Friday, December 13, 2013

Tobacco: Symbol of Corrupt Trade Policy

The deadly tobacco industry increasingly deploys trade charges intended to bludgeon countries from Uruguay to Australia into abandoning policies that keep kids from getting addicted, and help smokers quit, as well documented in today's NY Times.

The U.S. Trade Representative should fix this problem during negotiations on the proposed 12-nation Trans Pacific Partnership (TPP).  But stalemates in U.S. trade policy are perpetuating this obvious injustice.

Trade ministers derive priority status within governments based largely in outdated beliefs that they will magically conjure prosperity by conspiring in secret, allegedly to eliminate trade barriers such as tariffs and quotas which in fact have long go been substantially reduced.  The predominant business of agreements like the TPP is actually reducing "technical barriers" to trade - that is, democratically adopted laws and regulations that protect the public's health, environment, labor standards, and financial transactions.

In the secretive, rarified world of trade negotiations, even when public health succeeds in getting a proposal to the negotiating table on an issue like tobacco, it is subject to be traded away at any moment by a trade minister who views it primarily as a bargaining chip for deals on more important concerns, like sugar, cars, or financial derivatives.

The Center for Policy Analysis on Trade and Health (CPATH) has systematically documented how tobacco industry trade challenges threaten public health's rights to implement tobacco control measures. Medical and public health leaders in the U.S. and worldwide have echoed the call to "carve out" tobacco from trade agreements.

Malaysia presented a carve-out proposal at TPP talks in August, The USTR has advanced two increasingly weak compromises. Legal analysis from Georgetown [R. Stumberg, Safeguards for Tobacco Control: Options for the TPPA.  America Journal of Law and Medicine, 39 (213); 382-441] has confirmed in irrefutable detail that compromises short of a "carve out" would be virtually ineffective.

Tobacco use is the leading preventable cause of death worldwide, claiming 6.3 million deaths a year, including 1,200 Americans daily, and draining almost $200 billion a year in U.S. health care costs and lost productivity. Tobacco is barely a blip in the U.S. economy, and less than a fraction of a percent of our exports.

But the tobacco industry has made it clear that it will oppose any restriction on its rights to continue to appropriate trade rules. They've bought a box seat to the hermetically sealed, secretive trade negotiations, and the solid complicity of the U.S. Chamber of Commerce.

Public health has no such advantages.  Interestingly, though, we have the truth.  And in this possibly unusual case, the truth is increasingly difficult to ignore.

Wednesday, November 20, 2013

Report Back: CPATH to USTR - U.S. Must Protect Public Health in the TPP

The U.S. Trade Representative gave new meaning to the phrase, "magical thinking" at a Nov. 18 talk in San Francisco. And new urgency to the demand for an honest debate on the economy and on the Trans Pacific Partnership (TPP).
Last week, Wikileaks released the most detailed report of the proposed trade agreement to date It reveals the full text of the controversial intellectual property chapter, that would govern fundamental rights including access to medicinesinternet freedom, and cigarette package warning labels. In addition, it shows which countries support which versions of the proposals.
The U.S. does not look good. The leaked documents delineate that the U.S. would allow corporations including Big Tobacco and Big Pharma to rake in enormous profits while exposing the public's health to continued havoc by challenging tobacco control regulations, extending patent and trademark rights that would raise the prices of medicines, and raise the cost and availability of health care through patenting surgical techniques, for example. Disturbing enough.
Scores of members of Congress had already signed letters denouncing these proposals, and pledging to block them. Public health and medical organizations, and entire nations, have urged the U.S. to curb these abuses.
But on November 18, United States Trade Representative Michael Froman and Agriculture Secretary Tom Vilsack engaged in a discussion at the Commonwealth Club of San Francisco, moderated by the Club's Greg Dalton. When Dalton specifically asked U.S.T.R. Froman to address concerns regarding the trade pact's limits on internet freedom and access to medicines, he got back the same happy talk the Administration has been babbling all along.
In a breath-taking effort to imagine that the entire population had lost the capacity for literacy, Froman asserted, "What we're trying to do with the TransPacific Partnership is open up markets in some of the fastest growing regions in the world, raising standards on labor, the environment, access to medicines, intellectual property rights, and create new disciplines for the 21st century global economy."
He went on to claim both that the TPP was the most transparent trade agreement ever negotiated, in view of the USTR's many consultations with every sector of American society, and that the American people would only fully understand how beneficial the TPP is once the negotiations are concluded and the public sees the final product.
Just prior to the public event, San Francisco Supervisor Eric Mar and Co-Directors of the Center for Policy Analysis on Trade and Health (CPATH), met briefly with Ambassador Froman, and urged him to protect public health and rein in Big Tobacco in the TPP trade negotiations.
Supervisor Mar presented USTR Froman with a letter expressing his deep concerns that the provisions of the recently leaked Intellectual Property Chapter of the TPP "may undermine the right and ability of local, state, and national governments of participating countries from exercising their domestic sovereignty in order to adopt or maintain measures to reduce tobacco use and to prevent the harm it causes to public health." The letter posed key questions on U.S. proposals related to intellectual property rights and the tobacco industry, and requested a written response on how U.S. proposals will ensure that the United States and other TPP nations will be able to fully implement and enforce strong tobacco control legislation.
CPATH Co-Directors Ellen R. Shaffer and Joe Brenner articulated the concerns of major U.S. medical and public health groups, which are calling on the U.S. to take a leadership role to protect the public's health from tobacco-related disease and death, and to carve-out tobacco from the TPP negotiations. They presented a binder of letters and statements from CPATH, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists, American Public Health Association, CA Health Officers Association, California Council of Local Health Officers, and the Public Health Institute, CA-Public Health Association-North, and Alameda County Public Health Commission.
During questions from the public, CPATH Co-Director Joe Brenner asked, "San Francisco and California have taken effective action to reduce tobacco-related disease and death. When California attempted to ban the carcinogen MTBE from gasoline to protect health for years ago, a Canadian company, which made a component, filed trade charges against the U.S. and sued for $970 million for lost profits under "investor-state" provisions in NAFTA. The U.S. is proposing to give corporations these same rights in the TPP, including to challenge local tobacco control regulations. Why?" USTR Froman responded that the U.S. has never lost a court challenge under these provisions, and that new TPP provisions are different. Wait 'til we see it.
"The ongoing efforts to usher through in secrecy a pact with nations representing 40% of the globe's gross domestic product is corroding our democracy," says Shaffer. "For example, an editorial in Bloomberg erroneously equated the secrecy of the TPP with the embattled but entirely transparent Obamacare health care reform program.
"To be clear: Trade negotiations have been a corporate-controlled subterranean process for decades. The Obama Administration didn't start this. But it has utterly abandoned the responsibility to change it. It is an anomaly in our democracy which we can no longer tolerate. The technical details matter, and we have a right to understand the fine print as well as the broad strokes. The United States must lead the way towards a 21st century trade agreement, that starts, proceeds and ends with a fully public debate."
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Saturday, November 9, 2013

NYT: Why Some People Can’t Keep Their Insurance Plans

Despite repeated assertions by President Obama that people who like their health insurance will be able to keep it under the new health care law, many people who bought insurance on their own — a small fraction of the insurance market — will have to buy new plans. Related Article »

Medicare, Medicaid,
military coverage
Share of people with
Individual market
10-15 million people
Policies must meet new standards ...
Beginning Jan. 1, new policies issued must cover a minimum share of health care expenses and offer 10 “essential health benefits”:
Outpatient care
Rehabilitative and habilitative
services and devices
Emergency room visits
Lab tests
Maternity and newborn care
Preventive services and
chronic disease care
Mental health and
substance use treatments
Pediatric services, including
dental and vision
Prescription drugs
... unless a plan is grandfathered in ...
If a policy was in effect when the law passed in March 2010 and has not been changed significantly, people already on the plan could remain on it, and the plan would not have to meet the new requirements.
... but many people will need to purchase a new plan because:
• Many plans do not currently meet the law’s standards for coverage.
• Most people in the individual market do not keep their policies for more than a year, so most would not be eligible to be grandfathered.
• Insurance companies cannot change grandfathered plans or sell them to new customers, so they have incentive to cancel the policies.
Some people will also move to Medicaid coverage.
More than one million low-income adults currently in the individual market will be newly eligible for Medicaid in 2014 because they live in a state that has decided to expand the program.
Why Rates Are Increasing for Some People
The total cost of policies will be higher on average ...
Many plans offered on the individual market will have more benefits and more consumer protections than they did before. The pools will also cost more for insurance companies since they cannot deny people with pre-existing conditions.
In the individual market,
on average, rates for group will:
... but people will be affected differently ...
SEX The law bans insurers from charging women higher premiums than men of the same age.
AGE The law bans insurers from charging older adults more than three times the amount they charge younger adults.
HEALTH The law bans insurers from charging people with health problems more.
... and many people will be eligible for government subsidies.
An estimated 48 percent of people on the individual market will be eligible for tax credits to reduce their costs, based on their income level.

Obamacare: Making Lemonade

Responding to:
J. F. Wharam and Others
N Engl J Med 369:1481, October 17, 2013

The authors point out the real and predictable failings of a market-based health care system: it costs too much (duh).  And they suggest more market-based reforms to fix the problems of unaffordably high deductibles and co-pays in the Obamacare health insurance exchanges (premiums could be lower too).  California is perfectly poised to leverage the situation by taking the obvious next step towards a single payer system (a goal for 2017): authorize the elected Insurance Commissioner to set the prices of the health insurance plans. The legislation's been introduced and almost passed several times.  The Exchanges have already whittled down the insurance plans to only a few left standing, and set compulsory enrollment, and standardized benefits. Chopping their rates and profits gets pretty close to the role health insurance plans already now play in Medicare, as third party administrators.  

Sunday, October 6, 2013

Ellen Shaffer in the Media

Dr Ellen Shaffer reacts to the United States Government being shutdown
Cameron Green speaks to Co-Director of the Centre for Policy Analysis Dr Ellen Shaffer
ABC NewsRadio Afternoons - Last updated 16:07 Duration 7:12
ABC Australia 9-30-13

Impact of the Shutdown! Economic and Healthcare

The government shutdown will be the topic of conversation from the economic impacts to how long it may last.  Christian Dorsey, of the Economic Policy Institute, will talk about how the shutdown effects the lives of real people (as opposed to politicians and the next election) and the politics behind it.  Dr. Ellen Shaffer, UCSF, will talk about how the Affordable Care Act (ACA) is being impacted, if at all, and how the ACA will impact the lives of millions of currently uninsured Americans. 

Thursday, February 14, 2013

Shaffer in AJPH on the Affordable Care Act: The Value of Systemic Disruption

AJPH: The ACA; Value of Systemic Disruption – Ellen R Shaffer

It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA), anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve.  Passage of the ACA broke the political logjam that long stymied national progress toward equitable, quality, universal, affordable health care. It extends coverage for the uninsured, who are disproportionately low income and people of color, curbs health insurance abuses, and initiates improvements in the quality of care.   However, challenges to affordability and cost control persist.
Public health advocates should mobilize for coverage for abortion care and for immigrants, encourage public-sector involvement in negotiating health care prices, and counter disinformation by opponents on the right.

Tables in the article summarize major changes in coverage, insurance company protections, and quality/affordability.

 (Am J Public Health. Published online ahead of print February 14, 2013: e1–e4. doi:10.2105/ AJPH.2012.301180