I have written previously here on the challenges posed by persistent – indeed, rising – underinsurance that has not been remedied under the Affordable Care Act, despite the ACA’s great successes in reducing the share of uninsured Americans. In JAMA Internal Medicine, scholars at the University of Michigan addressed a related problem, which is the rising out-of-pocket expenditures for hospitalizations that Americans have faced between 2009 and 2013 (so to be clear, before​ the ACA went into effect). They evaluate data on approximately 50 million members (ages 18-64) of Aetna, United HealthCare, and Humana. Of the subjects within their database, 8.9% had experienced an inpatient hospitalization, and among those who were hospitalized, 84.4% had one hospitalization, 11.1% had two hospitalizations, and 4.5% were hospitalized more than twice in a given year.
 
The authors find that the total cost sharing per inpatient hospitalization increased 37% between 2009 ($738) and 2013 (1,013). Much of the increase in the average cost of hospitalizations was due to higher amounts applied to deductibles (86% increase during these years) and by increases in coinsurance (33% increase during these years). The growth in cost sharing was lower in individual-market and consumer-directed health plans, though the absolute out-of-pocket costs were markedly higher in individual plans ($1,875 in 2013) than for group plans ($997 in 2013). Moreover, the regional variation in cost sharing per hospitalization is striking, with New York and Massachusetts being among the low end of the spectrum, North Carolina, Texas, and Alaska being among the highest end ($>1200), much of the West and the South being the next highest ($1000-1199), and much of the Midwest and Northeast falling next lowest ($800-999). This regional variation is consistent when evaluating the price of doctor’s visits and various different medical procedures.
 
There are a number of challenges here. First, the authors cite a finding that only a small minority of individuals (11%) are able to correctly estimate their financial responsibility in the event of a hospitalization (and only 14% correctly answered multiple-choice questions about their deductibles, copayments, coinsurance, and out-of-pocket maximums) even when given information about admission and plan benefits. That is, most Americans, when given information about health plans, are unable to make sense of the benefits that they obtain and the responsibility with which they are still left when utilizing their benefits. In a sense, given the complexity of plans, it is not terribly surprising (after all, one might reasonably think that after an out-of-pocket maximum is met, one needn't still face ER copayments, though I recently learned the hard way that this is not the case).
 
Despite not being surprising, it is a big problem, because there is clearly a normative desirability that one be able to make informed decisions about their healthcare, both with respect to selecting insurance plans from a (potentially limited) menu of options -- that is, one may choose to have a higher premium but lower deductible and out-of-pocket maximum versus lower up-front costs but higher cost-sharing in the event that care is utilized -- and with respect to determining the value of seeking emergency room treatment versus postponing treatment. When I was healthier, I made calculated judgments that keeping money in my pocket on a monthly basis was preferable. I now happily (okay, maybe not happily) pay a higher premium so as not to wince over coinsurance when my doctor adds extra labs and so as not to think twice about going to the doctor or for other treatments. It is an informed decision that I now make. Some conditions simply must be treated in an emergent manner. One does not simply postpone medical treatment of appendicitis, let alone myocardial infarction. However, some conditions might be less severe and might resolve on their own or be able to be treated through urgent care. Being able to understand clearly the (literal) costs and benefits associated with using one’s health insurance is essential to making informed decisions about one’s medical care given the stresses that medical debt can pose.
 
The additional challenge is that of selection into a hospitalization, the financial effects of which are being estimated. That is, the study does not include those gauge correctly that they cannot afford the costs associated with obtaining medical care and thus do not seek hospitalization for their illnesses. Those most burdened by out-of-pocket medical costs are also those for whom the associated additional costs are most likely to pose the greatest challenges – for example, the loss of income associated with taking off several hours (let alone days) from work, particularly if working on an hourly basis. If people were to use their medical benefits purely with regard to medical necessity as opposed to delaying needed care in order to curb out-of-pocket costs, we would almost assuredly see that the out-of-pocket costs are higher than those estimated based on these hospitalizations, and that this increase over time would be more marked than that estimated given peoples’ rising deductibles and hesitation about obtaining needed care.
 
Indeed, according to the Commonwealth Fund, compared with those who are insured all year and not underinsured, those who are insured all year but underinsured are more than twice as likely to not go to a doctor regarding a medical problem, more than twice as likely not to fill a prescription, twice as likely to skip a recommended test or treatment or other follow-up care, and more than twice as likely to skip making an appointment with a specialist when it was recommended that one be consulted with. The extensive selection out of outpatient medical treatment even among those carrying insurance suggests at least as great a selection problem with respect to inpatient care, and thus potentially an even greater problem on our hands.   
 
Like many policy problems, there is an important racial component to these challenges, with minorities more likely to have chronic medical problems and for those conditions not to be managed well. For example, non-Hispanic blacks are 40% more likely than non-Hispanic whites to have high blood pressure and are less likely to manage the condition; the rate of diagnosed diabetes is 77% higher among blacks, 66% higher among Hispanics, and 18% higher among Asians than among whites; and blacks and Hispanics are more likely than whites to be obese. Such prevalence of chronic medical conditions raises the probability of requiring hospitalization (if the individual is able to access care), with healthcare utilization disproportionately used by those with multiple chronic conditions (a study of hospitalizations in 2009 revealed that 39% of inpatient discharges were of patients with 2-3 chronic conditions and 33% had 4 or more chronic conditions).  Such hospitalizations can then produce these financial strains to which the authors point in evaluating hospitalizations (some of which were tied to chronic conditions (e.g., heart attack, which can be impacted by weight, diet, and smoking status) and others not (e.g., knee replacement).   
 
That Americans are facing rising out-of-pocket costs associated with hospitalization is a problem in its own right, but particularly so given a) the racial disparity in the conditions likely leading to hospitalization, and b) the information problems to which the authors point with respect to patients understanding their health plans and financial responsibility associated with obtaining care. This suggests a few opportunities for those working in public health as well as in public policy and politics. There is clearly a long way to go in reducing inequality in the extent to which minorities and inner-city communities are faced with more adverse health outcomes with respect to the chronic diseases whose treatment adds to patients’ financial burden. Improving interventions that enhance the affordability of healthy food and that reduce rates of smoking and sedentary lifestyles are obviously in need. As a shorter-term solution, improving tools with which to help people shopping for health coverage – ideally in-person so as to tailor based on individual needs and health history, though perhaps an online tool could be better developed and made accessible across socioeconomic groups – will importantly reduce the information asymmetry that is leading individuals to face higher healthcare costs than they realize prior to making medical decisions. 

In Planned Parenthood v. Casey (1992), the Supreme Court evaluated in light of Roe v. Wade (1973) the constitutionality of a Pennsylvania law mandating a 24-waiting period prior to obtaining abortions, and in so doing established a new standard according to which the Court determined whether the purpose of the given restriction was to impose an "undue burden" on the woman seeking the abortion. An undue burden was construed as a "substantial obstacle in the path of a woman seeking an abortion before the fetus attains viability." This landmark holding on abortion policy paved the way toward state innovation in abortion policy to test the reach of this "undue burden" provision that the Court's 5-4 majority laid out. 

In the years since, states have answered the call. For example, 43 states prohibit abortions after a specified point of the pregnancy, typically fetus viability; 19 states prohibit late-term ("partial birth") abortions; 32 states and the District of Columbia prohibit the use of state funds except where federal funds are available (to protect the life of the woman or in the case of rape or incest); 17 states mandate that women receive counseling prior to obtaining an abortion; 27 states mandate that women wait a specified amount of time between receiving counseling and receiving the abortion (typically 24 hours but as many as 72); and 38 states require some parental involvement in obtaining an abortion for a minor, with 25 of those states requiring parental consent and 13 states requiring notification but not consent of the parent.

Whole Woman's Health v. Hellerstedt (2016), decided in a surprise 5-3 decision with Justice Kennedy (also in the majority in Planned Parenthood v. Casey) joining the liberal coalition,  centered on the Texas State Legislature's HB 2, passed in 2013 and signed into law by then-Governor Rick Perry. HB 2 out a number of provisions pertaining to abortions under the guise of protecting the health of the women in question but with the ultimate effect of precluding providers from meeting standards necessary to lawfully provide abortion access to those in need. Among those provisions were that physicians performing abortions have admitting privileges at a hospital within 30 miles of where the abortion was being performed, and that the abortion facility meet the requirements of ambulatory surgical centers despite the fact that abortions are highly safe outpatient procedures (indeed, evaluating the risks of childbirth versus abortions, compared with a mortality rate of 8.8 deaths per 100,000 live births, there is a mortality rate of 0.6 deaths per 100,000 abortions). While nominally still allowing abortion access, the legislation was deemed to have the effect of all but eliminating abortion facilities in the State of Texas. 

To impose marked restraints on abortion access is not unheard of. The State of Missouri has only 1 abortion provider in the entire state, and 89% of counties in the United States have no abortion provider. States are not always overt in their means of excluding abortion access, rather imposing requirements in the name of "safety," with the notion that satisfying the requirements of being a surgical suite will be positively correlated with the health outcomes of the abortions performed there. (Remember, even absent this requirement in most states, the mortality rate is still extraordinarily low). While meeting high standards of medical care is all well and good, the types of regulations that the legislation targets involve such issues as the width of corridors and the size of procedure rooms, neither criteria of which are demonstrably associated with better patient outcomes. (After all, when in the first ten weeks of pregnancy, it can be carried out without any procedure but rather with the so-called "abortion pill," or Mifepristone (RU 486)).The marked implications of such legislation has garnered it the title "clinic shutdown" law, and in the aftermath of the legislation's passage, while Texas previously had approximately forty abortion clinics, approximately half had closed due to the requirement of admitting privileges, and it was estimated that only eight or nine would remain if enforcing provisions requiring that the clinics meet the requirements of surgical centers. 

In his majority opinion, Justice Breyer noted the absence of scientific evidence for the necessity of HB 2, writing that "there was no significant health-related problem that the new law helped to cure." The majority cites a number of studies brought to the attention of the Court, noting that among first trimester abortion complications, the highest rate of major complications was less than 0.25%, and that even in the rarer second trimester abortion, the rate of major complication was still less than 0.5%, and that complication only required hospital admission 0.23% of the time and not necessarily on the day of the abortion (making admitting privileges far from a necessity, particularly given that patients will not be turned away from an emergency room). Thus, the majority notes, "We have found nothing in Texas’ record evidence that shows that, compared to prior law (which required a 'working arrangement' with a doctor with admitting privileges), the new law advanced Texas’ legitimate interest in protecting women’s health. We add that, when directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case."

While not providing evidence in support of the health advantages of this different standard of care, the Court notes that the admitting privileges requirement appeared to have had a marked impact on abortion facility closures, with the number of women of reproductive age living 150 miles or farther from an abortion provider going from 86,000 to 400,000, and the additional problems of longer waiting times, fewer doctors, and increased crowding. While increasing the driving distance is not alone enough to support a claim of undue burden, the Court said, the increases constitute an "additional burden" that combine with the abortion clinic closures and the virtually absent proven health benefit to support the District Court's finding that HB 2 constituted an "undue burden" in violation of Casey.

A number of states have so-called TRAP (targeted regulation of abortion providers) laws, which the Court's recent holding will implicate. Not unlike Casey, while affirming the right to abortion, the Court here still did not hold that any restriction on abortion access constitutes an undue burden. Indeed, effecting a change that would have the result of some clinic closures might still pass constitutional muster. But the intent and effect of the legislation here, given the absence of scientific support and the clearly marked policy effects, were both to restrict if not altogether preclude abortion access to an extent within the realm of the "undue burden" that Casey sought to avoid in negotiating reproductive freedom at the national level and the right of states to forge their own paths (within bounds). What remains to be seen is the extent to which Texas abortion facilities will reopen in the aftermath of the decision, and the trajectory of policy in the other states that had enacted similar legislation (for example, Arizona, on which I wrote previously). 

The Court appealed to states' legitimate interest in protecting women's health, with police powers -- typically, the protection of health, safety, and welfare -- typically falling within states' regulatory prerogatives under the Tenth Amendment. What is, of course, at odds in the abortion debate is what precisely constitutes protection of health, safety, and welfare. As Breyer finds, "The surgical-center requirement also provides few, if any, health benefits for women, poses a substantial obstacle to women seeking abortions, and constitutes an 'undue burden' on their constitutional right to do so... Record evidence shows that the new provision imposes a number of additional requirements that are generally unnecessary in the abortion clinic context." The Court rightly emphasized the health benefits, or lack thereof, provided by HB 2 (and by extension, other TRAP laws imposed by states) relative to other policies according to which women may obtain abortions. But an important additional dimension of states' protection of women's (indeed, citizens') health and safety is that in the absence of abortion access. 

By making abortion less accessible (reminder: these are laws on the ability to provide abortions and thus do not create exceptions for rape or incest), women are more likely to obtain abortions later in their pregnancy, and while abortions are very safe early in the pregnancy (when the vast majority of abortions are performed), the risks do go up when performed later (though as the statistics cited above indicate, the risks are still low). If unable to obtain a legal abortion, one may be more likely to seek an illegal, unregulated abortion, thus subjecting oneself to a host of potential harms to which one is not exposed when in regulated medical care. Indeed, cracking down on legalized abortion has been argued by some to have more impact on the safety than the incidence of abortion. And if one is unable to provide adequate care to a child but is unable to terminate the pregnancy, we are not only sentencing women to motherhood but are faced with a further question of whose life we really are protecting. If we are only protecting life before birth, we might need to reevaluate what we're fighting for. 

The Supreme Court's decision in Whole Woman's Health made important progress toward cracking down on overly restrictive state legislation and better defining what falls within the realm of "undue burden" on women's reproductive choice. By implication, the similar laws in effect in dozens of other states will likely be determined to be unconstitutional, though time will tell the speed with which we see policy changes go into effect.

In its June 20 ruling of Cuozzo Speed Technologies LLC v. Lee, the Supreme Court upheld the Obama Administration's Patent Office regulations and so doing, dealt a blow to the pharmaceutical industry, which held that the patent regulation "stifles innovation" in American medicine. The regulations were part of the 2011 congressional overhaul of the United States patent system, and at issue was the procedure for challenging patents through the procedure known as inter partes review, according to which patent challenges may be heard by an appeals board at the United States Patent and Trademark Office. While patents typically had been presumed to be valid, with the inter partes reviews that the Obama Administration established by rule, patents were more likely to be overturned. The Obama Administration's position was joined by generic drug companies and insurance plans that were alleging that drug companies had exploited the patent system to ensure higher drug prices, while the inter partes review standards would be both more likely to result in the patent's invalidation as well as a lowering of drug prices (though the case at hand did not deal specifically with prescription drugs, but rather GPS technology alerting drivers to whether they were speeding). The Court held that the Obama Administration was within its legal rights to impose this broader construction of patents in inter partes reviews.

Those standing to gain from the decision are technology companies that have used patent procedures to challenge the validity of patents seen as not making sufficient innovations, while the decision is seen as a setback for the pharmaceutical industry as well as biotechnology companies claiming that the rights of patent owners were being unfairly infringed upon. The unanimous decision was authored by Justice Breyer, though Justice Thomas authored a concurrence and Justice Alito (joined by Justice Sotomayor) filed a separate opinion concurring in part and dissenting in part. On the Patent Office's approach, Justice Breyer held that "in addition to helping resolve concrete patent-related disputes among parties, inter partes review helps protect the public’s 'paramount interest in seeing that patent monopolies.. are kept within their legitimate scope.'"

​I don’t want to need it.
 
That is a thought that has been all too familiar to me when I venture on the patient side of health care, an industry that I study as a scholar as well with the distance of one investigating a foreign land in which they do not intend to become entrenched.
 
It is a thought that has been all too familiar as I see added to my daily regimen new medications, some of which I trust, others of which I am skeptical after reading reports on the industries that brought them to the market. I am, after all, familiar with the pharmaceutical industry and, while well aware that many have been able to manage well their conditions thanks to their products, am also not without cynicism as to their profit-based motivations.
 
“I don’t want to need it,” is not a mature response to a debacle. It does not remedy the need, nor does it even truly acknowledge the need. It merely resents the medical treatment, the need of which remains in doubt. What it does not ignore is the problem, and the prescription for its solution, whether that prescription is proper or not.
 
I have been on countless medications over the last five years. What has surprised me more than the prescriptions for various medications – some of which I had never heard of previously, and others of which I had heard of through direct-to-consumer ads, which I dislike on principle – is the business aspect of these pharmaceutical companies with which I have been confronted in a way that I have seen discussed precious little: copay savings cards.
 
I was pleased at first. My otherwise $300 sleeping medication got promptly knocked down to $30, which almost made me forget that this particular doctor seemed to engage quite frequently with representatives from the pharmaceutical company pushing the drug. Almost, but not quite.
 
A couple of months later, a new medication got added to the mix to address a chronic parathyroid disorder. When seeing the price of $80 show up (post-insurance) on the pharmacy website made me wince, I did some research on the company website and other sources to weigh the (literal) costs and benefits of the medication. Lo and behold, the distributor Amgen provided a prescription savings card that knocked the price from $80 to $5. For $5, I’ll take my chances with the medication and see if it works for me.
 
Some research confirmed that these savings cards are not totally anomalous, and I have encountered them – sometimes in advance of filling prescriptions, and alas sometimes after the fact – with respect to other medications prescribed to me. And while it is normatively desirable to curb the rising costs of prescription drugs, what is striking about these savings cards is the limited information as to their very existence. My doctors did not point me in this direction. Nor did the pharmacist at Walgreens. I don’t expect that their failure to do so was in any way nefarious – they get no benefit from my paying $5 versus $80 per month – but it is unfortunate that their use depends on the patient being fastidious in their research prior to filling a new prescription.
 
Such an assumption may not be met given many individuals’ trust in, and deference toward doctors’ decisionmaking, with 70% of  Gallup survey respondents confident in the accuracy of their doctor’s medical advice and only 29% viewing it necessary to do their own research (though some research does support a decline in the public’s trust in physicians). Moreover, within this field in which there is ample information asymmetry – with the general public typically not as familiar (or for that matter, capable of becoming so) with the specifics of the medical decisionmaking (see, e.g., Arrow 1963) and potentially unlikely to research the cost-benefit analysis of prescription drugs and other medical treatments. The (even more) cynical part of me is left wondering whether prescription drug companies price their drugs higher than necessary to account for the use of such savings cards, akin to accounting for future "sales" in regular product pricing.
 
There is the additional concern that those who are engaging in that research are not the ones most in need of prescription savings. If – as I strongly suspect – those who do conduct their own research on medical treatments are those who are more highly educated and, relatedly, higher on the income ladder, then benefits are not being distributed appropriately. Sure, people of all income levels enjoy their tax breaks. But those who need the money are not those of higher socioeconomic status, but rather those living paycheck to paycheck and for whom the price of prescription drugs impacts adherence to medication regimens.  
 
Indeed, 20-30% of medication prescriptions are never filled, and 50% of medication prescriptions are not continued as prescribed, with medication adherence dropping after the first six months of following a given regimen. I am the first to confess that I contribute toward these numbers, partly out of frustration of several-times-a-day reminders of a need that I resent, and often out of financial concerns that trump medical concerns.
 
To be clear, these figures are not all attributable to prescription drug costs. Some may be attributable to skepticism, denial about the need for a given treatment, or a frustration with particular side effects that accompany the given drug. But it is difficult to imagine that prescription drug costs are a negligible contributor toward these numbers, which is particularly distressing given that non-adherence carries an economic cost of an estimated $100 to 249 billion annually as of 2009, while improved self-management of chronic diseases is estimated as having a 1:10 cost to savings ratio. It can literally pay to better incentivize adherence (at least setting aside the many questions as to whether we are being systematically over-treated in the American healthcare system).
 
That drug manufacturers provide greater savings to patients is doubtless advantageous in making it more feasible to treat illnesses without causing as much financial burden. As someone at the relatively unusual intersection of high education and relatively low income (lucky me), I am also, I suspect, at the relatively unusual intersection of conducting extensive medical research and benefiting immensely from any financial savings that come my way as a result. But were I less skeptical about the industry with which I interact all-too-much, I would not know that I could reap this reward.
 
It is unclear whether it is nefariously intentional on the part of prescription drug manufacturers that such savings be more in theory than in practice, relying on unrealistic expectations of consumers to do their own research on the medical and financial costs and benefits that they can expect, or whether this is simply a problem of information dissemination (or rather, lack thereof). To be sure, drug manufacturers stand to gain through their use relative to the financial losses incurred from consumers’ shifts to generic drugs instead. But physicians whose patients’ progress is monitored, and as the numbers above suggest, the American economy as a whole, all stand to gain as well. Increasing physician awareness of, and communication about, copay savings for prescription drugs will go a long way toward reducing reliance on consumers’ own savviness to do so, and in turn enhancing adherence to treatments prescribed. 

In its unanimous opinion delivered on June 16, 2016, the Supreme Court decided the case of Universal Health Services v. United States ex rel. Escobar regarding the False Claims Act. The opinion was authored by Justice Clarence Thomas, and held that companies can be subject to False Claims Act liability and implied certification claims, under two conditions: 1) when the claim does not only request payment but also "makes specific recommendations about the goods or services provided"; and 2) the defendant's failure to disclose noncompliance with requirements must make its representations "misleading half-truths."   

The case arose in the aftermath of the death of a Medicaid beneficiary being treated by Arbour Counseling Services, a behavioral health center operated by Universal Health Services and in which many of the staff were lacking in proper certification and supervision (indeed, the treating psychologist who identified herself as having a PhD failed to disclose that it was received from an unaccredited Internet college at that the State of Massachusetts had denied her application to be licensed as a psychologist; further, the medication was prescribed by one who lacked the authority to do so absent supervision). The clinic misrepresented the staff credentials, submitted numerous claims for Medicaid treatment, and the Medicaid program promptly paid those claims to Arbour, which has been subject to a number of investigations pertaining to such issues as billing practices, poor care, and inadequate staffing: "At Arbour-HRI two years ago, public health officials found the hospital failed to provide active treatment to some patients, whose diagnoses included bipolar disorder and paranoid schizophrenia. Instead of attending group therapy, inspectors said, patients spent many hours sleeping or wandering the hallways — an allegation the company disputed."

The First Circuit Court of Appeals held that implied in claims submissions is compliance with conditions for payments. To determine whether a claim was indeed fraudulent, one must ascertain "whether the defendant, in submitting a claim for reimbursement, knowingly misrepresented compliance with a material precondition for payment" (780 F.3d 512 (2015)). The Court granted cert to resolve the lower courts' disputes as to the scope of implied false certification theory of liability.

The Supreme Court addressed the question of what precisely it means to submit false claims under the False Claims Act (FCA), given that the services in this case technically were provided (albeit from those without proper qualification or transparency). The Supreme Court held that the failure to reveal this information regarding treatment providers was actionable under the FCA. Prior to this ruling, while implied certification has been the subject of a number of suits brought against providers, the federal courts have been divided as to the proper resolution of the legal challenges.  The recent Supreme Court decision has been seen as striking a balance between combating health care fraud claims and protecting against what some might construe as "frivolous lawsuits" over the FCA. Indeed, the Court clarifies that "the False Claims Act is not a means of imposing treble damages and other penalties for insignificant regulatory or contractual violations" and the Court did not address the issues of medical malpractice of which Arbour and other Universal Health Services-owned hospitals have been accused. While a number of health providers may newly be concerned regarding the potential FCA-related consequences of non-adherence to Medicare and Medicaid requirements, the Court's emphasis on significant legal and regulatory contractual obligations appears (perhaps consistent with its being unanimous in a time of marked polarization in both the legislative and judicial branches) a very reasonable approach to balancing ensuring effective enforcement while not leading to excessive litigation.  

​Reflecting in “Ode, Intimations of Immortality” on the diminished delights that he experienced relative to his youth, William Wordsworth wrote, “The rainbow comes and goes/ And lovely is the rose;/ The moon doth with delight/ Look round her when the heavens are bare;/ Waters on a starry night/ Are beautiful and fair;/ The sunshine is a glorious birth;/ But yet I know, where’er I go/ That there hath pass’d away a glory from the earth.”
 
At the risk of sounding like an overly curmudgeonly individual longing for the “good old days” – I know that I am too young to pull off such a rant in earnest (an am hardly one to contribute toward such a debate in the context of such issues as civility and profanity) – I can’t help but find myself despondent over the current state of affairs where writing is concerned. This feeling has been rendered all the more acute as in my health policy research I bask in the prose of Kalanithi’s When Breath Becomes Air and Gawande’s Being Mortal, both in themselves poignant reflections on what makes life meaningful, but also standing out in the language with which these physicians and writers conveyed these messages. Such talent for prose is not as common as one might hope among those in the sciences (or even the social sciences, for that matter) given the emphasis on statistical significance levels, science, and technical writing to the exclusion of eloquent prose. Yet through this powerful mode of communication, they connect with their readers about this important subject matter and render it all too easy to sigh wistfully and wonder why this is seemingly so rare.  
 
When I was a young child, I admittedly was quite advanced where reading was concerned. In elementary and middle school, I was reading Pride and Prejudice, Emma, Jane Eyre, Little Women, Gone with the Wind, the list goes on. Elizabeth Bennett and Jo March were the kindred spirits with whom I spent my summer afternoons. When I was a little older, it was Salinger, Hemingway, Faulkner, Eliot, Borges, Sartre, Kafka, Fitzgerald, Marquez, Baudelaire, and so many more.
 
A former professor of mine from graduate school advised that if given the choice between being a reader and being a writer, one should be a writer. Setting aside the joy that one can get from reading great writing (admittedly, this was professional and not personal advice toward developing a scholarly career), it is good advice, though with the caveat that reading great writing can inspire one to do the same. Indeed, I find that the greatest antidote to writers’ block is to read writing that inspires me, often in the tone that I most want to emulate. When I seek inspiration to write fiction, I read Faulkner. When I am writing more humorous fiction or creative nonfiction, I read Salinger, or perhaps on a more contemporary note, Carrie Fisher. When I need discipline in academic writing, there is no greater discipliner than Hemingway, whose prose took longer to grow on me than did the writing of Fitzgerald, but who over time has held up better as far more modern.   
 
My favorite poet, T.S. Eliot, said famously, “Immature writers imitate. Mature writers steal.” But stealing must be from a good source. Whether intentionally or not, we are often influenced by that which we read. It is unclear to me the most prominent culprit or combination of culprits: whether it is that schools have stopped assigning to students as many of the great writers whom we studied previously (I do not believe that this is the case), whether the average quality of writing in previous generations was not lower than the present but that which has survived is simply the upper tail of the distribution and thus is an unrepresentative sample against which we judge the present (potentially true, though some evidence supports a decline in quality over the course of the last few years and an entire Tumblr page is dedicated to the tortured writing submitted to teachers along with the students' mangled history accounts (e.g., an apparent belief that Martin Luther freed the slaves with his "I Have a Dream" speech)), whether the 24/7 nature of media and entertainment has reduced the quality of what people read outside of the classroom, whether it is that we have stopped teaching people how to write well in school, or whether the use of social media has induced an excessive casualness to writing that has reduced its overall quality. It is clear that people read fewer books now than in years previous, with an all-time high of 23% of Americans not having read a book in the last year in 2014, compared with just 8% in 1978 (though this trend is not unique to Americans, as a fifth of adults in the UK reportedly do not know who wrote "Hamlet", while a third did not know who wrote Great Expectations). People become all-too-accustomed to finding shortcuts to communicating ideas – u instead of you, thx instead of thanks, r instead of are, and the like – and forget how to take the traditional let alone the scenic routes of written communication.    
 
To be sure, as a former New Yorker (and still, a New Yorker at heart even when walking the streets of Saint Louis), I succumb to the walking equivalent of the modal American’s attitude toward writing. I speed walk even if I am not in a hurry. I rush those in front of me regardless of whether I have two minutes or two hours to arrive at my intended destination. I take shortcuts unless the walk is for the purpose of exercise (which I usually do at the gym, where I find my exercise regimen more efficient). I know that within this domain, just as others view writing through the domain of the internet, I value efficiency over the quality of experience (though to be sure I still enjoy a more leisurely jog through Riverside Park, the Hudson River and the land of my favorite musician off to the right and trees and relatively sparse populations of tourists to my left as my feet beat against the pavement for a few miles.
 
In an era of expecting instant rewards, not to mention experiencing constant distractions with technology, expecting one to curl up with Anna Karenina (let alone finish it) has become a lot to ask of an individual. I am by no means advocating any reduction in technology for the sake of living a la Thoreau for a time. Take away my iPhone, and my anxiety goes from a level 3 to a level 8 instantly from that single treatment effect. We read synopses instead of the real thing. We cut to the chase. We compress messages to the virtual universe into text messages or 140 (often grammatically incorrect) characters, despite the fact that at least 30% of adult Twitter users have a college degree or higher (as do 74% of Facebook users). “Text speak” has become so common that a list of hundreds of such expressions has been accumulated, including such phrases as 2G2BT (“too good to be true”), 4e (“forever”), gn8 (“goodnight”), w8 (“wait), and the like. It has apparently become a norm well beyond Tigger’s “TTFN – ta ta for now”). And yet there is such simplicity in the pleasure of curling up with a blanket and a book (and in my case, a cat) and losing oneself in the Hemingway’s Paris or Leopold Bloom’s interior monologue, a simplicity that today seems to be all too lost. What’s more, writing – or more specifically, good writing – can do so much good in the way of raising human consciousness to important issues as a number of prominent physicians have done on issues of health, medicine, and bioethics.
 
Harold Bloom’s unapologetic advocacy in favor of the “great books” is something to which I am sympathetic in an era of greater valuing of those degrees that are lucrative or more likely to pave the way toward lucrative professions, not to mention a depressing decline if not death of quality journalism. (As someone whose second major very nearly was Classics with a minor in English Literature, I was not at the age of twenty a shining example of following the path of practicality). It is not simply because of my desire for my students to get my references, though that of course would be nice (though to their credit, they consistently do get my Sorkin references). It is not simply because I appreciate reading their extra rhetorical flourish, though to be sure I do. And I do not have evidence to support that the decline in students’ and others’ writing is a reflection on not being exposed to the “right” people to emulate or if it is merely a reflection on our declining premium that we place on writing (while we do need to invest in better education, my strong suspicion is that it is the latter scenario, as the works of Austen and Hemingway will forever be in print and available for public consumption). There must also be a will to adapt, or in this case more aptly, to revert. It is out of my optimism, my hope that in becoming reacquainted with the greats (and recognizing them as such), we might renew our attention to the seemingly lost art of what it means to be both great writers (whether fiction or nonfiction), and more broadly great communicators.

​A common argument is that an important aspect of the doctor-patient relationship is that of information asymmetry. That is, while a patient can chronicle her symptoms, her history, her preferences over treatment, she lack the medical knowledge that her doctor has acquired over years of training through schooling, residency, and fellowship. Her doctor has a technical degree of knowledge about the body and about pharmacology that will be unmatched in that relationship. Thus, there is a power relationship: when one is sick and vulnerable, we defer to expertise in the management of technical detail, risk, and uncertainty. The physician can then use that informational advantage to recommend certain treatments, and their assessment of medical necessity or lack thereof can also help to moderate potential concerns of moral hazard given insurance coverage (see, e.g. Arrow 1963).
 
Concessions to expertise are the subject of much of scholarship on the American bureaucracy (and of course other fields outside my own area of expertise). Rather than take on the immense and impractical task of itself carrying out enforcement in technical policy domains, and rather than engage in the transaction costs associated with crafting longer and more detailed legislation to address the complexities before which the nation is faced, the legislature delegates to the agency given its technical expertise. The political principal (in this case, Congress) acknowledges that the agent (conveniently in this case, the agency) is better equipped to handle the matters of implementation, though there are information asymmetries of course in that only one party has the detailed knowledge of the given policy and how best to carry it into effect.
 
Such concessions to expertise occur throughout all of our lives in ways both great and small. We assume that the local mechanic will better ensure that our car gets fixed than will we. We assume that the local carpenter will better address home repairs. The list goes on. The catch is that in the context of medicine, rather than resulting in needing to take the train instead of driving, or having a less aesthetically pleasing apartment for some period of time, the stakes are life and death, and the relationship between doctor and patient becomes critical.
 
How physicians relate to their patients obviously need not – and indeed, should not exploit information asymmetry, but rather should work in as accessible a way as possible to reduce that asymmetry to facilitate the making of informed decisions that are collaborative rather than a paternalistic system in which the physician acts as an overly domineering principal toward their agent, the patient.
 
What seems to be a distinction between the nature of care for physical health and care for mental health (which is far more divided than it should be) is the additional layer of asymmetry added to the mix: cognitive asymmetry. That is, while physical and mental health are in many ways inextricably linked, mental health’s focus on cognitive capacity – the ability to process information, to maintain perspective in light of current and past events as well as future prospects, to make reasoned and rational decisions – are compromised, or at minimum are compromised with a probability high enough sufficient to compromise the patient’s credibility to work with care providers on remotely equal footing.
 
That is, in a world that values and requires informed consent, if a person does not want to receive medical treatment in a hospital, they may sign an AMA form (against medical advice), but such a form does not apply in a psychiatric emergency room. The flexibility of canceling a therapy session amid an emotional crisis may be reduced relative to the decision to postpone a physical exam. While patients will not be forced to take medication, the playing field is far less even, and in hospital settings can be infantilizing even among patients who, outside the context of that illness, are intelligent and successful. Of course, that is one of the many central challenges of such an illness, which is that it targets the reason with which one would otherwise be navigating the world and serving as an advocate for their own care and well-being.
 
It is unclear to me whether there is a solution to better managing these relationships in ways that level the playing field with respect to both information and power (which of course are not independent), to maximize patient autonomy while also protecting well-being. But in thinking more critically about opportunities to better advocacy, it is important to recognize the dual dimensions of heightened vulnerability experienced by this patient population as they work to navigate the already fragmented healthcare system. 

En route to Cornell University for a conference today, I read a book that had only recently come on my radar, admittedly very belatedly given my long and ever-growing interest in public health and medicine.
 
Within the pages of When Breath Becomes Air, one finds the at once inspiring and heart-wrenching account of a neurosurgeon, Paul Kalanithi, who succumbed to stage four cancer early in his career, and who brilliantly put pen to paper to reflect on medical ethics, on the humanity of medicine that can at times get lost in aggressive treatment, and on what it means to build a meaningful life. Such work speaks to that of Atul Gawande, whose Being Mortal likewise reflects on the role of modern medicine in shaping not only survival, but also the quality of life with which patients ultimately are left. Purpose, after all, is not universal, and indeed it is something with which Kalanithi grapples throughout his work of dually serving as physician and patient – whether to be a surgeon, a teacher, a writer, a husband, a father. Whether to be a writer for one year or a surgeon for five. With possibilities virtually limits where his intellectual capacity was concerned, within the confines of his illness, the choice was his, and as he notes, that feeling of purpose is itself fluid given the trajectory of his disease and the options before him.   
 
Medicine is about healing, but it is multidimensional in working toward that end. Medical interventions almost invariably are accompanied by potential benefits as well as potential harms, thus leaving the patient to make some degree of cost-benefit calculus with respect to the decision whether to pursue treatment. Interventions can sometimes make us worse even en route to making us better. It can also, at times, be at odds with personal preferences for valuing quality of life versus longevity, a trade-off that is at the heart of deciding for oneself what it means for a life to be meaningful.
 
Indeed, for all the emphasis on saving human life, in some cases amid the needless to say important statistics and randomized controlled trials and the like, the human aspect of medicine is not always front and center amid discussions of longevity. And yet, buying one an additional five years is not always the goal if those years involve the notoriously difficult chemotherapy. Kalanithi writes:
 
“Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives – everyone dies eventually – but guiding a patient or family to an understanding of death or illness… For amid that unique suffering invoked by severe brain damage, the suffering often felt more by families than by patients, it is not merely the physicians who do not see the full significance. The families who gather around their beloved – their beloved whose sheared heads contain battered brains – do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery – or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew – the full, vital independent human – now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluid going in, others coming out, to persist despite being unable to struggle. Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought” (87-88).
 
The eloquence with which he writes on this subject is remarkable, though the substance is in some ways intuitive despite being an uncommon perspective to hear from within medicine.
 
While public trust in doctors has historically been high, the International Social Survey Programme (ISSP) survey of public trust in American physicians from 1966 to 2014 reflected a decline from 73% to 34% expressing great confidence in the U.S. medical profession, despite there not being a similar decline in trust in physicians’ integrity or honesty and ethical standards. Interestingly, a growing minority of Americans argue that doctors ought to do everything possible to keep their patients alive, though arguably it should remain on the patient’s terms. Perhaps surprisingly, the United States is tied for 24th place in ranking of the proportion of adults viewing doctors in their country as being able to be trusted. This is particularly problematic because medicine is a field in which there is extensive asymmetric information. In simpler tasks, one can educate oneself, become expert, fact check. Medicine requires rigorous training in medical school, residency, and fellowship, and thus there is a greater differential between patient and expert (potentially even, as Kalanithi writes, as a patient who is also a physician). This is all the more crucial a disparity when considering that people enter this system often at their most vulnerable (and under those vulnerable conditions, there can be adverse consequences of bad news being delivered poorly to patients).
 
This vulnerability makes all the more important the preservation of the human side of medicine, even if it requires a broadening of the understanding of what it might in fact mean to “do no harm.” The notion of being able to intervene with a medical “fix” is tempting, even if only a temporary fix as opposed to no fix at all, but as Gawande notes, having the different kind of conversation – one involving more listening than talking, considering of the broader set of options and priorities – is difficult, and is it a conversation for which many physicians are ill-prepared, but it is also essential to good patient care (certainly with respect to end-of-life care). There is perhaps no more painful example than that of cognitive deterioration due to such conditions as Alzheimer’s or dementia, with an intact physical body of an individual who is no longer recognizable.
 
There are several types of courage to which Kalanithi’s work speaks directly. The courage of a patient, who must by definition be patient in enduring tests, procedures, probabilistic outcomes rather than a definitive future, pain, and other unpleasantness that she can choose to endure, to rage against the dying of the light, or to, as in Longfellow’s “Thanatopsis,” wrap the drapery of his couch about him and lie down to pleasant dreams. There is the courage of the doctor in fighting in the face of medical uncertainty and uphill battles, but also the courage to know when to allow the patient to be in the driver’s seat, to find the optimal balance between professional command and humility. And the courage as human beings – patients, doctors, teachers, children, parents – to persist in the face of adversity as we so often do throughout our lives (whether with hurdles great or small), and to know at what point to accept the equally brave task of moving toward the next stage of life, or rather its completion. We are taught to fight, to win, to “beat it,” and that to do otherwise is to admit defeat. This is not a defense of preemptive defeat. But it is a defense of looking more broadly. Kalanithi’s work is a beautiful treatise on the macro-level concept of the meaning of life while digging into the important substance of the practice of medicine and patient care today, and the balancing of the competing goals with which practitioners and patients alike are faced.

​Numerous reports have surfaced as to the dangers of opioid addiction and the need to reduce the dispensing of opioid prescriptions so as to combat this epidemic. The dangers of opioids were addressed by HealthCare Triage, StatNews, the New York Times, and others, and the FDA recently approved the first buprenorphine implant for the treatment of opioid dependence. Opioids are now deemed a leading cause of death in the United States, with over 40 Americans dying every day from overdose of opioids and 2 million abusing or misusing opioids each year, and with over six in ten drug overdoses being associated with opioids.
 
Congress is finally taking action to combat these nationwide challenges. Most recently, on May 26, HR 5189, the Opioid Abuse Crisis Act of 2016 (sponsored by Ann M. Kuster, D-NH-2) was referred to the House Subcommittee on Health. Additionally, grants toward addressing opiate abuse have passed the House and the Senate, with differences between the chambers currently being resolved. Other legislation has been introduced but has not yet met passage this session.
 
Chronic pain is far from trivial, and when not managed well can contribute powerfully to depression, which is a leading cause of disability and can coexist with a number of other health problems. Moreover, some setting out to responsibly treat pain can potentially inadvertently find themselves addicted. Yet the way that we have worked to address severe and chronic pain over the years has changed, such that despite not reporting marked changes in the level of pain experienced, prescriptions for opioids have increased dramatically since the early 1990s with the introduction of MS Contin and Oxycontin. The long history of pain management and the more recent onset of this addiction epidemic suggests that biologically-based interventions will be only limited in their efficacy, and looking at the underlying socioeconomic aspects will be essential for an effective medial and policy intervention with respect to the addiction to opioids (and other substances).
 
The fact that the face of opioid addiction has changed over the years, affecting diverse populations of different ages, makes complicated the determination of the most effective interventions. However, I decided to peruse the data (it’s what I do…). I began by looking at the ProPublica database of doctors and drug prescriptions participating in Medicare Part D, with the database tracking all prescriptions from these providers. I focus on the prescription of Hydrocodone-Acetaminophen, otherwise known as Vicodin, though I examined also the prescription of Oxycodone, another opiate. Of the fifty states and the District of Columbia, 17 states had Vicodin as the #1 most prescribed drug in 2013, and 42 states had Vicodin as one of the ten most prescribed drugs (out of over 1500 drugs enumerated). Admittedly, pain medication does have a more general applicability than the more specific application of a thyroid drug or one aimed at lowering blood pressure or cholesterol, though these numbers are nevertheless quite striking. The absolute lowest rank that Vicodin had was #37. Oxycodone-HCL, or Oxycontin, earned lower ranks in prescribing, as did Oxycodone-Acetaminophen, or Percocet, and there was only a modest relationship between the prescribing of those drugs and the propensity with which Vicodin was prescribed.
 
I then looked more systematically at the relationship between opiate prescription and health and economic factors. I used as the dependent variable the prescription drug rank that Vicodin took in state level prescriptions. Thus, the value of 1 indicates that Vicodin was the most common medication prescribed, while higher values indicate a lower prevalence of the medication among other prescriptions written in that state, based on the data provided by ProPublica from 2013. This value ranges from 0 to 37.
 
I looked at a handful of independent variables. To identify the parts of the country most likely to be affected by opiate addiction based on geographic factors, I include the state’s rank with respect to population density (ranging from 1 to 51, with higher values associated with sparser populations), as well as the state’s rate of unemployment, which ranges from 2.5 to 6.6.  To account for differences in the ideological orientation of the state and thus potential variation in the extent and nature of services provided, I account for the state government ideology using the measures provided by Berry et al (2011).
 
The extensive prescription of opioids does not necessarily lead to addiction. In theory, one can prescribe opioids to a large number of people who use them responsibly and do not become addicted. The Centers for Disease Control and Prevention (CDC) tracks the extent to which state health care expenses are attributable to opioid addiction or abuse, and I control for the percent of abuse-related health costs, which ranges from 0.1% to 17.1% (with California being the highest). Curiously, the states ranking in the highest on this dimension were not necessarily the states prescribing opioids to the greatest degree (California and Texas both prescribed Vicodin the most, but Florida and Ohio had Vicodin only in the top 10, and New York ranked at only 20).
 
Finally, to examine the effect of health spending on doctors’ propensity to dispense opioids, I looked at the extent of overall health spending as well as the extent of health spending specific to mental health. Given the close relationship between substance abuse and mental health, I focus on the results when controlling for mental health spending, though the results are consistent in both specifications.
 
While I examine the effects using ordinary least squares (OLS) given the large distribution of the dependent variable, the results are consistent when utilizing instead a negative binomial specification, which is appropriate to count data that exhibits overdispersion (as is the case here). I do not find that state ideology is associated with any difference in states’ doctors’ propensity to prescribe opioids. I find that a standard deviation increase in mental health spending is associated with a 2.7 standard deviation decline in the extent to which states prescribe opioids relative to other medications (p<.01). While, as I noted above, one can provide much access to the responsible use of opioids for the effective management of chronic or severe pain, I do find that a standard deviation in the percent of state health costs attributable to opioids is associated with a 1.6 standard deviation increase in the extent to which opioids are prescribed relative to other medications (p<.05).
 
Consistent with expectations, I find that a standard deviation increase in population density of a state is associated a 4.3 standard deviation increase in the extent to which opioids are prescribed relative to other drugs in the state (p<.01). I find also that a standard deviation increase in the state’s unemployment rate is associated with a 2.3 standard deviation increase in the extent to which opioids are prescribed relative to other medications in the state (p<.01). Replacing the state unemployment rate with the state poverty rate also produced a significant test statistic with a large substantive effect.
 
It goes without saying that these are simple models comprising only 48 observations (Florida and New Mexico did not report state mental health funding data) and a small number of controls. However, it is noteworthy that even with all of the demand on the data, there are clear patterns that emerge that are consistent with expectations: that we see greater opioid prescribing in more sparsely populated regions and those facing greater economic downturn, and that there appear to be strong associations between rates of opioid prescribing and the extent to which health expenditures are related to opioid abuse. Moreover, rather than being a fruitless effort to “throw money at the problem,” investing more in healthcare overall and mental health specifically may potentially be an effective intervention in working to combat these pervasive problems of abuse and addiction, whether by treating current addiction or by managing better peoples’ physical and psychological challenges leading one from responsible prescription use to abuse. While a number of the states investing larger amounts of money toward mental health care are wealthier and more populous (e.g., New York, New Jersey, Connecticut, Pennsylvania), that is far from the rule, with Alaska, Maine, Vermont, and Montana also ranking high on this dimension.
 
The data here cannot disentangle whether greater funding allocation helps to prevent the onset of major abuse by facilitating individuals’ reaching out to other resources for help, or whether that funding helps to intervene in reducing existing problems of abuse. Likewise, the data cannot tell us whether unemployment and poverty create conditions that become ripe for opioid abuse, or whether there are common factors underlying both unemployment and opioid abuse. However, what they can show is that given the strong associations that appear in these cursory regressions, we would be remiss in treating opioid addiction specifically as opposed to examining it in light of other economic factors as well as physical and mental illness to which it may be tied. For example, the highest rates of opioid prescriptions also occur in those states with higher rates of serious mental illness (though there does not appear to be an association with alcohol in general or binge drinking specifically). With high rates of co-morbidity between drug abuse and mood and anxiety disorders, given both genetic and environmental vulnerabilities and with economic downturn associated with increases in substance-use disorders, it is imperative that in addition to restricting the prescription of these substances in lieu of less (or non) habit forming medications such as NSAIDS, we look holistically at both the biological and socioeconomic factors underlying opioid abuse and its effective resolution, lest one abuse epidemic be replaced with simply another.