns out shared microbiota can actually survive on another person’s tongue. Samples of oral flora from the partner were more similar than those drawn from randomly selected passersby.
But despite this robust sharing of bacteria, not all of it is there to stay. Professor Remco Kort of the Netherlands Organisation for Applied Scientific Research (TNO), the group that conducted the study, told the BBC that “only some bacteria transferred from a kiss seemed to take hold on the tongue.”
Kort explained that in the end, kissing may be the least important factor. “It didn’t matter whether the couples said they french kissed nine times a day or nine times a year. Obviously, there are other important factors involved such as sharing the same diet or using the same toothpaste for example.” Nevertheless “these types of investigations may help us design future bacterial therapies and help people with troublesome bacterial problems.”
Now this knowledge can be yours. The researchers partnered with Micropia, the world’s first microbe museum, to create an exhibit called the “Kiss-O-Meter” which allows couples to take a look at their own shared bacteria.
For two decades Atlanta restaurant owner Jim Dunn offered a group health plan to his managers and helped pay for it. That ended Dec. 1, after the Affordable Care Act made him an offer he couldn’t refuse.
Health-law subsidies for workers to buy their own coverage combined with years of rising costs in the company plan made dropping the plan an obvious – though not easy – choice.
“I had a lot of regrets going into it,” Dunn, who owns three Italian Oven restaurants in suburban Atlanta, said of his decision. “I don’t think I have as many now — only because I’ve seen the affordability factor for my managers improve.”
Dunn and five managers are now covered under individual plans bought on healthcare.gov. How many other owners make the same decision will help set the future of small-business health insurance. Although the evidence so far is mixed, brokers expect more firms to follow in the next few years.
Companies like Dunn’s — those with fewer than 50 workers — provide medical coverage to roughly 20 million people. Unlike larger employers, they have no obligation under the health law to offer a plan. Now they often have good reason not to.
If employees qualify for government subsidies, like the managers who switched from Italian Oven’s corporate insurance to individual Obamacare coverage, everybody can win.
Owners don’t have to pay premiums, meaning they can give workers raises, invest in equipment or add to profits instead. And employee take-home pay can rise if subsidies — available even to families with middle-class incomes — are worth more than what a company was contributing.
Whether to cancel a company plan and let workers buy insurance on healthcare.gov or another online exchange “is something that I would say comes up in every conversation with a small-group” employer, said Adam Berkowitz, a consultant with Caravus, a benefits firm based in St. Louis.
“I just had another [small] business call in today and say, ‘You know, we can’t do it. We’re packing it in,’” said Roger Howell, head of Howell Benefit Services in Wilkes-Barre, Pa.This KHN story can be republished for free (details).
Anthem, the largest seller of small-business health insurance, lost almost 300,000 members in such plans — many more than expected — in the first nine months of the year. That was 15 percent of the enrollment. Many of those consumers are presumably switching to individual plans sold through exchanges, including those offered by Anthem, officials said.
It’s far from clear, however, that most companies will take the same steps as Italian Oven.
Many small employers see health coverage as an essential piece of compensation. They note that premiums in company-sponsored plans are tax-deductible — for workers as well as employers — while the tax advantages of individual plans are limited.
“I feel like we have to have a medical plan in order to hire people and keep them employed,” said Dan Allen, head of a 15-worker engineering firm in Decatur, Ill. Allen Engineering renewed its Coventry Health Care plan for 2015 even though the premiums rose 21 percent, he said.
No other major insurer has reported cancellation of small-business plans at the same rate as Anthem.
“We didn’t see that,” said Rick Allegretti, vice president of marketing at Health Care Service Corp., operator of Blue Cross plans in five states including Illinois and Texas. “We actually saw our [small-group] business grow slightly — mind you it’s probably a tenth of a percent.”
Businesses shifting workers into the individual exchanges tend to be the very smallest, employing a handful of people, said Skip Woody, a partner at Hill, Chesson & Woody, a North Carolina benefits firm. “Anything above 15, we haven’t had any dropping coverage,” he said.
Instead, many small companies are taking advantage of rules letting them maintain insurance bought before the health law took effect. President Barack Obama, who promised consumers they could keep coverage they liked, allowed carriers to extend noncompliant plans after facing fierce criticism over their imminent extinction.
Most, but not all, states approved the adjustment. Because older policies may lack features required by the health law and because their rates are often set according to employee health history, not community-wide costs, they can be less expensive than compliant plans, say brokers and consultants.
“I haven’t sold one of the new plans yet” to a small employer, said John Jaggi, an Illinois broker and consultant. Faced with price increases of as much as a third or more for new plans, all 40 or so of his small-business clients including Allen Engineering renewed older coverage for 2015, he said.
Heavy renewal of old plans plus workers shifting to individual coverage help explain why the health law’s online portal for new small-business plans has attracted only modest interest, analysts say.
For some companies there is logic to ending coverage altogether.
For Italian Oven’s Dunn, “it made sense to recommend that he drop coverage,” said Elena Merino, CEO of the Meridian Group, a benefits firm in Alpharetta, Ga. “It hurts me. But that was the responsible thing to tell him.”
Italian Oven employs the equivalent of about 30 people — less than the 50-worker threshold that would get it fined for not sponsoring insurance. The company does not offer coverage to servers and kitchen staff, but full-time managers have always had a plan.
All are eligible for tax credits to buy insurance on healthcare.gov, said Dunn. Next year, the subsidies are available for individuals with income of up to $46,680 and families of four with income of up to $95,400.
With subsidies factored in along with unrelated pay increases, the managers “are going to be saving money out of the deal” while getting coverage comparable to what they had before, Dunn said. “My managers actually got excited about it because they’re saving money on their health insurance.”
Brokers expect more small businesses to make the same move, especially after the ability to extend older, noncompliant plans expires between now and the end of 2017, depending on state policy. Allen, the engineering firm executive, is concerned premiums could rise even higher next year than they did for the 2015 renewal.
“If it’s up in the 25- to 30-percent increase [range] — I’ve heard as high as 40 — we’ll just have to drop it,” he said. “Turn everybody loose.”
The birth rate among teens in Massachusetts is at its lowest recorded level in the state’s history, a report out Friday says.
The birth rate of teens ages 15-19 fell 14 percent last year, from 14 births per 1,000 women in 2012 to 12 births per 1,000 women in 2013, the Massachusetts Department of Health reported.
“This is terrific news for all Massachusetts families, and a dramatic indication that our decisions to invest in our young people — through education, support and resources — can have a real and lasting impact on their lives and in their communities,” Gov. Deval Patrick said in a statement.
According to the report, there were 2,732 babies born to teen mothers between 15 and 19 years old in 2013, down from 3,219 the previous year. The number of children born to teen mothers in that age bracket is significantly lower than the 7,258 births reported in 1990.
- Municipalities with more than 50 teen births in 2013: Boston (318), Brockton (96), Chelsea (55), Fall River (89), Holyoke (70), Lawrence (139), Lowell (106), Lynn (106), New Bedford (126), Springfield (289), Worcester (179). All of the above municipalities — with the exception of Chelsea, Holyoke and Leominster — are among the state’s 30 most populated.
- There are 276 municipalities in the state that saw four or fewer teen births in 2013. (Click to see a complete list of these municipalities.)
However, the report does note that exact numbers could change to reflect updated information. It is also important to note that the exact figures above “are based upon the number of births and not on the number of mothers giving birth,” the report says.
As of its release Friday, the report says there were 71,618 births to mothers living in Massachusetts in 2013, down from 72,457 births in 2012. Its findings show that of those babies, 32,069 were born to mothers under the age of 30.
More on this year’s report:
This year’s report has an updated format that contains a “brief summary of birth data, comparisons to recent years in order to note emerging trends, and six special topic areas created to stir more thorough discussion on a variety of health issues related to pregnancy.”
The department statement added that other key data points in the document included:
- “In 2013, the percentage of pregnant women who had their teeth cleaned by a dentist or dental hygienist rose to 46 percent. Pregnancy can alter or complicate oral health in women, which can lead to adverse pregnancy outcomes and poor oral health in their children.”
- “In 2013, the prevalence of gestational diabetes (GDM) was 5.3 percent, which is comparable to the 2012 prevalence of 5.6 percent.”
- “In 2013, more than half of mothers (53.1 percent) had a normal body mass index (BMI) prior to becoming pregnant.”
- In 2013, the cesarean delivery rate was 31.5 percebt compared to 31.7 percent in 2012. This figure was 4 percent lower than the percentage for the entire United States (32.7 percent).
According to the report, data on births is based on information obtained from the Massachusetts Standard Certificate of Live Birth filed with the Registry of Vital Records and Statistics.Related:
How your employees can work remotely — and even use public Wi-Fi — safely
By Richard Knox
This flu season is shaping up to be a bad one. And this year’s vaccine doesn’t work very well against the most common flu virus going around. So should you even bother getting a flu shot?
Yes. Putting it a different way: my wife, my daughters and I will. And the evidence says you’d be somewhere between slightly foolish and dangerously blasé if you don’t – depending on your personal risk factors.
I know there are naysayers – the Internet is full of them. “I recommend that my patients of all ages not take these incessantly promoted immunizations, primarily because of their lack of effectiveness,” writes blogger Dr. John McDougall. He says he’s not one of those across-the-board vaccine deniers but just doesn’t think flu vaccines (of any given year) are worth taking.
To understand why I think he’s wrong – even this year, when vaccine effectiveness is expected to be even lower than usual — you need to know something about the situation we’re all in.
Several viruses circulate during any given flu season. And flu viruses are always changing — sometimes not so much from year to year; sometimes in a bunch of little ways (a phenomenon called genetic “drift”); and sometimes in a big, sudden way, called a “shift,” which touches off pandemics.
Drifts Or Shifts?
Public health researchers constantly monitor flu virus mutations. But even the smartest flu dudes can’t know in advance when they’ll happen, or whether mutations will be drifts or shifts.
This year, one of the flu viruses outwitted them. Or, since viruses can’t have intentions, it’s better to say that random genetic drift in that viral strain, called H3N2, happened in late March. That’s a bad time in the annual cycle of vaccine production.
Just a few weeks earlier, leading flu specialists gathered at the World Health Organization in Geneva and decided that this season’s vaccine (for the Northern Hemisphere) should contain the same viruses as last year’s — two type-A viruses (an H1N1 that caused the pandemic of 2009 and has stuck around since, and an H3N2 that first appeared in Texas two years ago) and two type-B flu viruses.
Making each year’s flu vaccine is a complicated business that waits on no virus. The recipe has to be decided in February to get the chosen viruses growing in hundreds of millions of special chicken eggs, the first step in vaccine production.
(There is a streamlined, egg-free flu vaccine production method, but so far only one U.S.-based factory uses it.)
When the mutant H3N2 popped up in late March, there were very few of them around and it wasn’t clear whether they were going to elbow aside the previous H3N2 strain.
By September, half of the flu viruses circulating in America were H3N2s – displacing H1N1 as the dominant strain. And half of those were the drifted H3N2 mutant that’s a poor match for the current vaccine.
But by then, this season’s flu vaccine was already out. “Essentially, the flu change was too late for the vaccine to be changed,” Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said in a recent teleconference with reporters.
So the current vaccine won’t protect very well against the dominant flu strain most Americans will be exposed to, Frieden says.
There’s yet another wrinkle. H3N2 viruses generally make people sicker than H1N1 strains. “This H3N2 strain historically has produced more serious illness,” infectious disease specialist William Schaffner of Vanderbilt University said in an interview. That means more will get complications such as pneumonia that require hospitalization and intensive care. And predictably, there will be more deaths from flu – a toll that ranges widely from year to year, from 3,000 to 49,000 fatalities.
“So that’s a double whammy — a rogue flu strain and it’s of the more severe type,” Schaffner says.
He’s also worried because this flu season has started on the early side. All but 10 states are reporting flu cases, and it’s already widespread in Maryland, North Carolina, Florida, Illinois, Louisiana and Alaska.
As all experts agree, even the best flu vaccines – those most closely matched to the viruses people will be exposed to – aren’t very good, compared to those against other infections.
The CDC says last year’s vaccine (considered a good match) was 47 percent to 56 percent effective for children and adults under age 65. Older adults don’t have such a robust immune response to vaccines, so last year’s flu vaccine was only 39 percent effective for them.
“Effective” means the percent of vaccinated people who don’t get sick. So people who got last season’s well-matched vaccine still had a 44 to 61 percent chance of getting the flu anyway – not great odds.
Tell Me Why, Again?
So why, you’re wondering, should I get a flu shot?
Here’s the argument:
•Flu is so common that even a mere 30 percent reduction in illness (or less) adds up to a lot of people. Last season, the CDC reports around 35.4 million Americans got the flu – one out of every 9 people. This season the misery is likely to affect millions more. There’s a good chance one of them might be you.
•Getting the flu can be more dangerous than you might think. The CDC says last year’s H1N1-dominant flu season saw nearly 400,000 hospitalized. This year the total could be substantially bigger. So could the death toll.
•Flu vaccination has both direct and indirect effects. It directly reduces the vaccinated person’s risk of getting sick, by some degree. And it indirectly lowers their chance of getting infected from someone else who got vaccinated. “You’re a better citizen because you will help protect those at work and at home,” Schaffner says. “No one wants to be a flu spreader.”
•To me, the most compelling argument is that even if vaccination doesn’t prevent you from getting sick, you’ll probably get a milder case. So you’ll be less likely to be hospitalized or die from flu complications.
The evidence is not iron-clad. One 2010 study found that active-duty military personnel who got flu shots were 42 percent less likely to get the flu, but 62 percent less likely to get a severe case.
A German study from 2012 suggests vaccination lowers the risk of being hospitalized for flu.
We need better evidence, but given the half-million or so hospitalizations and 50,000-plus deaths we might expect from flu this year, I’m not inclined to wait for it — not when the possible means of avoiding dire outcomes is as safe, simple, cheap and available as a flu shot.
Dr. Ben Kruskal agrees. He’s chief of infectious diseases for Harvard Vanguard Medical Associates, which cares for 450,000 people in Greater Boston.
“The million-dollar question is: Does flu vaccine not only prevent us from getting this really annoying illness, but does it prevent us from dying?” Kruskal says. “The data aren’t great. But they’re good enough to get me to immunize myself and my family and to strongly recommend it to patients.”
Important postscript: If you think you’re coming down with the flu in the weeks ahead, and you’re hearing that flu is prevalent in your community, ask a doctor or other health provider if you should be taking one of the two antiviral drugs approved for flu – Tamiflu or Relenza.
Those drugs can lower the risk of flu complications. But they need to be started within 48 hours of the first flu symptoms.
Antivirals are especially important if you’re at high risk for flu complications because you’re over 65; have chronic health conditions such as asthma, diabetes, heart, lung or kidney disease; or if you’re a pregnant woman. Children under 5, and especially those under 2, are also at high risk.
And how do you know if you have the flu versus a common cold?
“Flu invariably gives you a fever,” Vanderbilt’s Bill Schaffner says. “You feel very crummy, weak, lose appetite, may get muscle aches and a dry, persistent cough. Beyond anything else, there’s the sense that this is worse than a common cold.”
If this feels like you, and you know there’s flu in your vicinity, get thee to a physician.
The High Cost of Obesity on Government Budgets
America’s struggles with obesity are well-documented. Over the past 50 years, the share of obese adults gradually climbed from just one-in-eight in 1960 to over one-in-three today. In 2011–2012, obesity plagued 17 percent of American children and a shocking 35 percent of American adults—the highest adult obesity rate among developed countries. Unfortunately, the obesity epidemic shows no signs of abating: one report estimated that 44 percent of American adults will suffer from obesity by 2030.
One chief concern with our nation’s soaring obesity rates is the enormous pressure it places on health care spending. Although the magnitude of the estimated costs varies, a host of studies found the impact to be large. A study published by the Journal of Health Economics found that 20.6 percent of U.S. national medical spending—roughly $200 billion in 2005 dollars—was due to obesity, equal to over $2,700 in additional spending per person per year. Another article in Health Affairs estimated that over a quarter of the per capita growth in health care spending between 1987 and 2001 was due to obesity.
The high cost of obesity on medical spending has serious implications for federal and state budgets. One study found that in 2006 the additional Medicare spending due to obesity was estimated at over $1,700 per beneficiary (in 2008 inflation-adjusted dollars), while Medicaid spending due to obesity was measured at $1,021 per beneficiary—a more than three-fold inflation-adjusted rise since 1998.
These high obesity-related costs have materialized at a time when public spending on health care is soaring. Between 1974 and 2014, federal spending on major health programs rose from 1.0 percent of GDP to 4.8 percent and the Congressional Budget Office projects that this spending will rise to 6.1 percent of GDP by 2024. The high share of fiscal resources devoted to health spending suggests that investment in initiatives to curb the growth in obesity-driven health costs may be one strategy for reducing government deficits.Obesity-Attributable Medicare and Medicaid Spending By State
In this brief, we highlight the shares and levels of adult obesity-attributable Medicare and Medicaid spending across states. First, we report shares of Medicare and Medicaid spending calculated by a team of researchers— Justin Trogdon, Eric Finkelstein, Charles Feagan and Joel Cohen—who used data from the 2006 Medical Panel Expenditure Survey to estimate the fraction of Medicare and Medicaid spending attributable to adult obesity. Then, we calculate the amount by which obesity raises Medicare and Medicaid spending by multiplying the Trogdon et al. estimated shares by the program spending in each state. The results are presented in the maps below.
At the state-level, a substantial share —between 6 percent and 20 percent—of Medicaid spending goes to adult obesity-related expenditures. In 2006, Oregon (18.8 percent), Arizona (17.0 percent) and Colorado (16.2 percent) saw the highest shares, while Kansas (6.5 percent), Virginia (6.8 percent) and North Dakota (7.5 percent) devoted the smallest shares of Medicaid spending to obesity-related expenditures. On a state-by-state basis, Medicare spending due to obesity was substantial, too, with shares varying from 5.2 percent to 10.2 percent in 2004. The highest percent of obesity-attributable spending was found in Ohio (10.2 percent), Michigan (10.0 percent) and West Virginia (9.9 percent), while the lowest was in Hawaii (5.2 percent), Arizona (6.2 percent), and New Mexico (6.6 percent).
These adult obesity-attributable shares, coupled with high expenditures for Medicare and Medicaid, translate into $91.6 billion in federal outlays for obesity-related expenses through federal health programs. Medicare and Medicaid spending on obesity are driven largely by aggregate expenditures in each state, with the combined cost for these programs ranging from $119.4 million in Wyoming to $10.4 billion in California. Obesity-attributable Medicaid spending was highest in California ($6.1 billion), New York ($5.9 billion), and Texas ($2.7 billion), while Medicare spending was highest in California ($4.2 billion), New York ($3.2 billion), and Florida ($3.1 billion).Conclusion
One major cost stemming from the obesity epidemic is higher spending on Medicare and Medicaid. In these programs combined, obesity raised expenditures by over $90 billion in 2012, making obesity-related spending an important driver of state and federal fiscal pressures. These high fiscal costs also suggest that initiatives to prevent and reduce obesity should be a public-sector priority, as lower obesity can not only improve Americans’ health but also substantially lower government spending on health programs.
 To estimate state-level Medicare spending in 2012, we inflate Centers for Medicare and Medicaid Services data from 2009 by the Personal Consumption Expenditure Price Index for Health Care. State-level Medicaid spending data were derived from the Kaiser Foundation [http://kff.org/medicaid/state-indicator/total-medicaid-spending/].Authors
- Benjamin H. Harris
- Aurite Werman
One of the keepsakes given at the Library of Congress’s pre-inaugural black-tie gala for the ongoing Magna Carta exhibition was the commemorative coin depicted below. The coin’s obverse shows the name of the exhibition, Magna Carta: Muse and Mentor. Its reverse shows a reproduction of a medallion that appears on the title page of a 1774 imprint of the Journal of the Continental Congress.
When the First Continental Congress met in September and October of 1774, it drafted a Declaration of Rights and Grievances to clarify the colonists’ position on the rights of British Americans. Claiming all the liberties and privileges of Englishmen under “the principles of the English constitution, and the several charters or compacts,” the delegates sought the preservation of their democratic self-government, freedom from taxation without representation, the right to a trial by a jury of ones countrymen, and their enjoyment of “life, liberty and property” free from arbitrary interference from the Crown.
The Congress adopted the figure that illustrates the title page of the 1774 Journal of the Continental Congress as a symbol of unity: in a circle, twelve arms reach out to grasp a column which is topped by a liberty cap. The base of the column reads “Magna Carta.” The twelve arms represent the twelve colonies that sent delegates to the Congress (Georgia, which would have been the thirteenth colony, did not participate). Around the border can be seen a slogan in Latin: “Hanc Tuemur, Hac Nitimur,” which means, “This we defend, this we lean upon,” referring to Magna Carta and the Rights of Englishmen.
By Jessica Alpert
Sarah Parente, an Austin, Texas-based doula and mother of four, gave birth to her first child in the hospital with no complications. But then she decided to make a shift: Parente delivered her next three babies at home. “For women with low-risk pregnancies, home birth can be a great choice,” she says. “You have less stress because you are in your own home surrounded by a birth team of your choosing.”
Though home birth has recently gained cache in the U.S. — with some celebrities trumpeting the benefits of having their babies at home — the practice remains uncommon and the majority of pregnant women give birth in a hospital setting. Still, Parente may be getting a little more company, albeit slowly. Data released by the Centers for Disease Control (CDC) earlier this year shows the rate of homebirths in the U.S. has increased to 0.92 percent in 2013 and the rate of out-of-hospital births (including home) has increased 55 percent since 2004.
Experts in the United Kingdom are saying that’s a good thing.
The London-based National Institute for Health and Care Excellence (Nice) recently released recommendations that homebirths and midwife-led centers are better for mothers and often just as safe for babies as hospital settings. Of the 700,000 babies born in England and Wales each year, nine out of 10 are born in obstetric-led units in hospitals.
The Nice guidelines are recommended for the approximately 45 percent of women who, like Parente, are low-risk. Women considered high-risk include those over 35, women who have high blood pressure or heart disease, those who suffer from anemia, obese women, and women whose babies have fetal abnormalities.
According to the recommendations, low-risk women having their first child experienced fewer medical interventions at home and in midwife-led units as opposed to obstetric units in the traditional hospital setting. At the same time, the findings determined that babies of first-time mothers were at a slightly higher risk for stillbirth and other complications during homebirths. For second-time mothers, those risks diminished. It’s not entirely clear why there were fewer interventions during homebirths but researchers believe it could have to do with women being more comfortable in the home environment.
For Parente, this was indeed the case. “I felt confident in the skills and judgement of my midwife and knew that if I ever felt like something was not right, I had a hospital down the street. … For me, my homebirths were very sacred. I was able to feel comfortable enough to make a lot of noise if I needed to, to sing, or scream, or cry if I needed to. My birth team simply watched over me and my baby without disrupting the rhythm of my labor.”
Birth Is Cultural
In the United Kingdom, women who want homebirths still register at the hospital. Gene Declercq, professor of community health sciences and an assistant dean at the Boston University School of Public Health, said that this process allows health care professionals to keep an eye on the pregnancy. “That way, women who need to be referred, can be referred. And if they need to be referred during labor, it’s not a big drama to go to the hospital. In the States, that is not the case. Going to the hospital can be much more complicated.”
So could similar recommendations come out in the United States? “Birth is an inherently cultural issue,” says Declercq. “In Britain, the philosophy is ‘every woman deserves a midwife and some need an obstetrician, too.’ Midwives attend 8 percent of births in the U.S. and 80 percent in England.
Susan Bewley, professor of complex obstetrics at King’s College London and a member of the panel that developed these guidelines, stressed the importance of more midwifery-led units in hospital settings. She told the BBC that “midwifery-led settings have better outcomes for mothers than the traditional obstetric units and labor wards.” But that means that the National Health Service (NHS) would have to seriously reconfigure its care for pregnant women. Currently, there are 80 midwifery-led units in hospitals and 60 units elsewhere; the Royal College of Medicine has called for 5,000 new midwives to be recruited and added.
That’s on top of the some 35,000 midwives that currently practice in the U.K. Compare that to the approximately 13,000 certified nurse midwives (CNMs) who practice in the United States.
For more midwifery care to take place in the United States, more active support would have to come from obstetricians. “If you talk to OBs in England,” says Declercq, “their prestige comes from the fact that they are high-risk specialists and oftentimes the only people they see are high-risk cases. In the United States, the ideology is that OBs should deal with every mother in case something happens.”
Readers: Did a midwife assist your birth? Did you have a doula? How do you feel about these recommendations? Revolutionary or dangerous?