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These past two weeks at CBPP, we focused on food assistance, poverty and inequality, housing, health, Social Security, federal tax, and the economy.

Categories: Benefits, Poverty

Finland’s Independence Day and the Finnish Constitution of 1919

In Custodia Legis - 8 hours 31 min ago

Today marks Finland’s Independence Day, a day that was celebrated for the first time exactly one hundred years ago today, on December 6, 1919. Although the date marks the signing of Finland’s Declaration of Independence in 1917, the day was not established as a national holiday until November 20, 1919, through a government decision (No. 138 of 1919).

Statsrådets beslut därom, att den 6 december årligen skall firas såsom årsdag av Finlands självständighetsförklaring [Government decision that December 6 shall be celebrated annually as the anniversary of Finland’s Declaration of Independence] (Finlands författningssamling [FFS] 1919:138). Photo by Geraldine Davila Gonzalez.

The year 1919 is an important year in the history of Finland. Following its independence from Russia in 1917, the Finns set out to decide whether they wanted to become a constitutional republic or a constitutional monarchy. It proved to be a difficult decision. The conflict sparked the Finnish Civil War of 1918, which appears to still divide the Finns, some 100 years later.

The original draft of the Finnish Constitution did indeed designate Finland a constitutional monarchy, and the German-born Prince Friedrich Karl of Hesse was even chosen as King of Finland. He later declined the throne, prior to his coronation in December of 1918, following the complete defeat of Germany in the First World War, which led to the abdication of Kaiser Willhelm II. Thus, in July 1919, a constitutional republic was formed through the adoption of the Finnish Constitution of 1919. Then- regent Carl Gustaf Emil Mannerheim, who was known for being a monarchist, signed the constitution.

Suomen Hallitusuoto [Instrument of Government for Finland] [Finnish Constitution](Suomen Asetuskokoelma 1919:94) (in Finnish). Photo by Geraldine Davila Gonzalez.

Regeringsform för Finland [Instrument of Government for Finland] (FFS 1919:94) [Finnish Constitution of 1919] (in Swedish). Photo by Geraldine Davila Gonzalez.


Carl Gustaf Emil von Mannerheim, two head-and-shoulders portraits, facing left. , None. [Between 1910 and 1930] .Prints and Photographs Division Library of Congress.

The Constitution of 1919 contained a number of important provisions, including:

  • That Finland be an Independent and Sovereign Republic. (1 §.)
  • That the Head of State be the President. (2 § 2 st.)
  • How a president is elected. (23 §.)
  • That the People be represented through Parliament. (2 §.)
  • That there be a Prime Minister.
  • That Finnish Citizens are equal before the law. (5 §.)
  • Abolishment of Nobility. (15§.)
  • Freedom of the Press (originally obtained as the first country in the world, while part of Sweden in 1766).
  • That there be two supreme courts, one for civil and criminal cases (the Supreme Court), and one for public administrative cases (the Supreme Administrative Court). (2 § 4 st.)
  • Establishment of a right to belong or not to belong to a religion. (8-9 § §.)
  • That Finnish and Swedish be the official languages in Finland and that citizens have a right to communicate with the state and receive documents from the state in these languages. (14 §.) All military training was also to be conducted in the recruit’s language, although the military commando language was determined as Finnish (75 § ).

The “Language Question” was one of the more difficult questions to agree on. Swedish had been the language of the educated classes, but a nationalistic spirit, especially in the wake of the Civil War, led to an increase in support for a Finnish-only provision.

The Instrument of Government of 1919 also made clear that the text was only one of several constitutional texts, which together formed the Finnish Constitution. (1 §.) Other constitutional texts were the Diet Order of 1906 (which gave women the right to vote), The Riksdag Act of 1928, Minister Liability Act and the Law on Impeachment from 1922. The constitutional texts were replaced by one single Constitution in March of 2000 after being adopted in 1999, available in Finnish and Swedish. An English unofficial translation has also been made available by the Finnish Ministry for Justice.

As provided for in the Constitution of 1919, the lantdagen (Diet of Finland) elected the first president (94§). Thus, on July 25, 1919, Dr. Karrlo Juho Ståhlberg was elected the first President of Finland, defeating Gustaf Mannerheim with 143 to 50 votes. Mannerheim would later become the sixth President of Finland in 1944, during the Second World War.

Dr. K.J. Ståhlberg [Oct. 19, 1925 (date created or published later by Bain)]. Library of Congress Prints and Photograph Division.

Additional resources available at the Library of Congress:

Finnish Independence and Civil War:

Law Library Online Resources on Finland:


If you have a question regarding Finnish law, you can submit it using the Ask a Librarian form on our website.

Hyvää itsenäisyyspäivää!

Glad självständighetsdag!

Happy Independence Day!

Categories: Research & Litigation

Must-Reads Of The Week From Brianna Labuskes

Kaiser Health News - 9 hours 56 min ago
The Friday Breeze

Newsletter editor Brianna Labuskes, who reads everything on health care to compile our daily Morning Briefing, offers the best and most provocative stories for the weekend.

Happy Friday! Hope everyone had a lovely, restful Thanksgiving. And here’s your periodic (and I’m sure very appreciated and not at all tiresome) reminder not to be one of the nearly 40 percent of Americans who plan to skip their flu shot.

Now on to our jam-packed week of news! Here’s what you might have missed.

There seems to be some conflicting narrative around what exactly a new health care spending analysis means, but one thing is clear—we are now spending $11,172 per person and that is… uh… a lot, to say the least. Spending on health care grew at a slower pace than the economy overall. But the spending didn’t increase because people were going to the doctor more. Instead, price hikes made up for the slower usage growth found by the HHS analysis.

If you want a good plain-English breakdown of what this means, check out this Axios summary of it all; they do a better job than I could. (No one told me there’d be math!) Or listen to KHN’s “What The Health” podcast by our fabulously knowledgeable Julie Rovner.

The New York Times: Health Spending Grew Modestly, New Analysis Finds

Axios: Health Care Spending Grew At A Faster Rate In 2018

KHN: ‘What The Health?’: We Spend HOW MUCH On Health Care?

Speaking of outrageous hospital prices, in a move that shocked no one, hospitals officially filed a suit against the Trump administration rule that would compel them to share secretly negotiated prices for procedures.

The New York Times: Hospitals Sue Trump To Keep Negotiated Prices Secret

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There has been an absolute flood of news out of the Trump administration this week, so buckle up.

Nearly 700,000 Americans are slated to lose their food stamp benefits under a new rule that tightens the work requirements in the Supplemental Nutrition Assistance Program (commonly known as SNAP). The move will purportedly save the government $5.5 billion over five years. The Agriculture Department defended the decision to crack down on waivers that extend the amount of time a beneficiary can receive aid as essentially, if not now (when the economy is good) then when? 

Critics were quick to point out the economic and moral pitfalls of this kind of decision, among them being: most beneficiaries work and many of the ones who don’t usually have a reason beyond wanting the $1.83 per meal that they receive under SNAP; it’s been shown that SNAP spending helps cushion the economy during a recession; and the people being cut off are among the most vulnerable in the society.

The Associated Press: 668,000 Will Lose Food Stamp Benefits Under New Work Rules

As part of the administration’s goal to eradicate the HIV epidemic, HHS announced that uninsured Americans can now get free HIV-prevention drugs. While PrEP has been shown to be wildly successful, many people who are at high-risk of contracting the virus aren’t taking the drug for one reason or another.

(I wonder if this is all a bit awkward considering that HHS and PrEP’s-maker are locked in a bitter patent battle.)

The New York Times: 200,000 Uninsured Americans To Get Free H.I.V.-Prevention Drugs

Attorney General William Barr made waves when he suggested that communities upset with police brutality might lose protections from the cops they’re protesting. The remarks — which seemed to encourage abandonment as a form of retribution for those seeking criminal justice reform — were quickly condemned as dangerous.

The New York Times: Barr Says Communities That Protest The Police Risk Losing Protection

A new investigation from Reuters found that the FDA ignored warning bells about the dangers of talc from as early as the 1970s. The agency for decades deferred to the industry over outside experts’ advice.

Reuters: FDA Bowed To Industry For Decades As Alarms Were Sounded Over Talc

And a disturbing video obtained by ProPublica contradicts the Border Patrols’ account of the death of a sick 16-year-old who was being held in U.S. custody. The video shows the boy staggering to the toilet and collapsing on the floor, where he remained in the same position for the next four-and-a-half hours. According to ProPublica “The video shows the only way CBP officials could have missed Carlos’ crisis is that they weren’t looking.” Border Patrol also said it was agents who found his body — but in reality it was a cellmate who alerted them to his death.

ProPublica: Inside The Cell Where A Sick 16-Year-Old Boy Died In Border Patrol Care

Meanwhile, new documents reveal how a powerhouse consulting firm proposed money-saving methods for the detention centers that included proposed cuts in spending on food for migrants, as well as on medical care and supervision of detainees.

ProPublica: How McKinsey Helped The Trump Administration Detain And Deport Immigrants

Over on the presidential campaign trail, “Medicare for All” continues to trip up the candidates, including Sen. Elizabeth Warren (D-Mass.) whose fate seems to have become tied to the proposal that wasn’t even hers to start with. Politico takes us all the way back to a town hall in 2017 hosted by Sen. Kamala Harris (D-Calif.) to figure out how we got to where we are today.

Politico: Medicare For All: The Most Consequential Moment Of The 2020 Primary

The Washington Post: How A Fight Over Health Care Entangled Elizabeth Warren — And Reshaped The Democratic Presidential Race

Meanwhile, some Dems in the race are touting a “public option” as a moderate alternative to “Medicare for All,” but don’t let that fool you. That kind of shift could still send an earthquake through the health care landscape.

The New York Times: Why The Less Disruptive Health Care Option Could Be Plenty Disruptive

Gains made by the anti-abortion movement in recent years are often attributed to a well-executed ground game by the right. But there have also been crucial missteps on the other side of the abortion wars. Critics say the national abortion rights movement lost touch with the ways access was steadily eroding in Republican strong-holds, and that leaders grew overconfident during President Barack Obama’s term. As one director of a clinic in Atlanta told The New York Times: “We were screaming at the top of our lungs, everything is not fine, please pay attention.”

The New York Times: How A Divided Left Is Losing The Battle On Abortion

There’s been a ton of buzz around the first major gun case the Supreme Court took up in nearly a decade. But will it all be for naught? Arguments in the case that centers around a NYC hand gun ordinance focused on the fact that the city got rid of the contested limits in July.

Reuters: U.S. Supreme Court Justices Debate Whether To Dismiss Major Gun Case

I have to say I did not expect to read the phrase, “we are feared as a tiger with claws, teeth and balls,” when I kicked off my workweek, but here we are. As seems to be the case every time we get unsealed documents dealing with the Sackler family, the newest ones reveal how deeply involved Richard Sackler was in the aggressive push to market OxyContin.

Stat: Purdue’s Richard Sackler Proposed Plan To Play Down OxyContin Risks, And Wanted Drug Maker Feared ‘Like A Tiger,’ Files Show

So often opioid news focuses on the big players and court cases these days. But in this article people who were high school kids at the time the epidemic was really starting to brew talk about how their lives have been irrevocably changed by the crisis.

The New York Times: The Class Of 2000 ‘Could Have Been Anything.’ Until Opioids Hit.

Despite the fact that it seems warnings are everywhere about the dangers of vaping, a new survey reveals that nearly one in three teens have used a tobacco product recently. What’s more is that many students said they did not consider intermittent smoking of any product to be harmful.

The New York Times: Nearly A Third Of Teens Use One Or More Tobacco Products

In the miscellaneous file for the week:

•  In Rhode Island, 11 patients over a two-and-a-half year time span died because of a misplaced breathing tube (something that’s supposed to never happen in emergency medicine). The state is the only one in New England to allow responders other than the most highly trained paramedics place the tubes. But advocates say if they tighten those rules, it will cost even more lives because fewer patients will have access to the equipment.

ProPublica: EMS Crews Brought Patients To The Hospital With Misplaced Breathing Tubes. None Of Them Survived.

• Every once in a while we’re hit with a story that reminds us that relying on technology — especially when it comes to health care — is a dangerous game despite the benefits it brings. This time it was a glitch with diabetes monitors.

Stat: A Glitch In Diabetes Monitors Serves As A Cautionary Tale For Health Tech

• Patients who are desperate for a miracle are being given tips by stem cell clinics on how to raise enough money to afford unproven, and sometimes dangerous, treatments. There’s always GoFundMe, the clinics say when met with the patients’ financial barriers.

The Washington Post: Clinic Pitches Unproven Treatments To Desperate Patients, With Tips On Raising The Cash

That’s it from me! Have a great weekend.

Categories: Health Care

State: 6 Lung Illnesses Linked To Regulated Pot Vapes

CommonHealth (WBUR) - 13 hours 26 min ago

The new data marks the first time the state Department of Health has linked illnesses to vaping products bought at dispensaries.

Categories: Health Care

Longer Looks: The Psychology Of Voting; Overexcited Neurons And Artificial Intelligence; And More

Kaiser Health News - 14 hours 39 min ago
Each week, KHN finds interesting reads from around the Web.
Categories: Health Care

Viewpoints: Lessons On Getting Over-The-Top Prices On Life-Saving Drugs Under Control; Breakthrough For Alzheimer’s? Look At The Confusion

Kaiser Health News - 14 hours 39 min ago
Opinion writers weigh in on curbing the costs of pharmaceuticals and other issues.
Categories: Health Care

Mental Health Institutions, Playgrounds, And Dozens More: Va. Governor Vows To Eliminate Racist Laws Still On Books

Kaiser Health News - 14 hours 39 min ago
A task force assembled by Gov. Ralph Northam several months after a racist photo of him was found in his medical school yearbook recommended removing nearly 100 overtly discriminatory and racist laws still on the books.
Categories: Health Care

State Highlights: Texas Has Highest Rate Of Uninsured Women Of Child-Bearing Age. Look At Death Rates; Parents Sue Troubled Hospital In North Carolina Over Child’s Death

Kaiser Health News - 14 hours 39 min ago
Media outlets report on news from Texas, North Carolina, Connecticut, California, Minnesota, Florida, Georgia, Illinois, and Missouri.
Categories: Health Care

New Concepts About Mental Health Of Vets: Bad War Experiences Might Not Be What’s Leading To So Many Suicides

Kaiser Health News - 14 hours 39 min ago
Army-funded studies report there is a significant and growing proportion of soldiers entering the military with psychiatric disorders, requiring wider availability of mental health care for troops, even those who have never experienced combat. Public health news is on studies on dangers of PFAS, aging, face injuries from cellphones, time-restricted eating, postpartum depression among women of color, measles' steady comeback, raising boys these days, diabetes risks for preemies, and traumas brought on by patients, as well.
Categories: Health Care

Nearly One In Three High School Students Admit To Using At Least One Type Of Tobacco Product Recently

Kaiser Health News - 14 hours 39 min ago
Public health officials are concerned that despite wide-scale publicity intended to deter vaping, especially in the wake of recent illnesses and deaths, not only did the practice continue to surge, but students also did not seem to be particularly alarmed about e-cigarettes. What's more is that students also reported using other nicotine products, revealing a widespread problem with addiction not limited to just vaping. Meanwhile, a tale of two states shows the effects of what happens when there's a vaping ban in one.
Categories: Health Care

Medicare Advisory Commission Deems Payments To Ambulatory Surgical Centers As Already High Enough

Kaiser Health News - 14 hours 39 min ago
Eliminating the increase would produce cost savings for Medicare without hurting access to care or the willingness of ambulatory surgical centers to deliver services to Medicare beneficiaries, the Medicare Payment Advisory Commission ruled. In other news, Saturday is the deadline for Medicare enrollment, but some advocates are calling for flexibility because of the difficulties some beneficiaries have encountered while trying to sign up.
Categories: Health Care

Supreme Court’s Question Of The Day: Does The Constitution Give Homeless The Right To Sleep On Sidewalks?

Kaiser Health News - 14 hours 39 min ago
The ruling from the 9th Circuit Court of Appeals says so long as there is no option of sleeping indoors, the government cannot criminalize indigent, homeless people for sleeping outdoors on public property. But dissenters say the decision shackles the hands of law enforcement who are trying to deal with an escalating homeless crisis.
Categories: Health Care

Tufts University Latest Organization To Distance Itself From Sackler Family Following Opioid Crisis Fallout

Kaiser Health News - 14 hours 39 min ago
“Our students find it objectionable to walk into a building that says Sackler on it when they come in here to get their medical education,” said Dr. Harris A. Berman, the dean of the Tufts University School of Medicine. Tufts won't return the money Sackler has donated over the years, but will instead set up an endowment to help combat the epidemic.
Categories: Health Care

In Amicus Brief, Lawyers Use Personal Experiences With Abortion To Urge Supreme Court To Block Louisiana Bill

Kaiser Health News - 14 hours 39 min ago
“Becoming a first-generation professional would have been impossible without access to safe and legal abortion services,” one signer wrote. The Supreme Court is set to hold oral arguments on the case, which centers around hospital admitting privileges, in March.
Categories: Health Care

First Edition: December 6, 2019

Kaiser Health News - 16 hours 56 min ago
Today's early morning highlights from the major news organizations.
Categories: Health Care

Analysis: Choosing A Plan From The Impossible Health Care Maze

Kaiser Health News - 18 hours 27 min ago

In this highly partisan political moment, there’s one issue that nearly every American can agree on: Our health care system is a mess and in need of dramatic overhaul.

That’s not just because it is absurdly expensive compared with the systems of other developed countries. It’s also because it is so dauntingly complex.

That complexity, in large part, derives from the fact that the health care system has been driven significantly by profit, rather than by measures of health. Countless providers, companies, consultants and intermediaries are trying to get their piece of the $3.5 trillion pie that is U.S. health care. Nora Ephron said, “Everything is copy.” In 21st-century U.S. health care, everything is revenue, and so everything is billed.

That has led to a maze-like system — with twists and turns and barriers and blind alleys and incomprehensible signposts — that ordinary people are expected to navigate.

We say American patients should be happy because our system gives consumers choices. We tell people that to benefit they just need to be smarter shoppers.

What we are really telling them is to perform the impossible.

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How can they choose an insurance policy when there are endless permutations involving personal budget calculations and modeling that would defy a post-doc in economics? For each policy, there’s an in-network deductible and an out-of-network deductible, overlapping for the family and each individual. There are copays and coinsurance (yes, they’re different), as well as an annual maximum personal out-of-pocket outlay (which may not include some of the above).

Likewise, how to choose between a PPO and an HMO, especially when the PPO network may be — or may become — so narrow during the term of the policy that it affords little or no choice of doctors? Should patients pair an insurance plan with a tax-advantaged flexible spending account or health savings account — and how to understand the difference anyway?

I’m a medical doctor and have spent years as a journalist covering health care. But I am grateful that my company chooses my PPO health plan — not just because it’s good, but also because it means I don’t have to try to decide between hundreds of options when there is no good way to make a rational choice.

The system is rigged against patients — thanks largely to its opacity and complexity. Insurance plans list an array of covered services but then can refuse to pre-certify a prescribed treatment or decide it was not medically necessary and deny coverage after the fact. For example, a patient goes to the emergency room with chest pain, which turns out to be just a pulled muscle. So, in retrospect, it wasn’t an emergency. Coverage denied!

Informed consent is regarded as a moral and legal obligation by physicians; for every procedure performed, doctors are required to tell patients the chance of success, potential side effects and problems. And yet when it comes to navigating our convoluted system, patients travel in the dark.

The current complexity is an outgrowth of countless decisions over the past 30 years, many of which sounded logical at the time but which grew out of financial considerations. All the players are effectively licensed to reach into our wallets when they can’t get the money they want from one another.

As prices spiraled upward, insurers (backed by economists) imposed copayments and coinsurance so patients would have “skin in the game,” to encourage them to use health care more sparingly, more wisely. But with prices in medicine now so high, the skin-in-the-game theory now means many patients live with debilitating symptoms, delay needed treatment or don’t get treated at all.

In one study, 1 in 4 diabetics reported taking less insulin than prescribed because of costs. Another found that one-fifth of cardiac patients with “financial hardship” cut back on both food and medicines.

In a world where everything is billable (and nothing is under warranty), and when part of the system is found to be broken, the answer has often been to add another layer of complexity rather than to remedy the underlying flaw.

We’ve turned somersaults not to do what almost every other developed country has done: restrain charges by setting prices or by large-scale national negotiations. We hope that by structuring incentives for providers and patients — with PPOs, HMOs, HSAs, FSAs, coinsurance, copayments, pre-authorization, drug tiering, PBMs and more — the market will respond.

And it does, but often not with cheaper, simpler health care.

“Innovation” in our profit-oriented system is not just about developing lifesaving treatments, but also about inventing new ways to bill and new charges that don’t exist elsewhere.

Consider this analysis from a report urging patients to consider changing Medicare drug plans to save money:

“The millions of patients with CVS Health’s popular SilverScript drug plan will see a $2 decrease in their average monthly premium, from $31 in 2019 to $29 in 2020 …” That’s good, right? Here’s the catch: The plan will go from no deductible, in most areas in 2019, to a deductible of $215 to $435 in 2020.

So patients who feel like they’re getting a good deal when they hear their premiums are going down will actually pay more.

Americans trying to be smart shoppers are understandably confused about navigating the open enrollment season, as they are doing currently. And just when they have figured it out for one year, they have to do it all over again. The odds of success are small.

Categories: Health Care

Black Mothers Get Less Treatment For Postpartum Depression Than Other Moms

Kaiser Health News - 18 hours 27 min ago

Portia Smith’s most vivid memories of her daughter’s first year are of tears. Not the baby’s. Her own.

“I would just hold her and cry all day,” Smith said.

At 18, Smith was caring for two children, 4-year-old Kelaiah and newborn Nelly, with little help from the partner in her abusive relationship. The circumstances were difficult, but she knew the tears were more than that.

“I really didn’t have a connection for her,” said Smith, now a motivational speaker and mother of three living in Philadelphia. “I didn’t even want to breastfeed because I didn’t want that closeness with her.”

The emotions were overwhelming, but Smith couldn’t bring herself to ask for help.

“You’re afraid to say it because you think the next step is [for the authorities] to take your children away from you,” she said. “You’re young and you’re African American, so it’s like [people are thinking], ‘She’s going to be a bad mom.'”

Smith’s concern was echoed by several black women interviewed for this story. Maternal health experts said some black women choose to struggle on their own rather than seek care and risk having their families torn apart by child welfare services.

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Nationally, postpartum depression affects 1 in 7 mothers. Medical guidelines recommend counseling for all women experiencing postpartum depression, and many women also find relief by taking general antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft).

In March, the Food and Drug Administration approved the first drug specifically for the treatment of postpartum depression, which can include extreme sadness, anxiety  and exhaustion that may interfere with a woman’s ability to care for herself or her family. The mood disorder can begin in pregnancy and last for months after childbirth.

But those advances help only if women’s needs are identified in the first place — a particular challenge for women of color and low-income mothers, as they are several times more likely to suffer from postpartum mental illness but less likely to receive treatment than other mothers.

The consequences of untreated postpartum depression can be serious. A report from nine maternal mortality review committees in the United States found that mental health problems, ranging from depression to substance use or trauma, went unidentified in many cases and were a contributing factor in pregnancy-related deaths. Although rare, deaths of new mothers by suicide have also been reported across the country.

Babies can suffer too, struggling to form a secure attachment with their mothers and increasing their risk of developing behavioral issues and cognitive impairments.

‘I Was Lying To You’

For many women of color, the fear of child welfare services comes from seeing real incidents in their community, said Ayesha Uqdah, a community health worker who conducts home visits for pregnant and postpartum women in Philadelphia through the nonprofit Maternity Care Coalition.

News reports in several states and studies at the national level have found that child welfare workers deem black mothers unfit at a higher rate than they do white mothers, even when controlling for factors like education and poverty.

During home visits, Uqdah asks clients the 10 questions on the Edinburgh Postnatal Depression Scale survey, one of the most commonly used tools to identify women at risk. The survey asks women to rate things like how often they’ve laughed or whether they had trouble sleeping in the past week. The answers are tallied for a score out of 30, and anyone who scores above 10 is referred for a formal clinical assessment.

Uqdah remembered conducting the survey with one pregnant client, who scored a 22. The woman decided not to go for the mental health services Uqdah recommended.

A week after having her baby, the same woman’s answers netted her a score of zero: perfect mental health.

“I knew there was something going on,” Uqdah said. “But our job isn’t to push our clients to do something they’re not comfortable doing.”

About a month later, the woman broke down and told Uqdah, “I was lying to you. I really did need services, but I didn’t want to admit it to you or myself.”

The woman’s first child had been taken into child welfare custody and ended up with her grandfather, Uqdah said. The young mother didn’t want that to happen again.

April McNeal (left), a community health worker with the Maternity Care Coalition, made visits to Stephanie Lee’s home while Lee was pregnant with and after she gave birth to son Santeno Adams. After testing Lee for postpartum depression, McNeal recommended she take advantage of the coalition’s free, in-home therapy. “You don’t have to tell anybody,” McNeal says about the program. “They’re not coming here with their therapist super hat — it just looks like, oh, my girlfriend is coming over, and lo and behold, they’re giving you therapy.”(Kimberly Paynter/WHYY)

Screening Tools Don’t Serve Everyone Well

Another hurdle for women of color comes from the tools clinicians use to screen for postpartum depression.

The tools were developed based on mostly white research participants, said Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center. Often those screening tools are less relevant for women of color.

Research shows that different cultures talk about mental illness in different ways. African Americans are less likely to use the term depression, but they may say they don’t feel like themselves, Breland-Noble said.

It’s also more common for people in minority communities to experience mental illness as physical symptoms. Depression can show up as headaches, for example, or anxiety as gastrointestinal issues.

Studies evaluating screening tools used with low-income, African American mothers found they don’t catch as many women as they should. Researchers recommend lower cutoff scores for certain African American women in order to better identify women who needs help but may not be scoring high enough to trigger a follow-up under current guidelines.

Bringing Treatment Home

It took Smith six months after daughter Nelly’s birth to work up the courage to see a doctor about her postpartum depression.

Even then, she encountered the typical barriers faced by new mothers: Therapy is expensive, wait times are long, and coordinating transportation and child care can be difficult, especially for someone struggling with depression.

But Smith was determined. She visited two different clinics until she found a good fit. After several months of therapy and medication, she began feeling better. Today, Smith and her three daughters go to weekly $5 movies and do their makeup together before big outings.

Other mothers never receive care. A recent study from the Children’s Hospital of Philadelphia found that only 1 in 10 women who screened positive for postpartum depression at the hospital’s urban medical practice sites sought any treatment within the following six months. A study examining three years’ worth of New Jersey Medicaid claims found white women were nearly twice as likely to receive treatment as were women of color.

Noticing that gap, the Maternity Care Coalition in Philadelphia tried something new.

In 2018, the nonprofit started a pilot program that pairs mothers with Drexel University graduate students training to be marriage and family counselors. The student counselors visit the women an hour a week and provide free in-home counseling for as many weeks as the women need. Last year, the program served 30 clients. This year, the organization plans to expand the program to multiple counties in the region and hire professional therapists.

It was a game changer for Stephanie Lee, a 39-year-old who had postpartum depression after the birth of her second child in 2017.

“It was so rough, like I was a mess, I was crying,” Lee said. “I just felt like nobody understood me.”

She felt shame asking for help and thought it made her look weak. Lee’s mother had already helped her raise her older son when Lee was a teenager, and many members of her family had raised multiple kids close in age.

“The black community don’t know postpartum,” Lee said. “There’s this expectation on us as women of color that we have to be … superhero strong, that we’re not allowed to be vulnerable.”

But with in-home therapy, no one had to know Lee was seeking treatment.

The counselors helped Lee get back to work and learn how to make time for herself — even just a few minutes in the morning to say a prayer or do some positive affirmations.

“If this is the only time I have,” Lee said, “from the time I get the shower, the time to do my hair, quiet time to myself — use it. Just use it.”

This story was reported as a partnership that includes The Philadelphia Inquirer, WHYY, NPR and Kaiser Health News.

Categories: Health Care

Patient-Induced Trauma: Hospitals Learn To Defuse Violence

Kaiser Health News - 18 hours 27 min ago

SAN DIEGO — When Mary Prehoden gets dressed for work every morning, her eyes lock on the bite-shaped scar on her chest.

It’s a harsh reminder of one of the worst days of her life. Prehoden, a nurse supervisor at Scripps Mercy Hospital San Diego, was brutally attacked last year by a schizophrenic patient who was off his medication. He lunged at her, threw her to the ground, repeatedly punched and kicked her, and bit her so hard that his teeth broke the skin and left her bleeding.

The incident lasted about 90 seconds, but the damage lingers.

“Even if I didn’t have a scar, the scar is in your head,” said Prehoden, 58. “That stays with you for the rest of your life.”

Nurse supervisor Mary Prehoden was brutally attacked by a patient with schizophrenia at Scripps Mercy Hospital in San Diego. (Heidi de Marco/KHN)

Prehoden was left with a bite-shaped scar on her chest.(Heidi de Marco/KHN)

Violence against health care workers is common — and some say on the rise.

According to the Occupational Safety and Health Administration, workplace violence is four times more common in health care settings than in private industry on average, yet it still goes underreported. Patients account for about 80% of the serious violent incidents reported, but stressed-out family and friends also are culprits. Co-workers and students caused 6% of the incidents.

In a 2018 poll of about 3,500 emergency room doctors conducted for the American College of Emergency Physicians, nearly 70% said violence in the emergency department has increased in the past five years.

About 40% of the doctors believed the majority of assaults were committed by psychiatric patients, and half said the majority were committed by people seeking drugs or those under the influence of drugs or alcohol.

In California, a state law requires hospitals to adopt workplace violence prevention plans and report the number and types of attacks to the state. The state then compiles the data into annual reports.

In the first full report, 365 hospitals tallied 9,436 violent incidents during the 12-month period that ended Sept. 30, 2018, ranging from scratchings to stabbings. Workers were punched or slapped in one-third of the assaults and were bitten in 7% of cases.

“I don’t know that you ever expect to have to defend yourself at your workplace,” Prehoden said. “It’s not anything you’re prepared for.”

Scripps Mercy Hospital officials have made a number of changes to help protect employees from what they refer to as an epidemic of violence. They’ve launched a “rapid response” team made up of staff members who try to defuse potentially violent situations. And the hospital has introduced a behavioral screening tool to help identify patients prone to violence. When patients get flagged, they must wear a green wristband, and a green peace sign is placed on their door.

Security manager Ryan Sommer leads a de-escalation training for hospital staff at Scripps Memorial Hospital Encinitas. Sommer asked participants to raise a hand if they have been assaulted on the job. Nearly all did. (HEIDI DE MARCO/KHN)

Ryan Sommer, who is the head of security at Scripps Memorial Hospital Encinitas, leads violence de-escalation training for Scripps staff at different locations throughout San Diego County.

On one recent morning, about 20 employees at the Encinitas facility learned how to deter an agitated and combative patient. One tip Sommer shared: Behavior influences behavior, so listen with empathy and establish a personal rapport with the patient. And, he told them, don’t lose your cool; the goal is to get agitated patients to calm down.

Scripps hospital employees learn defense tactics from security manager Ryan Sommer at Scripps Memorial Hospital Encinitas. Workplace violence is four times more common in the health care sector than in private industry. (HEIDI DE MARCO/KHN)

Sommer also taught self-defense tactics should the situation escalate. In groups of two, employees practiced how to disengage from a hold and block strikes from an attacker.

“How many of you have been attacked on the job?” Sommer asked. Nearly all the participants raised their hands.

“This happens daily. They get punched, scratched, spit on, yelled at,” he said later.

Sommer said the number of violent incidents at the Scripps hospitals is rising and the injuries are becoming more severe.

All Scripps Memorial Hospital’s security guards have been armed with stun guns and stab-proof vests for the past year due to what the health system calls an epidemic of violence against its workers. “We hope they work as a deterrent,” says security manager Ryan Sommer. (HEIDI DE MARCO/KHN)

Since earlier this year, security guards at all Scripps hospitals have been armed with stun guns, said Janice Collins, a spokeswoman for Scripps Health. They wear stab-proof vests and are stationed strategically around the facilities. The stun guns are used when security guards believe they are needed to protect life, Collins said. Prehoden’s situation would have met that criteria, she said.

Hospitals across California are taking similar measures with the hope of reducing violent confrontations, said Gail Blanchard-Saiger, the California Hospital Association’s vice president of labor and employment.

Some sites use panic buttons, metal detectors, security dogs, increased police presence and security cameras, in addition to de-escalation training.

The efforts vary by location and risk, Blanchard-Saiger said.

Scripps hospitals use a behavioral screening tool to help identify which patients might be prone to violent behavior. If a patient gets flagged, they must wear a green wristband upon admission and a green peace sign is placed on their door.(Heidi de Marco/KHN)


Additional support from local law enforcement would make a difference, she said. “Unfortunately, I’ve heard plenty of stories where they don’t even come to the hospital,” she said. “They’re short-staffed, underfunded. They’re prioritizing.”

Prehoden has attended the de-escalation training and is now on the rapid response team at Scripps Mercy Hospital.

It took her three weeks to return to work after she was beaten in August 2018. A nurse for almost 40 years, she admits being a little on edge now, and feels as if her attacker robbed her of her confidence. He served six months in jail for the attack.

“This cannot be the new face of nursing,” Prehoden said. “We can’t afford to lose our staff because somebody decides not to take his medication.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Categories: Health Care

Website Errors Raise Calls For Medicare To Be Flexible With Seniors’ Enrollment

Kaiser Health News - 18 hours 27 min ago

Saturday is the deadline for most people with Medicare coverage to sign up for private drug and medical plans for next year. But members of Congress, health care advocates and insurance agents worry that enrollment decisions based on bad information from the government’s revamped, error-prone Plan Finder website will bring unwelcome surprises.

Beneficiaries could be stuck in plans that cost too much and don’t meet their medical needs — with no way out until 2021.

On Wednesday, the Centers for Medicare & Medicaid Services told Kaiser Health News that beneficiaries would be able to change plans next year because of Plan Finder misinformation, although officials provided few details. And the website and representatives at Medicare’s call center had no information about that option.

The overhauled Plan Finder debuted at the end of August, and 2020 plan information was added in October. Over the past three months, Plan Finder problems reported to CMS by the National Association of Insurance Commissioners, the National Association of Health Underwriters, and state and national consumer advocates included inaccurate details about prices, covered drugs and dosages, and difficulty sorting and saving search results, among other things.

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CMS made almost daily corrections and fixes to the website, which is the only tool that can compare dozens of private drug and medical plans ― each with different pharmacy networks, covered drugs and drug prices. The website provides information for more than 60 million people with Medicare and their families, as well as state Medicare counselors and the representatives who answer the 800-MEDICARE help line.

In an unsigned blog article published on a Medicare website last week, officials said they’re “not done improving the Plan Finder.” And they promised “in the coming months we’ll be scoping out additional improvements that we can implement based on lessons we learn this year.”

Although CMS has earned praise for responding to errors identified by Plan Finder users, some people may have signed up for plans before the mistakes were caught ― mistakes they may not notice until their coverage kicks in next year.

“Seniors should be able to choose the plans that work best for them,” said Sen. Susan Collins (R-Maine), chairwoman of the Senate Special Committee on Aging. “Issues with Medicare’s new Plan Finder website, however, have reportedly created confusion among beneficiaries as well as those assisting them.” She added that she was concerned “this problem even occurred.”

Medicare’s response, Collins said, “must be vigorous with extensive outreach to inform seniors of special enrollment periods.”

Sen. Bob Casey of Pennsylvania, the senior Democrat on that committee, also said Medicare needs to reach out so people know they can request a “special enrollment period” if they discover next year they made a wrong choice due to inaccurate Plan Finder information.

“People with Medicare must be aware that this reprieve exists and should not have to jump through hoops to qualify,” he said. The administration should “use all means necessary” to let beneficiaries know about their options for a special enrollment period.

In the statement to KHN Wednesday, CMS said it provides special enrollment periods for a number of reasons. It added that beneficiaries can get a special enrollment period related to Plan Finder issues anytime next year.

They can “call 1-800-MEDICARE and explain to our call center representatives that they have an issue with their plan choice. It is not CMS’s expectation that beneficiaries will have documentation or screenshots,” the statement said. The call center representatives “are trained and ready to help the beneficiary through the rest of the process.”

CMS officials refused to be identified but would not give a reason.

Information about Plan Finder special enrollment periods will be available on the website and at the call center, a CMS spokesman said.

However, nothing was posted on the website Thursday, and when Kaiser Health News called Medicare twice Thursday, both representatives said it would not be possible to switch plans next year because of inaccurate information from the Plan Finder.

Applying for a special enrollment period could be tricky. In the blog post, Medicare officials said the information on the Plan Finder is “the most current and accurate information on premiums, deductibles and cost sharing that Medicare Advantage and Prescription Drug Plans provide.” They noted that the “information changes frequently because plans regularly update drug formularies and renegotiate drug prices.”

America’s Health Insurance Plans, the trade group representing health insurers, “is not aware of any systematic problems with the Plan Finder, which is operated by CMS,” said spokeswoman Cathryn Donaldson.

People who enroll in a private Medicare Advantage policy, an alternative to traditional government-run Medicare that covers both drugs and medical care, already have an alternative. They have until March 31 to change plans or enroll in traditional Medicare.

Collins and Casey are not the only members of Congress raising the issue. Sen. Sherrod Brown (D-Ohio) wants CMS to provide a special enrollment period in these cases and clearly communicate the details, a spokesman said.

Rep. Richard Neal (D-Mass.), who chairs the House Ways and Means Committee, believes Saturday’s deadline should be extended, a committee aide said. The committee has heard about the Plan Finder’s problems from numerous seniors’ advocates and counselors from state health insurance assistance programs, as well as the insurance companies that sell coverage.

Since enrollment for 2020 coverage began Oct. 1, the National Association of Health Underwriters, which represents 100,000 insurance agents, has sent CMS officials 54 Plan Finder problems and is still receiving reports from agents, said John Greene, the vice president for congressional affairs.

The Medicare counselors at Nebraska’s Senior Health Insurance Information Program  flagged more than 100 issues as of mid-November, said Alicia Jones, the program’s administrator.

After receiving complaints about the Plan Finder, Delaware’s insurance commissioner, Trinidad Navarro, issued a consumer alert last week.

Tatiana Fassieux, education and training specialist at California Health Advocates, said her organization wants CMS to offer a blanket, nationwide special enrollment period instead of  granting it case by case. The group helps train Medicare counselors for California’s Health Insurance Counseling and Advocacy Program, known as HICAP.

Leslie Fried has been an elder law attorney in Washington, D.C., since 1985, so imagine her surprise when she was stumped last weekend helping her mother pick a policy through the Plan Finder.

Fried, who is also senior director of the Center for Benefits Access at the National Council on Aging, did the same search three times for the least expensive plans that cover her mother’s drugs and came up with a different result each time.

“Beneficiaries should be able to have confidence in the Plan Finder after a single search,” she said.

For assistance reviewing drug and medical plans, call your state’s Senior Health Insurance Information Program at 877-839-2675 or the Medicare Rights Center at 800-333-4114.

Categories: Health Care

Health Spending Grew Modestly, New Analysis Finds

Medicare -- New York Times - Thu, 12/05/2019 - 4:41pm
For the first time in many years, the government reported that spending on health care last year grew more slowly than the economy overall.
Categories: Elder, Medicare


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