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: , , , , , .


The fight against hidden suffering: El Salvador to decriminalize abortion

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This post was written by Andrés Constantin. Andrés is an Adjunct Professor of Law at Universidad Torcuato Di Tella. Any questions or comments can be directed to aconstantin@utdt.edu. 

The opportunity has presented and it is time to seize it

The ruling party in El Salvador, Frente Farabundo Martí para la Liberación Nacional (FMLN) has proposed a law decriminalizing abortion in cases where the mother’s life is in danger or where the pregnancy is the result of rape to the Parliament.

It has been almost two decades since El Salvador criminalized abortion in all circumstances, despite the global commitment at the International Conference on Population and Development to prevent unsafe abortion. The criminalization of abortion forces women and girls to resort to unsafe abortions to save their own lives. Consequently, since 1998, women have been prosecuted and convicted on charges of induced abortion with sentences of up to 40 years imprisonment.

The health and human rights impact of restrictive abortion laws is devastating on women’s and girls’ life, leaving them at risk of preventable maternal deaths. Evidence shows that between 8% to 18% of maternal deaths worldwide are due to unsafe abortion. Indeed, the World Health Organization has noted that maternal mortality increases in countries that criminalize abortion. In a 2012 report on maternal mortality, the UN Human Rights Council noted that “[i]f abortion laws are overly restrictive, responses by providers, police and other actors can discourage care-seeking behavior,” leading women to choose between prison or death.

In this post, due to words constraints, I will just focus on the impact of criminalization of abortion on women’s right to life.

Decriminalization of abortion is necessary for the respect of the women’s right to life

El Salvador has ratified a number of human rights instruments, thus undertaking a legal obligation to protect and guarantee human and women’s rights, in particular. Moreover, the Salvadorian Constitution provides for the protection of the right to life, liberty and health, and further considers international treaties as laws of the country.

The right to life has been recognized as part of customary international law and is provided in several international and regional human rights treaties. In that sense, article 6 (1) of the International Covenant on Civil and Political Rights (ICCPR) provides that: “Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life.” In 2011, the Special Rapporteur on violence against women stated that the total ban on abortion in El Salvador puts women’s and girls’ lives at risk, constituting a violation of the right to life.

Whereas some opponents of abortion have resorted to Article 6(1) in order to argue that the right to life includes the fetus, and consequently abortions violate this right by ending the life of a fetus, it must be noted first that it is generally recognized that international human rights conventions are not applicable before birth of a human being, and second that during the drafting of the ICCPR, a set of proposals protecting the right to life from the moment of conception were rejected and it was understood that Article 6(1) of the Covenant stipulates that the right to life is inherent to the “human being” understood as the person that is born

Likewise, the CEDAW Committee, the body that monitors compliance with the Convention on the Elimination of All forms of Discrimination against Women (CEDAW), has stated that “unsafe abortion is a leading cause of maternal mortality and morbidity. As such, States parties should legalize abortion at least in cases of rape, incest, threats to the life and/or health of the mother, or severe fetal impairment, as well as provide women with access to quality post-abortion care, especially in cases of complications resulting from unsafe abortions. States parties should also remove punitive measures for women who undergo abortion.”

Similarly, the Committee on the Rights of the Child, which monitors the implementation of the Convention on the Rights of the Child, has urged States to “decriminalize abortion, ensure that girls have access to safe abortion, review legislation with a view to guaranteeing the best interests of pregnant adolescents, and ensure that their views are always heard and respected in abortion decisions.”

Moreover, the Committee on Economic, Social and Cultural Rights, which monitors compliance with the International Covenant on Economic, Social and Cultural Rights (ICESCR) in its General Comment No. 22 (2016) on the right to sexual and reproductive health, noted that denial of abortion often leads to maternal mortality or morbidity, which in turn constitutes a violation of the right to life or security and expressed its deep concern regarding the general prohibition of abortion with no exceptions.

Additionally, the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health noted that an “absolute prohibition [of abortion] under criminal law deprives women of access to what, in some cases, is a life-saving procedure” and recommended that states decriminalize abortion.

At this point, we should recognize that it is true that the American Convention on Human Rights provides the right to life from the moment of conception. However, Article 4 has been interpreted by both the Inter-American Commission on Human Rights and the Inter-American Court of Human Rights. The Commission, in 1981, found that the Convention’s founders “left open the possibility that states parties… could include in their domestic legislation ‘the most diverse cases of abortion’.” For its part, the Court stated that “it can be concluded from the words ‘in general’ that the protection of the right to life under this provision is not absolute, but rather gradual and incremental according to its development, since it is not an absolute and unconditional obligation, but entails understanding that exceptions to the general rule are admissible.”

Article 144 of El Salvador’s Constitution provides that in cases of conflict between domestic and international law, the latter should prevail. The Salvadorian Law prohibiting abortion in all circumstances clearly violates both El Salvador’s domestic and international obligations to protect women’s right to life. It is time for El Salvador to pay close attention to article 144 of its own Constitution and meet its international legal obligations.

Photo 2 source: pinterest.com

Posted in Human Rights;


Solidarity in Our Diversity

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If you were in New York City and its environs in the weeks and months after September 11, 2001, as I was – or, I expect, just about anywhere in the United States – you will recall the American flags in the storefront windows, outside homes, everywhere really. Those banners of solidarity reminded us, as one song of the time had it, we were all Americans. It was a time of solidarity in our unity, in our oneness. It was time of our national motto, e pluribus unum – out of many, one – with an emphasis on the unum.

I was reminded of this not long ago when I saw another window display in New York, at a synagogue in midtown Manhattan. It spoke of another kind of solidarity. “Our Diversity Is Our Strength,” read one sign. “Gay and Jewish Here!” proclaimed another. “Jews Support Our Muslims Neighbors,” affirmed a third. This was solidarity for modern times: solidarity in our diversity.

This is the solidarity of peoples who will not be divided. It a type of solidarity the global health movement knows well. Think of “I am HIV positive” t-shirts, worn by people living with HIV/AIDS — and by people without HIV, standing in solidarity.

And it is the type of solidarity we need now, to counter policies and rhetoric in the United States that would divide us, and further marginalize the marginalized. And what a toll these policies are taking. Research a few years ago revealed that “in families with one or more undocumented parents, the threat of detention and deportation is harming the mental and physical health of their children.” These effects included being twice as likely as other children not to have access to medical care and high rates of symptoms consistent with post-traumatic stress disorder. How much worse all this must be now, with no undocumented immigrant feeling safe from the threat of deportation. Another study reported similar findings and others, such the high likelihood that children of an undocumented parent who has been deported or detained will have insufficient food. This second study also found that partners of undocumented immigrants who have been deported have a lower income that is associated with a shortened lifespan.

Immigrants with legal documents, particularly Latinos, in California and elsewhere are canceling or not applying for the Supplemental Nutrition Assistance Program despite qualifying. They fear that legally present immigrants who access public assistance programs are next up for deportation, or that using public assistance programs will reduce their chances of becoming citizens. And they are reacting to the general atmosphere of fear from raids by the Immigration and Customs Enforcement agency. Health consequences of food insecurity include “increased rates of depression, diabetes and other chronic illnesses, and mental and behavioral problems in children.”

Like the signs in the New York synagogue, there are things we can all do, from speaking out and political activism to visible displays of solidarity, like posting our own signs, or waving flags proclaiming our oneness (rainbow flags, flags celebrating our diversity [in Spanish]), or wearing t-shirts of solidarity (how about taking a page from the HIV movement: “I am an undocumented immigrant, and America is my home”), to take a few possibilities.

There are also things that those of us in the health sphere can do. Along with speaking out against policies that harm people’s health – a failing of the obligation to respect the right to health, among other rights – and always ourselves being respectful towards all people, we can promote health policies and tools that reflect unity in our diversity. National health equity strategies could lead to comprehensive strategies to advance health equity, addressing each marginalized population and covering not only the health sector, but also all other spheres of life that are part of the social determinants of health. Regular use of health impact assessments – even where now rarely used, such as for immigration policies – would at the least make transparent the health harms of divisive policies, and may go a step further in insisting on a different approach. Globally, a Framework Convention on Global Health could embed approaches such as these into international law, and help create the spaces where those who now face disparagement and discrimination can make their voices heard.

We are one, and we are many. That is our strength. If we let the tempest of our time toss aside some of us, we let today’s storm toss us all into the sea of inhumanity. And that is why, if we are to stand for humanity, we will stand for each other.

Posted in Global Health, Human Rights, National Healthcare; Tagged: , , , , , , , , .


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