Contraception, women's health and dignity, teens, and stupid legislators

A bill before the Maine legislature would allow women to obtain a year’s worth of oral contraceptives at a time, rather than the previous 3-month limit. This is a good thing, as argued by its sponsors and supporters. Women typically take oral contraceptives for long periods of time, and the requirement that they return to refill their prescriptions every 3 months is at best an inconvenience and at worst a burden. It is a burden women should not have. Indeed, there is no good reason to require a prescription for oral contraceptives at all.

This does not mean that there are no reasons put forward by opponents; if there were none, there would be no opponents. Overall, the opposing arguments fall into 3 categories: money, control, and wacko paranoia. If women only have to fill prescriptions once a year there will be fewer prescriptions being filled, which could be a small hit to pharmacies. The bigger objection is from insurers, as addressed in an article in the Portland Press-Herald of April 19, who worry that it could become a “mandate” for coverage with no cost share for other contraceptives, particularly those that are more expensive for insurers.

Control is a big and insidious issue. The idea that women are incapable of making their own decisions, particularly with regard to their reproductive systems, is as outrageous as it is persistent. For generations women have fought and often won struggles to be considered legally as “people” (implicit definition: men); to have the vote, to own property, to divorce. But no area has been as fraught with (yes, “fraught” requires a preposition!) opposition as the entire area of women’s reproduction. From before the time of Margaret Sanger, every source of pressure – religious, economic, and legal – has been brought to bear against the idea that women should have control of their own bodies and particularly their reproduction. The struggle continues; abortion rights are the most vulnerable today, but as the opposition to the Maine bill illustrates, contraceptive rights are scarcely secure.

Even among the biggest supporters of contraception, there can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood advisory board, and many of its members were surprised that I strongly opposed a requirement that women have a Pap smear before receiving a contraceptive prescription. The logic of those who supported it was that the inducement of receiving contraceptives would encourage women to get their Pap, which was then recommended. My position was that the negative incentive of the Pap (and associated pelvic examination, see below) would keep women, especially young women and teens, from getting their contraceptives, and thus likely increase unwanted pregnancies. I am sure that that Planned Parenthood, and other contraceptive providers, no longer have such a requirement. Indeed, we no longer recommend Pap smears for women under the age of 21, and for others, they are recommended only every 3 years. Regarding the screening pelvic examination, it simply violates the first criterion for a screening test – there must be condition that can be screened for in an asymptomatic person. This has led the American College of Physicians, having reviewed the evidence, to recommend against it, while the US Preventive Services Task Force (USPSTF) somewhat incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or against) recommendation. This is summarized in a recent review from the Agency for Health Research and Quality (AHRQ). The American College of Obstetricians and Gynecologists still basically advocates it, although it suggests the decision be made individually between the woman and her doctor, no real change from when I discussed it on July 3, 2014 (”The screening pelvic examination: not annual, not ever”).

Being a major provider of contraception does not save PP from the wrath of Congressional Republicans; indeed, while abortion is the flaming tip of the spear of conservative opposition, the right’s opposition to PP is also against those that do not do abortions, but mainly provide contraception and other women’s health services. The good news is that the GOP may be unable to attach defunding PP to the “health” bill (Obamacare repeal) because it is being done at a budget resolution. You might think that providing contraception would be seen as a good thing, since fewer unwanted pregnancies would lead to fewer abortions, but this is not their logic. [I think that they are, basically, anti-sex, at least that practiced by others, as demonstrated by all the patently false claims we hear constantly in school-based clinics that prescribing contraception will “encourage” sex.]

Of course, it does not. Hormones encourage sex, yes. Social pressure encourages sex, for sure. But not contraceptives; what they do is prevent pregnancy. Amazing. And if the whole campaign against PP, as well as opposition to allowing a year’s worth of OCPs, is grounded in a mindset that wants to control women, the issue for young women (and their partners) is far worse. They are seen as not only women, but immature and incapable of making wise decisions. There is some basis for the idea that they are immature, as parents know; the brain is not fully developed until at least the mid-20s and the last part to develop is the ability to make “executive decisions” – taking the information that you have, looking at it completely and objectively, and making a smart choice.  This is why teens and young adults make poor decisions in driving and, conversely, make the best soldiers.

But this is not a justification for restricting access to contraceptives, condoms, or other health services that might prevent bad outcomes. Because teens make not make the most mature decisions, and often regret them later, it doesn’t mean that they won’t make them. So we need to make it as easy as possible for them to not have long-lasting negative consequences, like STIs and unintended pregnancy. There need to be as few barriers as possible for young people to not get (or make another) pregnant, to not get preventable sexually-transmitted infections (STIs). These would include making oral contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman (or man) come to a clinic for care, invite them in, see them quickly, meet their needs. For goodness sake, don’t make it hard, don’t send them somewhere else to register as they’ll walk out the door!

The editorial in the New York Times, May 13, 2017, “The health care bill’s insults to women”, documents the degree to which women in rural and underserved areas, where more than half of PP’s clinics are, will lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties, PP is the only provider of reproductive health services. The editorial starts with insensitive “sophomoric” quotes from several congressmen and senators, including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my mammograms!”. Sen. Roberts would be well advised to identify which of the areas in Kansas, particularly in the very rural “Big First” district he once represented as a congressman, would be among those losing services. A lot, actually, especially since one OB/Gyn from Great Bend is now busy representing the district in Congress. Of course, Dr. Roger “the poor just don’t want health care” Marshall probably didn’t take care of many underserved folks.

This is not the way to go. Our goal must be to increase health as much as possible, not to create obstacles to it.

Trump's "bad doctors": mostly greedy and bad for the public's health

My recent post, Doctors and health reform: maybe they do stand for health!, March 25, 2017, lauded the positions of many medical organizations, including the American Medical Association (AMA) for their positions in opposition to the American Health Care Act (AHCA), the Trump-Ryan bill that never even got to a vote, and apparently was never even available to House members to read before the vote was scheduled.  But I also pointed out some “bad” doctors, defined as those who advocate policies that are bad for the health of the American people. They argue that they are really for health, but this means mostly health care, especially medical care, for those who can afford it. There is no small tinge of racism as well as classism in these positions, because poor people and minorities are those most likely to be left out, and because, well, these perpetrators don’t care.

The prime example I cited was Secretary of Health and Human Services Tom Price, who, as a representative from a wealthy suburban Atlanta House district, continuously railed against the Affordable Care Act (ACA), as well as, in fact, Medicare. Dr. Price is an orthopedic surgeon, and my essay noted that this specialty is over-represented in the cohort of opponents of expansion of access, possibly because their high average income puts them in an elite economic group, and many are more concerned with their self-interest than the health of the overall population. Price was not the only bad doctor I mentioned; I also cited the “tone-deaf” comments of Rep. Roger Marshall of Kansas, an obstetrician-gynecologist. “Tone deaf”, of course, is a mild and polite term for his racist, classist comments, summarized as “the poor just don’t want health care”. Tone deaf, by the way, is also the term commonly used to describe the demeaning commercialization of the Black Lives Matter protest movement evident in Pepsi’s commercial featuring Kendall Jenner, now mercifully withdrawn. That was a result of the strong and sustained protest of a large number of people, especially on social media.

Price and Marshall are abetted by the non-physician politicians in Congress and the administration who also would deny health care to a lot of people, and even, through changes in Medicare and Medicaid, make the coverage of many people who now feel moderately secure in their insurance status greatly at risk and much more expensive. Speaker of the House Paul Ryan and Vice President Mike Pence met with the “Freedom” Caucus of the House to discuss just how regressive a health care bill would have to be to get their support. Pretty bad, it turns out. Its chairman, Rep. Mark Meadows of NC, is quoted by the NY Times as saying “Lower premiums have to be our first and only priority. By repealing community rating and the essential health benefits, it allows for lower premiums across the board.”Well, lower premiums are something everyone wants (except probably insurance companies) but there are different ways to get there. “Repealing community rating” means that insurers would no longer have to cover people who have chronic disease and are often older (and, ironically, often Trump and Freedom Caucus voters) at the same rates as less sick people. Those people would not have lower premiums; their premiums would either be fantastically higher, as they were before the ACA passed (and when many of them were without coverage) or be altogether unavailable. This is not something that the vast majority of Americans want. Similarly, “essential health benefits” are, well, essential. Like, for example, maternity care, and preventive health care. The fact that Rep. Meadows used that word and didn’t replace it with some euphemism, illustrates how tone-deaf he is.

But not all doctors who I would characterize as “bad” are reactionaries who are trying to figure out how to deny health care to the American people. Some are just traditionally greedy, seeking to fill their own pockets with as much money as possible. This is not a problem limited to the right; even folks who are progressive on social policies can be guilty of “going where the money is”. An excellent example is Trump’s nominee to head the FDA, Dr. Scott Gottlieb. Gottlieb, like many researchers, has been highly paid (at least on the order of hundreds of thousands of dollars) by drug manufacturers. Gottlieb assures us that this will not affect his decision making at FDA, and that he can be trusted, as in the title of the NY Times article of April 5, 2017, in which he “deflected” criticism. While some Democrats, like Sen. Patty Murray of Washington, noted that he had ‘“unprecedented financial entanglements with the industries he would regulate,”’ Republicans like Lamar Alexander of Tennessee agreed with Dr. Gottlieb that “his experience with the pharmaceutical industry would be an asset in regulating it.” This is terrific tortured fox-guarding-the-henhouse logic, like having Goldman Sachs financiers regulating Wall Street, or petroleum company flaks running EPA (which we, in fact, have). This concept worked fine on “It Takes a Thief”, but not so much in real life.

Taking huge amounts of money from drug companies may be morally reprehensible (or not, depending on your view; in mine it is), but more concerning are the positions that Gottlieb has taken. While he is open (he says now) to lowering drug prices by importing drugs from Canada, something Trump has occasionally voiced support for, he has previously written against it (when he was in the pay of the drug companies). The issue is what the policies pursued by the FDA, HHS, CMS, and the overall Trump administration and Congress regarding the people’s health will be. Disrespect for preventive care (“essential services”) and environmental pollution bodes very poorly for public health, as the core principle of “cut benefits” does for medical care. And, as always, the most vulnerable – from poverty, age, illness, geographic region – will suffer the most.  It would be really good if we could count on doctors like Price, Marshall and Gottlieb to protect the health of the people, but don’t count on it. We are going to need huge public protest, at least as big as those that ending up canceling the Pepsi commercial.

Well, it could be worse. Another physician, Dr. Bashar al-Assad, is gassing his own people with chemical weapons. And there was also Dr. Josef Mengele. So far, none of Trump’s nominees are in that league.

Doctors and health reform: maybe they do stand for health!

The new GOP health plan, the American Health Care Act (AHCA), aka “Trumpcare”, has crashed to defeat. The President, who pushed hard for it, looks like his greatest nightmare, a “loser”. It is worth thinking, however, about who opposed it. In Congress it was Democrats and (the few) moderate Republicans and very right-wing Republicans are against it, for different reasons. From outside government the response was pretty negative, with a 17% approval rating (amazing they could still think they could pass it!). Far-right “conservatives” thought that AHCA was too much like Obamacare in that it actually provides some federal support for some people, and  they don’t believe in the government ever helping anyone, except maybe themselves and their friends. (Oh, yes, and fabulously rich people. They deserve a lot of help.) The criticism from most of the rest of the universe (to say “the left” would be inaccurate, since it includes many quite a bit right of center, since, in fact, “Obamacare” started life as a Republican plan) was mostly because it would be a disaster for health coverage for Americans. Projections by the Congressional Budget Office (CBO) were that 24 million people would lose their health insurance, that access to care would be more and more limited, especially for the middle class and poor, and that costs would rise for patients exponentially. Also that the public health and preventive health infrastructure would be gutted and many of our advances in those areas lost.

The main “positive” in the CBO’s projection was that it would reduce the federal deficit by $337 billion over 10 years. This was only because it shifted costs to others, to states and employers and individuals. Those who could not pay with money would pay with their health and sometimes their lives. While, as I have pointed out (‘We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us, March 16, 2017) many would have lost their insurance because of cuts in subsidies through the exchanges, the biggest impact would have been through the loss of Medicaid. This is clearly explained by Dr. Daniel Derksen, a family physician and director of the University of Arizona’s Office of Rural Health in a video on MedPage Today.

Among the many groups criticizing the draconian cuts in health care (as well as taxes on the rich) are almost all of the major hospital associations (including the American Hospital Association, the Catholic Hospital Association, and others), and physicians’ groups, most notably the American Medical Association (AMA) as well as most specialty societies including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), as well as many others. They have been joined by the major nursing organizations and by patient advocacy groups. It should not be surprising, I suppose, that most of these groups would be critical of such a devastating attack on health care for Americans, but if it isn’t, it is at least a relief. The AMA is important in part because of its major role in opposing most historical expansions of health care access by the government, including President Truman’s attempt to get a national health insurance program (where they were successful) and President Johnson’s creation of Medicare and Medicaid (where they were not).

Of course, not all health providers and certainly not all physicians opposed the AHCA’s changes. MedPage Today published quotes from a number of physicians, and some were quite supportive; Darrell S. Rigel, a dermatologist at NYU, for example, said “It looks like it is a significant improvement over the ACA [the Affordable Care Act, aka Obamacare].” The most noteworthy physician advocate for the AHCA and Trumpcare was naturally Tom Price, MD, the Secretary of Health and Human services. As I discussed before his appointment (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters, December 3, 2016), Secretary Price, as a congressman from Georgia was a leader in the Tea Party caucus and an opponent of ACA or any other program to expand health coverage to Americans. Another recent voice to both support AHCA and channel the administration and GOP’s contempt for regular people is Rep. Roger Marshall, an obstetrician from Great Bend, KS who is the Representative from Kansas’ “Big First” district. Dr. Marshall told the Washington Post that “the poor just don’t want health care”. He kind of walked back those remarks later, but his analysis is telling:

“Just like Jesus said, ‘The poor will always be with us,’ ” Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. “There is a group of people that just don’t want health care and aren’t going to take care of themselves.” He added that “morally, spiritually, socially,” the poor, including the homeless, “just don’t want health care….The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,” he told STAT, a website focused on health-care coverage. “So there’s a group of people that even with unlimited access to health care are only going to use the emergency room when their arm is chopped off or when their pneumonia is so bad they get brought [to] the ER.”

I may not be the best person to comment on his bizarre interpretation of the Gospel, but I can say that for many of us the challenges that poor people face in just getting through their lives are reasons why we need to make health care accessible, not reasons to just write them off. I also wish that I could say that, in my experience, physicians with attitudes like those of Price and Marshall are rare, but sadly they are not. To some degree, there are differences by specialty, with primary care physicians and psychiatrists more likely to support government-involved health care and even single payer plans than surgeons (including orthopedists). I am sure that at least in part this difference is driven by income; while all physicians have relatively high incomes compared to most Americans (top 10%), some specialties, including orthopedics (at the top), radiology, cardiology, surgery, and dermatology make much more; the mean reported income for orthopedists, about $467K (which seems low to me based on those I know) is about the cutoff for the top 1%. When a friend of mine (who later became a surgeon) was on his surgical rotation in medical school, he was impressed by all the talk in the surgeon’s lounge about the “Big Board” – until he found out they meant the stock market, not the board listing upcoming surgeries! And primary care doctors are not immune; when I lived in Texas one family physician regularly railed against the liberal government spending our money. One day, however, his attacks were on delays in payments to doctors from Medicare. Umm…

Doctors are, of course, like other people. Their perspectives vary widely, with most being caring and some caring mostly for themselves. My family physician colleague’s self-centered view is not so different from that of those Trump voters who are now against the AHCA because they see that their benefits are being cut; see “Trump budget cuts put struggling Americans on edge”, NY Times March 18, 2017. The authors cite a retired nurse with lung cancer whose heat was cut off in the middle of the winter; she was rescued by a heating subsidy funded by the federal government and likely to be cut. “I understand what he’s trying to do, but I think he’s just not stopping to think that there are people caught in the middle he is really going to hurt,” she said. Somehow, I suppose, she thought that the cuts would only be to other people…

So, while it is true that doctors, like others, often share the perspectives of their class, and callously disregard or rationalize opposition to ensuring health care for everyone, they often do understand the situations their patients are in and serve as advocates for them. In 2001, the AMA passed its “Declaration of Professional Responsibility: Medicine’s Contract with Humanity”.  It includes the following “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”  The AMA was on the right side of the AHCA fight. I hope that most doctors agree with, and even practice, that principle.

I hope Tom Price and Roger Marshall are aberrant exceptions.