Prescribing housing for the homeless in Hawaii

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Homeless in Hawaii. Image courtesy of Sen. Josh Green.

With severe threats to the health and well-being of the most vulnerable Americans populating the headlines – from repealing and replacing the Affordable Care Act with a system that would send the number of uninsured skyrocketing, with poorer and older Americans suffering most, to the administration’s proposed FY2018 budget, with its drastic cuts in a social safety net that already lets millions of people fall through it – it is easy to focus only on limiting the damage. Yet even now, there are initiatives to advance health equity and the right to health within the United States. Most far-reaching may be the initiatives in states including California and New York to create a single-payer health system to provide universal health coverage. Perhaps the most innovative initiative comes from Hawaii, with a proposal that could dramatically improve the health some of the state’s most marginalized residents, and serve as a model for the nation.

Many doctors who recognize the underlying vulnerabilities of their patients would like to be able to address them directly. A prescription for economic opportunity for people with depression or substance abuse disorders that appear to stem from economic uncertainties. A prescription for peace to reduce post-traumatic stress syndrome. A prescription for fruits, vegetables, legumes, and whole grains for patients experiencing symptoms of poor nutrition, from childhood stunting and anemia to diabetes and heart conditions. A prescription for housing to address the multitude of health risks that give the homeless population in the United States about 30 years lower life expectancy than that of the overall U.S. population.

This last possibility is suddenly within the realm of possibility thanks to an emergency room doctor and Hawaii state senator, Josh Green. At the beginning of 2017, he introduced two pieces of legislation aimed at enabling doctors to literally prescribe housing and supportive services for chronically homeless individuals. As the Senator said, “The single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing.” Senator Green further observes, “We’re already spending the money on homeless people, we’re just paying for it in the most inefficient, expensive way possible.”

One piece of legislation would have required health insurers to cover treating homelessness, though the bill was later significantly amended in committee, and would instead require the state auditor to study using Medicaid funds “for the treatment for homelessness.” The other billwould have required the state Department of Human Services to create a Medicaid housing benefit plan.” It, too, was amended in committee, and instead would require the department to “continue to pursue efforts to utilize Medicaid to provide supportive housing services for chronically homeless individuals.”

The linchpin for Senator Green’s proposals is the economics of Medicaid, which would be the source of funding. Hawaii’s $2 billion in annual Medicaid spending is not spread evenly across the state’s 362,000 Medicaid beneficiaries. Rather, reflecting health care costs writ large, where most of the spending is directed towards a small proportion of people with the poorest health and greatest medical needs, 60% of Medicaid spending in Hawaii ($1.2 billion) goes towards about 3.6% (13,000) of the state’s most vulnerable residents. Among these are chronically homeless people, whose condition leads to frequent, expensive emergency room visits and other care that would become unnecessary if they were no longer homeless.
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Posted in Human Rights, National Healthcare; Tagged: , , , , , , , , .



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Hanhsi Indy Liu is an SJD candidate at Georgetown University Law Center. Sarah Roache is a Senior Associate at the O’Neill Institute for National and Global Health Law. Any questions or comments on this post can be sent to: hl580@georgetown.edu.

Advocates for public health-based soda taxes had two important victories this month: a Pennsylvania appeals court dismissed an industry lawsuit challenging Philadelphia’s soda tax and the Seattle City Council became the ninth US jurisdiction to tax sodas.  

On June 14, 2017, the Pennsylvania Commonwealth Court ruled in favor of the tax in a 5-2 decision., This is the second judicial affirmation of the legality of the tax in Philadelphia, which has the second highest prevalence of obesity (29.3%) and diabetes (10.7%) among large US cities.

Appellants, led by the American Beverage Association, argued that the 1.5 cent-per-ounce tax violates the prohibition on duplicative taxation and is pre-empted by the federal Food Stamp Act and the Tax Code, which prohibit taxes on items purchased under the Supplemental Nutrition Assistance Program (SNAP). The majority opinion written by Judge Wojcik, rejected the appeal, holding that the tax does not violate either Pennsylvania state laws or federal law because it applies to non-retail distribution transactions and not retail sales to the consumer.

Philadelphia mayor Jim Kenney released a statement on the same day, saying “Two courts have now considered the arguments of the beverage industry and both are certain that the Philadelphia Beverage Tax stands on solid legal grounds.” He urged the beverage industry to cease its legal and public relations battle that has already cost millions. “Our entire city desperately needs us to be able to move forward with the programs funded by the tax and we will be unable to do that in full until full legal action is resolved.”

The city has committed to spend revenue from the soda tax on for improving Pre-K and community education, rebuilding city facility like libraries, parks and community centers. Revenue is predicted fall short of the $46.7M projected for January-June 2017. At this stage, the reason for the shortfall is unclear. But if the reason is decreasing soda purchases, then the tax is achieving its public health objectives to discourage consumption.

Moving from the East coast to the West, Seattle City Council passed its $ 1.75 cent-per-ounce soda tax on June 5, 2017. The 7-1 vote makes the emerald city the ninth US jurisdiction to embrace a public health-based soda tax, joining Albany, Berkeley, Oakland, and San Francisco in California; Boulder, Colorado; Cook County, Illinois; Philadelphia, Pennsylvania, and the Navajo Nation. The legislation covers sweetened beverages such as soda, juice, sports drinks, flavored water, energy drinks, and pre-sweetened coffee or tea, with exceptions for mike products, 100% juice, formula or sweetened medication. Diet soda was slated for taxation in Mayor Ed Murray’s proposal, but it was eventually removed by the City Council on the basis that diet sodas are less harmful to health than regular sweetened beverage products. The tax will take effect on January 1, 2018, and is expected to collect $15 million annually. The revenue will be spent on education programs and food access strategies like fresh bucks, which will help ensure access to nutritious food and beverage products.

Seattle’s new soda tax confirms the growing momentum behind soda taxes as a popular and effective means of helping to reduce sugar consumption and obesity. The appellate court’s ruling on Philadelphia’s soda tax confirms that cities can take on – and overcome – industry efforts to undermine valuable public health interventions.

Posted in Non-communicable diseases; Tagged: , , .


Silver and Gold: California’s and Nevada’s Pushes Towards Universal Health Coverage

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Neil Sircar, J.D., is an LL.M Candidate in Global Health Law at Georgetown University Law Center & the O’Neill Institute for National and Global Health Law. Any questions or comments related to this post can be directed to nrs53@georgetown.edu.








The Golden State: All That Glimmers?

Critics of the Trump Administration did not envision it to foster improved health coverage anywhere in the country (quite the opposite), however on the ground at least two states are en route to potentially do just that. California has once again brought to the floor a proposal to create a single-payer health insurance system for the state. Inspired by the “Medicare-for-All” movement championed by Senator Bernie Sanders, the latest rendition of California’s attempts to create a publicly financed health care system is now before the State Assembly for a vote. The last time a bill like this was in California’s legislature it passed only to be vetoed by then Governor Schwarzenegger. Governor Brown has not come out against the measure but has voiced his concern over its gargantuan cost: $400 billion, of which half would need to come from new revenue sources (i.e. taxes). Vermont famously tried something similar only to see its plan collapse under the burdens of needing an extra $2.5 billion for it.

Single-payer systems elsewhere are generally less expensive for both individuals and nations than what the US pay. There are trade-offs to single payer systems in terms of patient experiences, but in the United States there is also a legal question around constitutionality and federalism. The Affordable Care Act’s Medicaid Expansion was curtailed in NFIB v. Sebelius in part because the Supreme Court felt that it was too coercive to the States to have adopt it. Medicare-for-All could easily fall prey to the same arguments of federal government overreach into a sector largely regulated by the States.

A Silver (State) Lining?

Across the Sierra Nevada Mountains a similar proposal is underway. The Nevada Legislature passed a bill that would ensure complete access to Medicaid for Nevadans regardless of income. Medicaid-for-All has not garnered as much traction as its cousin Medicare-for-All, however Medicaid may end up becoming the functional universal health coverage system that UHC advocates want with less risk of running afoul of the Constitution (as interpreted today). Medicaid is not flawless but structurally the system enables the “public option” Democrats long for if not true UHC and typically at lower cost. Nevadans could buy-in to Medicaid (and take cheaper health coverage in exchange for waiting times and the like), or pay for private insurance and enjoy perks. States have more say in Medicaid spending as well, with some states covering more services than others. Nevada Governor Sandoval has yet to decide on this bill, though he does not support a rollback of the Medicaid Expansion so he may not be opposed to locking in a public option for Nevadans so long as the private insurance sector remains viable. While not creating a uniform health system, a United States of Medicaid-for-All could expand coverage to a large number of people and reduce individual costs for many.


Ultimately, the goal of UHC advocates is to increase access and availability for health care to all persons as a fundamental human right. The United States is an interesting enigma for arriving at anything “universal” in name, but perhaps a tapestry of Medicaid public options could get there.


Posted in Human Rights;


Ebola: Fifteen Years of Silence

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“The music is not in the notes, but the silence in between.”   – Wolfgang Amadeus Mozart


If one were to describe the history of Ebola outbreaks, one method would be to construct a timeline, with a point on the line for each outbreak.  You could create this timeline with a varying number of points, depending on your methodology, but regardless of how you built your timeline, there would be spaces between these points. This is due to the nature of Ebola; it appears, it disappears, and it appears again. To the Ebola virus, these gaps are periods of convalescence. To us, they are periods of absence and mystery, and one of these gaps stands out as the most mysterious.

The CDC lists five Ebola outbreaks in the late 1970’s. The “first” Ebola outbreak took place in 1976, though we now recognize the event as two simultaneous and separate outbreaks. Between June and November 1976, 284 cases (151 deaths) of Ebola Sudan occurred near what is now Nzara, South Sudan[i]; between September and October 1976, 318 cases (280 deaths) of Ebola Zaire occurred near what is now Yambuku, Democratic Republic of Congo (DRC)[ii]. In November 1976, a researcher in England that was working with samples from the Nzara outbreak accidentally infected himself[iii]; CDC lists this accident as the third Ebola outbreak (the individual recovered). In June 1977, a child became sick and died from Ebola Zaire in Tandala, DRC[iv]; though there was only one confirmed case, subsequent epidemiological investigations of the area uncovered several other historical, probable cases. Finally, between July and October 1979, 34 cases (22 deaths) of Ebola Sudan occurred, unbelievably, in Nzara, Sudan[v] – the same community where the first cases of Ebola emerged just three years prior. In the span of just 39 months, the terror of Ebola had introduced itself to the world five times (638 cases, 454 deaths) and then… silence.

Ebola would not reappear for ten whole years, and even then, the subtype was Ebola Reston, which does not affect humans. Ebola Reston was first discovered in imported non-human primates designated for laboratory testing. Though it was discovered that humans could be infected with Ebola Reston, the infections were asymptomatic. Though CDC lists four Ebola Reston outbreaks between 1989 and 1992, the world would not see another case of Ebola virus disease in humans until late-1994, in Gabon[vi]. Even then, the outbreak (52 cases, 31 deaths) was mischaracterized as yellow fever for several months. Perhaps the virus’s long absence from the spotlight had removed it from the collective consciousness in 1994, certainly in the presence of those pathogens that had been circulating and consuming our attention in the meantime.

The fifteen-year disappearance of Ebola, particularly in light of its frequent and severe outbreaks in the late 1970’s, has perplexed researchers for decades. The mystery lies, to some extent, within the lack of complete knowledge of the virus reservoir, though scientists have long suspected bats. It’s hard to detect disease when you cannot pinpoint the source. Surveillance and reporting has been another confounding element.  How many times in that fifteen-year period was an illness misdiagnosed as yellow fever, dengue hemorrhagic fever, or some other similar illness, because of lack of knowledge or diagnostic capabilities, or simply because there was no health care around?  We will probably never be able to answer this question. Finally, our perceived zone of endemicity at the time was limited to northern DRC and southern Sudan. Was the virus appearing elsewhere, unbeknownst to us? We certainly weren’t expecting it to emerge in Gabon in 1994 (and Uganda in 2000[vii], and West Africa in 2014).

Scientists today continue to be perplexed by the emergence of the virus. What brings Ebola out from its hiding place? Is its emergence/re-emergence tied to climate change? globalization? the changing interface between humans and wildlife? If it has to do with any of these increasingly significant factors, how do they explain the fifteen-year disappearance?

These days, the virus comes and goes with some predictability—since 2000, outbreaks have approached a near-annual incidence, sometimes skipping a year, sometimes lasting more than a year. The periods between outbreaks are growing shorter. Is this because our capability to detect Ebola outbreaks is improving, or is the virus able to infect humans more frequently? One thing is for sure: the world knows that when one outbreak ends, another will eventually follow, and we need not wait fifteen years.



[i] WHO. Ebola haemorrhagic fever in Sudan, 1976. Bull World Health Organ. 1978;56:247–270.

[ii] WHO. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271–293.

[iii] Emond RT, Evans B, Bowen ET, et al. A case of Ebola virus infection. British Medical Journal. 1977;2(6086):541-544.

[iv] Heymann DL, Weisfeld JS, Webb PA, et al. Ebola hemorrhagic fever: Tandala, Zaire, 1977-1978. Journal of Infectious Diseases. 1980;142(3):372-376.

[v] Baron RC, McCormick JB, and Zubeir OA. Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. Bulletin of the World Health Organization. 1983;61(6):997-1003.

[vi] Georges AJ, Leroy EM, Renaud AA, et al. Ebola hemorrhagic fever outbreaks in Gabon, 1994-1997: epidemiologic and health control issues. Journal of Infectious Diseases. 1999;179:S65-75.

[vii] MacNeil A, Farnon EC, Morgan OW, et al. Filovirus Outbreak Detection and Surveillance: Lessons from Bundibugyo. Journal of Infectious Diseases. 2011;204:S761-S767.

Posted in Uncategorized; Tagged: .


O’Neill Institute Contributes to Public Comment on PrEP for HIV Prevention

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I would like to discuss the O’Neill Institute’s contribution to a recent public comment. The content of the public comment will be reviewed by the U.S. Preventive Services Task Force (USPSTF), but also may be of interest to general audiences. On March 22, 2017, Jeffrey S. Crowley and I partnered with researchers at The Fenway Institute and Emory University’s Rollins School of Pubic Health to submit comments on the USPSTF’s draft research plan for the use of pre-exposure prophylaxis (PrEP) in preventing the transmission of HIV. Once finalized, the research plan will be used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center and will form the basis of the USPSTF’s Recommendation Statement on PrEP. While it may take several months or even years before the USPSTF makes its final recommendation, we submitted comments to inform the process and encourage the USPSTF to consider specific issues and relevant evidence within its research plan. PrEP is an important HIV prevention tool, and the USPSTF’s recommendation has the potential to make PrEP more accessible to individuals and communities most impacted by HIV.

The USPSTF is a federally-appointed independent body of physicians and other experts that conducts evidence-based reviews of various prevention interventions. Once the USPSTF conducts a review, it provides a rating: An A or B rating means that the evidence is strong in support of an intervention, whereas a rating of a C means that an intervention is recommended, but that the evidence for it is weak. Medicare and health plans operating on health insurance marketplaces in accordance with the Affordable Care Act are required to provide prevention services free of enrollee cost-sharing for all interventions with an A or B rating by the USPSTF. Medicaid programs are encouraged to extend the same coverage, although state programs have the discretion to make their own coverage determinations.

Based on the draft research plan posted for public comment from February 23, 2017 through March 22, 2017, the USPSTF seeks to assess the benefits of PrEP use and how these benefits differ by regimen, dosing strategy, and population sub-groups. It also aims to assess rates of adherence and how adherence impacts the effectiveness of PrEP.

Our comments highlight research completed and underway. While it may be appropriate for the USPSTF to consider a range of PrEP agents in the future, we recommend that the USPSTF limit its current review to evaluating clinical effectiveness of oral tenofovir disoproxil fumarate and emtricitabine (TDF-FTC), the medication approved by the U.S. Food and Drug Administration in 2012 for use as PrEP for HIV prevention. Beyond assessing the effectiveness of PrEP regimens, the comments encourage the USPSTF to place emphasis on looking at how different population sub-groups benefit from PrEP. This is particularly important, given that certain population sub-groups (men who have sex with men, transgender people, and heterosexual women in communities with high HIV prevalence, i.e. Black and Latina women) are particularly at risk in the U.S. The comments also note that consideration should be given to a recommendation for persons that self-identify to their providers as being at high risk of HIV infection, which may be particularly important in the context of population sub-groups.

With respect to adherence, our comments emphasize that adherence rates should only be systematically reviewed from studies powered and designed to test the effectiveness of PrEP, not studies designed to demonstrate the initial efficacy of PrEP. Efficacy studies may demonstrate substantially lower adherence because researchers and participants do not know if the drug will produce the intended outcome even with perfect adherence. Placebo-controlled trials, for instance, have been found to have lower rates of adherence than primary care-based service delivery. Adherence counseling and support interventions can also increase adherence.

Given that the USPSTF has the potential to greatly facilitate access to PrEP, the O’Neill Institute will continue to work with partners on subsequent public comments. For more information on this work, please check out our webpage.

Posted in National Healthcare; Tagged: , , , , , .


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