A Deeply Divided Supreme Court Hears Argument Over ACA’s Contraceptive Coverage Requirement

Written by: Tina Batra Hershey, JD, MPH, Health Policy and Management
Copy editors: Linda S. Duchak, EdM, MCHES, Associate Director, and Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center

US Supreme Court Building

Once again, the Affordable Care Act (ACA) came under fire before the Supreme Court on March 25, 2014.  Nearly two years ago, the high court heard extensive arguments regarding whether the landmark health reform law’s individual mandate and expansion of Medicaid were constitutional.  This time, the Supreme Court focused on the ACA’s requirement that for-profit employers with 50 or more employees offer such employees coverage for contraceptives.

Under the ACA, new private plans must provide coverage for a broad range of preventive services, including all methods of contraception approved by the Food and Drug Administration.  Houses of worship are exempt from the requirement.  The Obama administration also offered an “accommodation” for religiously affiliated nonprofits, such as church-run hospitals, parochial schools and charities.

Two for-profit secular companies brought suit, claiming that the contraceptive coverage requirement violated the tenets of their faiths.  Hobby Lobby, operated by the Green family who are Protestant, and Conestoga Wood Specialties, owned by the Hahn family who are Mennonites, filed separate suits that were then consolidated for review by the Supreme Court.  Hobby Lobby objects to Plan B and Ella (emergency contraceptives) as well as IUDs, claiming these types of contraception are abortifacients.  Conestoga Wood Specialties objects to Plan B and Ella on the same grounds. 

The case is considered to be one of the most important decisions of this Supreme Court term.  At issue is a question that has not been answered by the Court in previous decisions: Can a corporation exercise religion and thereby be entitled to protection under the Constitution and the Religious Freedom Restoration Act of 1993 (RFRA)?  Under RFRA, the government is prohibited from imposing a substantial burden on a person’s exercise of religion unless there is a compelling government interest and the means to achieve the interest are the least restrictive and most narrowly tailored.

The Court appeared deeply divided along ideological lines at oral argument.  As is frequently the case, Justice Kennedy seems to hold the key vote in the decision; however, it is unclear from his questions which way he will vote.  Although he expressed concern about the effect on employees when a religious employer denies contraceptive coverage, he was also troubled that a for-profit corporation could be forced in principle to pay for abortions if denied protection under RFRA.

There is some speculation among legal scholars that Chief Justice Roberts may be looking for a narrow ruling in favor of Hobby Lobby and Conestoga Wood Specialties that would apply only to closely held corporations, and not publicly traded companies.  Only time will tell, as the Court is expected to issue its ruling in June 2014.

Distilled Wisdom from the PAPHTC Grant Writing Class

Map of the Foundation Center's
Funding Information Network

For a number of years I have team-taught a grant writing class sponsored by PAPHTC as well as classes on how to find grant funding opportunities for audiences at the University of Pittsburgh and around the state of Pennsylvania. As a librarian and public health informationist, I usually teach the sections on how to find funding and evaluation of the funded activities. My colleague Pat Murphy, with her years of experience in non-profit management and grant writing teaches the rest.

Here are a few of the most important bits of information distilled from those classes:

• Rather than reacting to funding opportunities that pop up, have a plan. What do you want to accomplish as a researcher, an institution, a nonprofit organization? Seek funding that supports those goals.
• Don’t assume that you will get all the funding you need for a project from one source.
• The role of a grant proposal is to answer the funder’s questions. Don’t stray from that purpose, you will lose them.
• Follow the directions precisely. If the directions aren’t clear, or contradict themselves, contact the funder and get clarification. You don’t want them to ignore your proposal because you used the wrong size font.
• Become familiar with who funds work similar to yours. Include state and federal government, foundations, public charities, community foundations, and corporate giving programs in the types of funders you evaluate. For a list of resources to consider, see http://hsls.libguides.com/grants.
• Once you know the funding landscape, automate the receipt of new funding opportunities as much as possible by using tools such as email alerts, RSS feeds, and organizational newsletters.
• When writing your proposal, eliminate jargon. Don’t assume the funder knows your field. Have someone outside your field read the proposal and evaluate its clarity.
• Need help with grant writing? There are many fine books on the topic available at public libraries with Foundation Center cooperating collections and in academic libraries.

The Importance of Modeling Human Behavior on Health Decisions

Written by: Molly M. Eggleston, MPH, CPH, MCHES, MIDAS Project Coordinator, Public Health Dynamics Laboratory
Copy editors: Linda S. Duchak, EdM, MCHES, Associate Director, and Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center

People are neither perfectly informed nor perfectly rational. In epidemics, individuals do not always make logical health decisions to protect themselves and others. Realistic modeling of human behavior in the context of infectious disease allows public health practitioners to prepare for likely reactions to and spread of contagion.

Human behavior can affect the course of an epidemic through several mechanisms. Vaccine acceptance, work absenteeism, adoption of protective measures, isolation, and compliance with containment strategies and hygiene advice are among a wide range of personal health choices that influence epidemic dynamics.

Modeling simplifies real systems, such as waves of an epidemic, into a representation using a computer program. A model allows researchers and practitioners to test interventions that often cannot be tried on a real population.¹ Developing realistic models of individual behavior can help forecast epidemic processes and better inform preparedness policy options. For example, a simulation of behavior of a population with emotions, attitudes, and behaviors can help inform risk communication campaigns during emerging epidemics. An understanding of individual’s compliance with government directives can assess the effect of various interventions.

Computational models of infectious disease hold great potential for studying the interactions between epidemic dynamics and efforts to reduce the impact. These efforts, known as mitigation strategies can include vaccination, anti-viral drugs, social distancing, and school closure policies.

Modeling people’s health behavior is a tool with value for many public health professionals. It can determine which course of action is likely to produce the desired health behavior in a population. Modeling human behavior is a strategic tool for planning for infectious diseases, as well as other health risks.

Citation: 1. Agent-Based and Individual-Based Modeling: A practical introduction, Steven F Railsback and Volker Grimm, Princeton University Press, 2012

ACA Implementation: Welcome to the Marketplace

Written by: Jennifer Kolker, MPH, Co-Principal Investigator, Pennsylvania Public Health Training Center
Copy editor: Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center

On October 1, 2013, enrollment began for the Marketplaces under the Affordable Care Act (ACA) for coverage beginning on January 1, 2014. Signed into law in 2010, the ACA makes critical changes to health insurance in the United States. Some of the ACA changes (extending health insurance coverage of children until age 26 on parents’ insurance plans, for example) took effect in 2010. In January 2014, the most important changes go into effect.

A key component of the ACA is to increase the accessibility of health insurance for all Americans. To do this, the Health Insurance Marketplaces were established. The Marketplace in each state is made up of private health insurance plans that must cover a basic set of benefits, including preventative care (such as screenings and check-ups), other doctor visits, prescriptions, hospitalization, family planning and maternity care. It provides people with different plan options and costs. Approximately half of the states are operating their own Marketplace; the federal government is operating the Marketplace in the 26 states that opted not to create their own.

People who purchase insurance through the marketplace may be eligible for tax credits or a cost-sharing reduction, depending upon their income. Income also determines how much people have to pay for copays, co-insurance and deductibles. In some states people whose annual incomes are below 138% of the Federal Poverty Level ($15,856) may be eligible for premium-free coverage through Medicaid. People who can afford to purchase insurance may face a penalty fee if they decide not to buy it.

Pennsylvania has a Poor National Standing for Infant Mortality

Written by: Linda S. Duchak, EdM, MCHES, Associate Director, Pennsylvania Public Health Training Center
Copy editor: Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center  

In the U.S., for every 1,000 babies born, about 6 die before age 1. In Pennsylvania, for every 1,000 babies born, about 7 die before they reach age 1 (2010). Only 11 states in the U.S. had higher rate of infant mortality than Pennsylvania.

Infant mortality is defined as the death of an infant before his or her first birthday. The infant mortality rate (IMR) measures this occurrence per 1,000 live births. In addition to being a key marker of maternal and child health, the IMR has been called the most sensitive indicator of overall societal health.

In the United States, substantial progress has been made over the last 50 years in reducing the IMR. Yet with an IMR of 6.05 in 2011, the U.S. still has a relatively poor global standing. In 2010, the United States ranked 32nd among the 34 nations of the Organization for Economic Cooperation and Development in infant mortality with an overall IMR three times that of the countries with the lowest IMRs. The main reason that the U.S. IMR remains higher than that of European nations is because the U.S. has a high percentage of preterm births (12%).

Infant mortality is divided into two age periods: neonatal (birth–27 days) and post-neonatal (28–364 days). Approximately two-thirds of all infant deaths occur in the neonatal period and are caused by complications arising from low birth weight, birth defects, maternal health, preterm birth, complications of labor and delivery, and lack of access to appropriate care at the time of delivery. These problems can be linked to a complex group of conditions, including systematic inequality and lack of access to care.

Racial and geographic disparities remain persistent. Non-Hispanic black infants continue to die at nearly twice the rate of non-Hispanic white infants. Additionally, preterm-related causes of death among black infants occur at a rate three times greater than that of white infants. Geographically, Pennsylvania is included with a majority of southern states in the top quartile for infant mortality.

Further reduction of preventable infant deaths remains a challenge. Prevention of infant deaths should begin in the preconception period; opportunities are available to improve the health of mothers and thus avoid preventable infant deaths. The rates of preterm birth, including rates of late preterm birth (births between 34 and 36 weeks of gestation) and elective preterm delivery, need to be reduced. Opportunities exist to reduce the mortality rate among infants born preterm by addressing key risk factors such as maternal smoking, drinking, drug use, and chronic maternal health problems such as high blood pressure and diabetes. Many very low birth weight infants in the United States are not born in hospitals that have level III neonatal intensive-care units, which have been shown to significantly reduce mortality, indicating a need to increase access to high quality care.

Source: Morbidity and Mortality Weekly Report, August 9, 2013 / 62(31);625-628.

What is the Community Guide?

Written by: Linda S. Duchak, EdM, MCHES, Associate Director, Pennsylvania Public Health Training Center
Copy editors: Jennifer Kolker, MPH, Co-Principal Investigator, Pennsylvania Public Health Training Center; Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center 

www.thecommunityguide.org

• Building a public health program or developing policy?
• Considering research to close a gap in an area of need?

The Guide to Community Preventive Services (Community Guide), a collection of evidence-based findings and recommendations grounded in systematic reviews, is a useful tool to inform public health activities. Development of the guide is overseen by the Community Preventive Services Task Force (Task Force), renowned for its expertise in public health research, practice, prevention, and policy.

The Community Guide informs public health program and policy development as well as priorities for funding by providing descriptive information, estimated costs, and potential return on investment of community preventive services, programs, and policies that have been proven to be effective. Findings and recommendations focus on a broad range of topics, including adolescent health, asthma, birth defects, chronic disease, emergency preparedness, health equity, mental health, oral health, tobacco, violence, and worksite health promotion. Public health practitioners based at state and local health departments; board of health members, policymakers and legislators, health plans, hospital and their community advisory groups, educators and school administrators, city and county planners, social service agencies and organizations, and clinicians and community health centers use the Community Guide to address public health issues.

The findings and recommendations are based on evidence from systematic reviews found in the scientific literature. The reviews evaluate the evidence by:

• Analyzing all available evidence on what works to promote health and prevent disease, injury, and disability;
• Assessing the economic benefits of the interventions found to be effective; and
• Identifying where more evidence is needed.

The Community Guide is in the public domain and available online at www.thecommunityguide.org. Contact us at paphtc@pitt.edu (Western PA) or paphtc@drexel.edu (Eastern PA) if you need help developing public health programs or policies.

The Health Benefits of Engaging in Art and Civic Programs

Written by: Jason Flatt, PhD, MPH, Postdoctoral Fellow, University of Pittsburgh
Copy editor: Jennifer Kolker, MPH, Co-Principal Investigator, Pennsylvania Public Health Training Center; Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center

Art and civic programs, including visual, musical and other creative art programs, are something that can be appreciated and enjoyed throughout one’s lifespan. Who would have thought that being active in the arts would have health benefits? Several studies have shown that engaging in artistic endeavors can help to relieve negative symptoms associated with cancer, may promote positive mental health, relieve emotional distress and pain, help with minimizing the stigma associated with a debilitating disease and increase opportunities for enjoyable social interactions (Carnic & Chatterjee, 2013; Stuckey & Nobel, 2010). Research has also shown that participating in various types of art programs have benefits for older adults with dementia.

A recent project looked at the benefits of visiting an art museum and participating in art-making for older adults with dementia and their caregivers. Four focus groups were conducted with participants at the end of their visit to the Andy Warhol museum, and participants also completed a very short satisfaction survey. Participants reported that they thoroughly enjoyed the experience, especially because of the opportunities to socialize with others, be creative, and feel accepted by others. Caregivers also enjoyed the experience and mentioned how art provided them and their family member with an opportunity for mental stimulation and to reminisce about the past.

This highlights the need for a greater connection between public health and art and civic programs, such as museums and other recreational activities.  These programs have a lot of potential benefits for health, and there is a need for further exploration of the benefits of being engaged in art and civic programs.

Silk Screen Paintings by Persons with Dementia and their Caregivers

References:
Carnic, P.M., & Chatterjee, H.J. (2013). Museums and art galleries as partners for public health interventions. Perspectives in Public Health, 133(1), 66-71. doi: 10.1177/1757913912468523

Stuckey, H. L., & Nobel, J. (2010). The connection between art, healing, and public health: a review of current literature. American Journal of Public Health, 100(2), 254-263. doi: 10.2105/AJPH.2008.156497