Genetic Information Non-Discrimination Act

On May 21, 2008, President Bush signed into Law the Genetic Information Nondiscrimination Act which will ensure that individuals genetic histories cannot by used against them in gaining insurance or employment. Insurance companies may not request that individuals receive genetic tests, access personal genetic information, or use genetic data in premium and enrollment decisions. Similar standards were set for employers, including stiff fines for collecting genetic data illegally. Concerns, however, have arisen that the law “is emblematic of this country’s piecemeal and inconsistent approach to health care policy,” as noted by Korobkin and Rajkumar in the New England Journal of Medicine (Volume 359, 335-337). The authors argue that the law will not cover an individual with a family history of colon cancer whose recent colonoscopy reveals pre-malignant polyps. As a result an insurance company may still legally raise the costs for this individual, though the individual may bear as of yet unknown colon cancer markers. The critique of the law may be found at http://content.nejm.org/cgi/content/full/359/4/335.

Post-Election Medicaid Regulations

The Bush Administration recently announced that it will enforce a new regulation, initially proposed in 2007, limiting the provision of outpatient hospital services to individuals on Medicaid. The rule is scheduled to take effect on December 8, 2008. The administration argues that payments for some services have become excessive and the regulation notice states that the rule “represents a new initiative to preserve the fiscal integrity of the Medicaid program.” Various hospitals and officials have argued that these reductions will cut back on services like dental and vision care, diagnostic and laboratory services, and medi- cal transportation. Charges for outpatient services for Medicaid, which provides healthcare coverage for over 50 million individuals with low incomes, are typically higher in hospital settings. The administration has already posted several new regulations regarding Medicaid, all of which would have cut services. However, Congress has posted moratoriums on the remaining rules, though it did not do so in this case. A comprehensive overview of the regulations can be found through the Kaiser Family Foundation website at http://www.kff.org/medicaid/upload/7739.pdf:http://www.kff.org/medicaid/upload/7739.pdf.

Genome of Individual with Cancer

Researchers at the University of Washington in St. Louis have recently sequenced the genome of a woman who died at age 50 from acute myeloid leukemia. The effort marks the first time that large scale genetic sequencing has been used to sequence cancerous cells and compare them against normal cellular DNA. Ten mutations were observed within the cancerous cells, eight of which had been previously unobserved by conventional small scale genome studies. The mutations observed accounted for factors such as the cancerous cell’s ability to grow abnormally and resist chemotherapy. Current practical applications of the research are limited, but scientists expect the findings to contribute towards the development of new treatments and the ability to tailor therapy plans for patient specific cancers. The complete paper “DNA sequencing of a cytogenetically normal acute myeloid leukaemia genome,” can be found in the November 6, 2008 issue of Nature (Volume 456, 66-72).

National Children’s Health Study

In 2000, Congress passed the Children’s Health Act which was designed to provide funding and support for a “national longitudinal study of environmental influences (including physical, chemical, biological, and psychosocial) on children’s health and development (Section 1004).” Now researchers have finally begun to assemble the 100,000 pregnant women whose children they will follow for the next 21 years. Researchers hope that the project, which is slated to cost nearly $2.7 billion, will discover some of the factors contributing to the current rise in autism, premature births, obesity, asthma, diabetes, mental health disorders, and many other health related issues. Subjects in the study will be drawn from 105 study locations and selected from a mixture of ethnic, racial, economic, religious, geographic, and social groupings. The health study was designed by over 2,400 researchers and will be administrated pri- marily through major health institutions and universities, totaling forty regional centers. Preliminary results from the study are expected to be available as early as 2011. Additional information regarding the study and its goals is available at http://www.nationalchildrensstudy.gov.

Physician-Assisted Suicide

On November 4, 2008 voters in Washington State passed Initiative 1000 by a margin of 59 to 41 percent, approving the prescription of medication by physicians to terminally ill patients to accelerate the patient’s death. In order to request this service patients must be deemed mentally competent, be residents of the state, and have a predicted life expectancy of less than six months, as deemed independently by two physicians. The patient must also submit the request orally and in written form. The patient is required to administer the medications him- or herself and they are required to be informed about alternatives to the procedure. For more information about physician assisted death see Dr. Timothy E. Quill’s paper on the topic in the Hastings Report 38, no. 5 (2008) at http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=2232.

Doctors Prescribe Placebos

A survey of 1200 randomly chosen internists and rheumatologists, of whom 679 responded, found that approximately half prescribed placebo treatments. Vitamins and analgesics were the two most commonly prescribed forms of placebos. Those physicians who did prescribe placebos often described them as either potentially useful or did not inform the patient what the medication would actually do. The study is in the BMJ 2008; 337:a1938 and is available at http://www.bmj.com/cgi/content/full/337/oct23_2/a1938.

Cardiac Transplantation for Infants

Cardiac transplant surgeons at the Denver Children’s Hospital decided to remove the hearts of infants 75 seconds after the hearts stopped beating. No heart has been recorded as spontaneously restarting after more than 60 seconds. The physicians decided to allow 75 seconds for two of the infant donors, after allowing 18 minutes of cardiac-death pre-transplantation for three other infant donors. Current organ donor rules indicate that the donor must be declared either brain-dead or suffer from cardiac-death. The procedure remains ethically and medically controversial at the time. For more information, see the study, published in the New England Journal of Medicine (Volume 359:709-714) at http://content.nejm.org/cgi/content/full/359/7/709.

Research Highlights: Healthcare Policy

During this election cycle healthcare once again returned as a pivotal issue. The election of Senator Barrack Obama has led many to believe that fundamental change in the American healthcare system will follow in the next four years. Yet, the current economic crisis and the details of the Obama proposal make many wonder whether reform will be possible. In this special section TuftScope highlights current views on the healthcare system, the Obama/Biden plan, and critiques of the proposal.

Overview

 “Myths and Misconceptions about U.S. Health Insurance”

Health Affairs. Web Exclusive, October 21, 2008 http://content. healthaffairs.org/cgi/content/abstract/hlthaff.27.6.w533

 “The Politics of Paying For Health Reform: zombies, Payroll Taxes, and the Holy Grail”

Health Affairs. Web Exclusive, October 21, 2008 http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.6.w544

 “Voters and Health Reform in the 2008 Presidential Election”

The New England Journal of Medicine. Volume 359:2050-2061. http://content.nejm.org/cgi/reprint/359/19/2050.pdf

Obama Plan

 “Affordable Health Care for All Americans”

JAMA. 2008; 300(16):1927-1928 http://jama.ama-assn.org/cgi/reprint/300/16/1927

Critiques

 “Symptomatic Relief, but No Cure — The Obama Health Care Reform”

The New England Journal of Medicine. Volume 359:1648-1650. http://content.nejm.org/cgi/content/full/359/16/1648

 “The Obama Plan: More Regulation, Unsustainable Spending”

Health Affairs. Web Exclusive, September 16, 2008 http://content.healthaffairs.org/cgi/reprint/hlthaff.27.6.w462v2