Dear Friends and HAIMUSIC/HAIMUSIQUE listeners

All of us in HAIMUSIC wish you and your family a Happy New Year 2010; peace, prosperity and happiness.

Last year, you made us the third most listened Haitian radio on the Internet; thank you for standing with us in the pursued of ways to help improve the Haitian communities' social, economic and political development throughout the world. Through our community services and panoply of broadcasts aiming to inform and educate our listeners, we have gathered foreign and Haitian listeners around the world and created initiatives to improve Haiti's wildlife habitat and restore our natural resources, strengthen the operation and administration of the "Collectivités Territoriales", provide historical analysis of Haitian's politics and public administrative structures, and assist in local development projects at Guillème (Torbeck), Les-Cayes and Beaumont, etc.

This year, we count on your stewardship to continue this initiative and hope that you will invite all your friends, family members and colleagues to participate in this project by contributing to one or more of our broadcasts, field research, community services, fundraising, etc. While we are improving our technical settings and services to the community, we exhort you to continue standing by us in order to extend our services to a broader audience and to become more effective to our target populations.


Once again, we thank you for all your help and looking forward to continue working with and for you in 2010.


Best Regards,



HAIMUSIQUE
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Tying Federally Funded Health Care to Doctors' Orders?

Macceau Médozile
November 15th, 2009
Special thanks to prof. Madeline Jacobs, CUNY (Brooklyn College)

The West Virginia Case

United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status (Schroeder, 2007), for the American health care system is very inefficient: high cost and poor outcomes. To address that health care issue, in 1965,United States Congress enacted Title 19 of the Social Security Act, under which, Medicare and Medicaid were created: one for the elderly (65 yrs. of age) or people of any age with kidney failure or long term disability, etc. and the other, for the “poor”. Managed by the states, Medicaid reimburses for health care services provided by hospitals and physicians to those who are unable to pay for their own medical expenses. It covers about 40% of the costs of childbirths and 60% of the costs of elderly individual health care. In 2002, The Kaiser Commission on Medicaid and the Uninsured reported that the Federal Medicaid expenditures were estimated at about $146 billion. In 2005, economists, physicians and politicians throughout the nation debated on the inefficiency of the health care system and proposed that patients be more involved in the promotion of their own health.

In 2006, the State of West Virginia required that Medicaid beneficiaries sign a Comprehensive Medicaid Redesign Proposal (CMRP) agreement, aiming to help the state to streamline the administration, tailor services to meet the needs of enrolled populations, coordinate care and provide members with opportunities and incentives to be responsible for maintaining their health and their family’s (Levine, p.260). The CMRP is supposed to be implemented through Healthy Awards Accounts (HRA) based upon a model called Consumer Directed Health (CDH) used mostly by the private sector. This model encourages health care beneficiaries to consume least expensive pharmaceutical drugs in order to help their insurance providers save money. The CMRP requires Medicaid beneficiaries to be constrained to their physicians’ expectations when it comes to addressing their unhealthy behaviors (smoking, using illegal drugs, drinking alcohol and being overweight), keeping their doctors’ appointments, annihilating their non-emergent use of emergency services and complying with “preferred drug list”. Those who sign this agreement are provided with enhanced benefits _ mental health counseling, long-term diabetes management, cardiac rehabilitation, prescription drugs, home health visit if needed and antismoking and nutrition classes (Levine, p. 258) _ but will lose them if they fail to sustain the State’s expectations. Beneficiaries who simply chose not to sign the agreement only receive the basic services required by the federal law. On the other hand, the plan raises fundamental issues of fairness, for the standard of behavior required of Medicaid participants are not required of patients with private insurance (Bishop, p. 267). When analyzing the social, economic and medical outfalls of this proposal many argue that the inability of Medicaid participants to meet the proposed standard is inherent to their socio-economic status (SES). The Medicaid population has an income below the national poverty benchmark, therefore, basic needs such as transportation (when it is not provided), healthy nutrition _ social and medical catalysts _ and
literacy can prevent the participants from keeping their doctor’s appointments and their bodyweight in proportion. This paper aims to support the idea of tying (federally) funded health care recipients to certain responsibilities towards their own health promotion.

Following a healthy lifestyle is likely to improve patients’ health status and reduce the amount of taxpayers’ money spent to cover Medicaid’s beneficiaries. When it comes to premature death, behavioral causes account for nearly 40.0% of all deaths in the country, followed by genetic predisposition (30%) and social circumstances (15%). In 2000, about 435,000 Americans (smokers) died up to 15 years earlier than non-smokers (Schroeder, 2007). The U.S. Center for Disease Control and Prevention (CDC) reported that from 2000-2004, Medicaid beneficiaries were accounted for about 30% of all smoking specific-mortality, while $35 million has been allocated yearly in educative programs targeting those specific lifestyles. Empirical studies indicated that smoking (cigarettes and illicit drugs) _ along with other unhealthy behaviors _ is correlated with low SES populations. However, since smoking is not a disease, federally funded health care participants (Medicaid, Medicare, VA Health Care program, etc.) _ idem for all other SES patients _ should be self committed to eradicate this costly and fatal habit. The Medicaid Patient’s Bill of Rights stipulates that patients/beneficiaries must take greater responsibility to maintain good health; this is the same goal that the West Virginia’s CMRP entailed to pursue. It is unfortunate that about 15.5 million smoking-related premature deaths (Shroeder, 2007) could be prevented if only federally funded health insurances rules (private and/or employers’ based heath care as well) along with state and federal regulations were more stringent.

In a study on national cost attributed to overweight and obesity, Finkeslstein et al (2003) reported that in 2002, $92.6 billion were spent in medical expenses in United States, from which, about $38.0 billion were covered by Medicaid and Medicare. The state-level estimated cost from 1998 to 2000 ranged from $87.0 million (Wyoming) to $3.5 million (New York). In 2004, Buescher et al conducted a study among enrolled Medicaid adolescents in North Carolina to examine
patterns of expenditure for medical care and the use of medical care services. The investigators reported that at-risk-for-overweight adolescents group had medical expenditures that were 33.0% higher than those of the normal-weight group. A significantly higher percentage of overweight adolescents had claims for diabetes, asthma and other respiratory conditions. The study concluded by affirming that overweight adolescents and those who are at-risk-for-overweight
had higher average Medicaid expenditures than did normal-weight adolescents. According to the U.S. Department of Health and Human Services (HHS), the percentage of overweight young people has more that triple since 1980. In addition to psychological and social issues of stigmatization, those adolescents are at far greater risks to developing cardiovascular diseases, type 2 diabetes and several other diseases that may likely contribute to reducing their length and
quality of lives (HHS, 2002 report).

On the other hand, Data from a cohort study on coronary heart disease and changes in diet and lifestyle in a population of 85,941 women (34-59 yrs. of age) suggest that a reduction in smoking, a change in diet (et al) can generate a decline in the incidence of coronary diseases.
For 14 years, Dr Hu et al (2009) documented 1,304 newly diagnose cases of coronary heart diseases and observed, over time, an overall decline in the incidence of myocardial infarction and other coronary diseases in those who adopted a change of comportment in their diet and other lifestyles. Many other studies have indicated a relationship between health status improvement and cessation of smoking cigarettes, dieting, exercising and suggest that lifestyle
changes can reduce health care cost in the U.S.

Improving, proportionally, the health status of the U.S. population is a challenge to all health care stakeholders. However, controlling the health indicators related to unhealthy behaviors should be the primary responsibility of all patients and everybody. Although the amount of federal dollars spent to provide health care services to the needy ones is disparately distributed, but all federally, employer-based, non-profit funded health care beneficiaries should be held accountable for improving their own health status. The State of West Virginia’s CMRP not only sought to reduce its spending but also wanted to promote patients’ self-responsibility by offering them medical incentives so they can meet and sustain the program’s expectations. It is obvious though that health status improvement is correlated with SES improvement. Thus, adopting a healthy lifestyle suggests that those families of three who are making $6,142 per year (in West Virginia) should be provided with more education and skills (along with transportation, more nutritive WIC food, among others) to sustain the CMRP’s requirements. Unhealthy behaviors are not immutable; the ban of cigarettes smoking in public buildings, restaurants and bars in many cities and states, proves how regulations can be used to change people’s lifestyles: the wearing of seat belt (Motor Vehicles) regulations of 1993 is a great example. All funded health care beneficiaries should be constrained to stop smoking cigarettes (and other illicit drugs), to reduce their alcohol consumption, exercise and control their BMI (as much as they can), check with their primary physicians prior to landing into an emergency room for “non-emergent” needs, etc. Improving the U.S. population entails also the enhancement of the workforce
productivity, “the boost of the national economy, the reduction of healthcare expenditures, and most importantly, the improvement of people’s live (Schroeder, 2007).



Levine, Carole. Taking Sides: Clashing Views on Bioethical Issues. 12th ed., McGraw Hill,2008. pp. 258-269

Schroeder, Steven. We Can Do Better – Improving the Health of the American People. The New England Journal of Medicine, 357;12. Sept. 2007

Finkelstein, EA; Fiebelkron, IC; Wang, G. National Medical Spending Attributable to Overweight and Obesity: How much and who’s Paying? Health Affairs 2003;W3;219-226

Buescher, Paul A; Whitmire, Timothy J., Plescia Marcus. Relationship Between Body Mass Index and Medical Care Expenditures for North Carolina Adolescents Enrolled in Medicaid in 2004. Preventing Chronic Disease 2008. vol. 5, No. 1. pp1 1-9.

Bishop, Gene; Brodkey, Amy C. Personal Responsibility and Physician Responsibility – West Virginia’s Medicaid Plan. NEJM;355;8;756-758 Aug. 2006

United States Department of Health and Human Services, Obesity and Adolescents. Report 2002

The Kaiser Commission on Medicaid and the Uninsured. The Medicaid Resource Book, July 2002

The Center for Disease and Prevention (CDC). MMWR, Nov 10, 2006. 55(44);1194-1197

Hu, Frank; Stampfer, Meir; Manson, JoAnn; Grodstein, Francine; Colditz, Graham; Speizer, Frank; Willet, Walter. Trends in the Incidence of Coronary Heart Disease and Changes in Diet and Lifestyle in Women. NEJM:343;8. Aug. 24, 2000