Physicians May Make a Difference in Concussion Surveillance

Physicians and other independent observers may help improve concussion surveillance during ice hockey and other athletic events, according to a new study. (Image: Christopher O Driscoll/

Physicians and other independent observers may help improve concussion surveillance during ice hockey and other athletic events, according to a new study. (Image: Christopher O Driscoll/

A small study of college ice hockey players in Canada in which physicians and other independent observers watched games from the stands and evaluated injured players indicates that college hockey players’ concussion rates there may have improved over the past 2 years but remain vastly underreported.

Appearing today in Neurosurgical Focus, a peer-reviewed online journal, the study followed up 20 men and 25 women who played ice hockey for college teams in Canada during the 2011-2012 season. All players underwent comprehensive preseason neuropsychological testing and magnetic resonance imaging (MRI) scans. At each game, a sports medicine physician and an independent observer watched the action from seats positioned higher than rink level to get a clear view of injuries. Continue reading

Spinal Infections Emerge as Latest Fallout From Exposure to Contaminated Steroid Injections

Spinal infections at the injection site are emerging as the latest concern for patients exposed to steroid injections contaminated with a fungus, Exserohilum rostratum. Image: CDC

About 2 months after the initial cases of fungal meningitis were traced back to injections of a contaminated steroid drug from a New England compounding pharmacy, new patients continue to be identified. The latest wave of patients are presenting with spinal infections, according to Melissa K. Schaefer, MD, of the US Centers for Disease Control and Prevention (CDC).

As of Monday, the CDC has received 510 reports of infection, including 36 deaths, from 19 states among patients exposed to injections of methylprednisone acetate from contaminated lots prepared at the New England Compounding Center (NECC) in Framingham, Mass. Schaefer, who spoke at a CDC briefing for clinicians on Tuesday, noted that two-thirds of the more than 90 cases reported since the beginning of November involve patients with spinal or paraspinal infections, including epidural abscess, phlegmon (inflammation of soft or connective tissue, caused by infection), discitis (infection of the disc space between vertebrae), vertebral osteomyelitis, or arachnoiditis (inflammation of one of the membranes that protects the nerves of the spinal cord) at or near the site of injection. These infections have been seen in both patients with fungal meningitis and those without, according to a CDC alert. Continue reading

JAMA Forum: Key Decisions Loom for States About the Health Care Law

Larry Levitt, MPP

Larry Levitt, MPP

Much attention has been focused recently on whether states will set up health insurance exchanges under the Affordable Care Act (ACA) as a December 14 “go” or “no-go” deadline looms.

Exchanges are, to be sure, a key element of implementing the ACA. Starting in 2014, individuals and small businesses will be able to go to an exchange—virtually, in most cases, much like an online shopping site—compare benefits and premiums across health insurers, and enroll in the plan of their choosing. Insurers will be required to accept everyone who applies, regardless of whether they have a preexisting health condition. Premiums will not vary by health status as they do today, and the amount they vary by age will be limited. Federal tax credits will also be available to low- and middle-income individuals to make premiums more affordable. The exchange will determine an individual’s eligibility for these tax credits, as well as for Medicaid.

The Congressional Budget Office projects that by 2016, 23 million people will be buying health insurance through exchanges, with 19 million of them receiving tax credits to cover part of the cost.

Yet as of last week, Kaiser Family Foundation tabulations show that 16 states have decided not to build an exchange, while 11 states are still pondering the decision.

So it is possible that in huge swaths of the country, people will be without exchanges and the consumer protections that come with them, right? Not exactly. The law anticipated this possibility and provided a fallback. If a state does not set up an exchange, the federal government will instead run the exchange in that state. There is also the potential for a “partnership” exchange, where the federal government and the state share responsibility, and at last count 6 states were planning to go that route.

There are strong arguments that state-run exchanges are preferable to federal ones. States have historically licensed and regulated health insurance companies, so the oversight and negotiating role exchanges will play fit naturally at the state level. Also, outreach to consumers will be key, and states are likely to do that more effectively than the federal government. But whether an exchange is federally operated, state-operated, or some hybrid, the same rules will apply, so the consumer protections and subsidies will be the same.

The story is quite different regarding the other big decision states now face: whether to expand Medicaid. The ACA originally required that all states operating Medicaid programs (which all now do) would be required to expand Medicaid to everyone with income below 138% of the poverty level (currently $15 415 for a single person and $31 809 for a family of 4). Unlike with exchanges, the law did not provide a federal fallback if states refused to expand coverage because none was thought to be necessary.

However, the Supreme Court ruling in June altered the parameters of that decision dramatically when it said that states could not be penalized for refusing to implement the Medicaid expansion, in effect making it voluntary.

Still, although states are not required to participate, the expansion offers a substantial enticement: the federal government will pay 100% of the cost for the first 3 years, phasing down over time to 90%. States choosing to go ahead will be able to expand coverage to low-income residents for pennies on the dollar, leveraging federal dollars that will save state and local government funds that now go to pay for uncompensated care.

Because states will ultimately have to foot some of the bill if they expand Medicaid coverage, many are still hesitant to do so, out of fiscal or ideological concerns. There is no formal tally yet of states’ decisions about expanding Medicaid, but according to one estimate, as of November 19, 8 states were planning not to take up the expansion, 5 were leaning in that direction, and 21 were still undecided.

The consequences of this decision are significant, not just in fiscal terms but for people, as well. The result in a state deciding not to expand Medicaid would be an odd patchwork of insurance coverage. Many people with incomes below the poverty level—particularly adults without children, but many parents, too—would be ineligible for any assistance, as they are today under Medicaid’s current eligibility rules. At the same time, people who are uninsured but with incomes above the poverty level would be eligible for tax credits to help them afford insurance purchased through exchanges.

According to a study just released by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, researchers at the Urban Institute estimate that 10 million more poor people would be uninsured if no state took up the Medicaid expansion. That includes 1.2 million in Texas (which does not intend to implement the Medicaid expansion) and 869 000 in Florida (where Gov Rick Scott previously said he was opposed to implementation of all elements of the ACA—although he more recently indicated some openness, at least about health insurance exchanges).

Health insurance exchanges have, in many ways, become synonymous with “Obamacare” in state-level debates. The judgments of governors and state legislatures about whether to go ahead with them are indeed significant ones, in both practical and political terms. The option of federally run exchanges in states that refuse to create them on their own, however, provides a fallback for individuals and small businesses. But without such a fallback for the Medicaid expansion, the consequences for consumers, hospitals, and health professionals in states that decide not to participate are in fact far greater.


About the author: Larry Levitt, MPP, is Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation. Among other duties, he is Co-Executive Director of the Kaiser Initiative on Health Reform and Private Insurance.

About The JAMA Forum:  JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Protection From Pertussis Vaccine Wanes Over Time

Lara K. Misegades, PhD, MS, of the CDC’s meningitis and vaccine preventable diseases branch, and colleagues found that the effectiveness of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine declines over time, leaving children more vulnerable to pertussis. Image: James Gathany/CDC

Children become more vulnerable to infection with pertussis the more time passes after their last dose of the acellular pertussis vaccine, according to a study published in JAMA today.

After a record-breaking epidemic of pertussis in California in 2010, many public health officials became curious why so many 7- to 10-year-olds became ill, even though most had been vaccinated with the diphtheria, tetanus, and acellular pertussis vaccine (DTaP). The acellular vaccine was added to the recommended vaccination schedule in the United States in 1997, replacing the whole-cell pertussis vaccine, because the acellular version was associated with fewer adverse effects. But some recent evidence suggests that the newer, safer vaccine may not protect as well as the older version.

To probe whether protection from the 5-injection DTaP series may wane over time, researchers from the US Centers for Disease Control and Prevention and the California Department of Public Health analyzed data on 682 pertussis cases among children aged 4 to 10 years and a control group of 2016 children without pertussis. The researchers found that 7.8% of the cases and 0.9% of the controls had not received any of doses in the DTaP series. Cases were less likely than controls to have received their final dose of pertussis vaccine in the past year; only 2.8% of cases had received a dose within this time period compared with 17.6% of controls. The more time that had elapsed since a child had received a DTaP dose, the likelier he or she had contracted pertussis. For example, 33.9% of cases and 14.3% of controls had received their last vaccination at least 5 years prior to the study. Continue reading

Too Much or Too Little Physical Activity May Increase Knee Osteoarthritis Risk

A new study found that both rigorous physical activity and sedentary behavior are associated with early damage to cartilage in the knee that might progress to knee osteoarthritis. (Image: Ken Tannenbaum/

Chicago—Numerous studies have demonstrated the benefits of physical activity in reducing the risk of a variety of health problems, including heart disease and Alzheimer disease. Now, new findings suggest that for at least 1 condition, osteoarthritis of the knee, both sedentary living and rigorous exercise are linked with early degenerative changes in knee cartilage that might lead to osteoarthritis.

The finding was presented during a press conference today at the Radiological Society of North America’s Scientific Assembly and Annual Meeting.

The researchers, from the University of California, San Francisco (UCSF), analyzed magnetic resonance imaging (MRI) studies of 205 patients, aged 45 to 60 years, who were enrolled in the Osteoarthritis Initiative, a National Institutes of Health study on the prevention and treatment of knee osteoarthritis. The study participants were followed up for 4 years and were periodically assessed with MRI-based T2 relaxation times to track the evolution of early degenerative cartilage changes. (There is increased water movement in damaged cartilage, which presents as increased T2 relaxation time.) Using information from a questionnaire given to participants, the researchers divided the enrollees into 3 groups based on their level of physical activity. Continue reading

JAMA Forum: Women’s Health, Contraception, and the Freedom of Religion

Lawrence Gostin, JD

Lawrence Gostin, JD

Although the 2012 Presidential election settled many issues related to the health care law, there is one that will linger well into President Obama’s second term: contraception and religious freedom. The Affordable Care Act (ACA) requires employers to provide women with cost-free coverage for preventive care and screenings. The Obama administration interprets this provision to require coverage of sterilization and the full range of contraceptive methods approved by the US Food and Drug Administration, including emergency contraception—an interpretation that has been under attack.

When the Catholic Church and other religious groups claimed this rule violates their freedom of religion, the Obama administration agreed to grant a “safe harbor” exemption to church-affiliated hospitals, schools, and other religiously affiliated employers. In such cases, contraceptive coverage would be offered to women directly by the employer’s insurance company, “with no role for religious employers who oppose contraception,” the administration said.

Despite this compromise position, more than 35 lawsuits have been filed challenging the rule as a violation of the Religious Freedom Restoration Act of 1993, which prohibits the federal government from “substantially burdening a person’s exercise of religion” unless it advances a compelling government interest and is the “least restrictive” means of achieving it. The lawsuits fall into 2 categories: those filed by religious and nonprofit groups that qualify for the temporary “safe harbor” and those filed by private for-profit employers with no religious affiliation.

In October, a federal district court in St Louis dismissed a lawsuit filed by a secular mining company owned by a Catholic businessman, which claimed that the ACA rule forced it to cover contraception in violation of its religious freedom. In its ruling, however, the court said that such coverage represented only a trivial and remote imposition on the employer’s religious freedom. The 1993 Act, the court said, “does not protect against the slight burden on religious exercise that arises when one’s money circuitously flows to support the conduct of other free-exercise-wielding individuals who hold religious beliefs that differ from one’s own.”

Despite this rebuke, it looks like the legal challenge will receive serious judicial attention. Two district courts have granted preliminary injunctions to block the contraception rule as applied to secular companies. Although these courts did not indicate which way they might adjudicate on the merits, they said that even a minor impairment to religious liberty could cause “irreparable harm” on private companies. The Justice Department announced that it would not object to the case being heard by the Fourth Circuit Court of Appeals based in Richmond, Va.

The multiple challenges to the contraception rule, moreover, almost ensure the issue will come before the Supreme Court. Like the individual mandate case recently decided by the Supreme Court, the conservative strategy of forcing a split among the circuit courts could signal that the case will come before the highest court by 2014.

What are the merits of the claim that the contraception rule does violate religious freedom? To begin with, secular employers are just that, not religiously affiliated. They are providing a benefit (health insurance) to employees for which they receive handsome tax privileges from the government. A requirement to cover certain services neither prevents employers from practicing their religion nor does the negligible financial contribution towards women’s health coverage significantly burden the employer’s freedoms. Suppose, for example, a secular employer objected on religious grounds to covering a blood transfusion or other life-saving treatment? Would it be permissible for the employer to refuse to cover that service? If so, it would undermine the major purpose of health insurance.

Even if employers could justifiably claim that paying for contraception coverage did violate their constitutional freedoms, it would need to be balanced against the women’s freedom to have control over their own bodies and reproductive health. By refusing to cover contraception, employers are, in effect, imposing their religious beliefs on their female employees. The Justice Department’s position in these cases is that the federal government has a “compelling” interest in mandating contraception coverage: to improve the health of women and children and to promote greater gender equity. Women’s health needs are different from men’s, and many women may not be able to pay for contraception services. No such restriction is posed on men. Contraception coverage, moreover, enables some women to pursue their careers and serve productively in the workforce.

The question for the courts, and for the body politic, is whether a purely secular employer (say, a hospital, public school, or car company) can impose its will on female employees who are seeking to exercise their fundamental reproductive freedoms. That is a question with which the Supreme Court will likely grapple. But the Court will also likely have to decide the challenges of truly religious organizations, which claim that forcing their insurers to cover contraception still encroaches on their religious freedom. Even though the funds flow from insurers, could church-affiliated entities (eg, Catholic universities) successfully claim that there remains a fundamental violation of their rights?

We all may have thought that the Presidential election and Supreme Court case on the individual purchase mandate settled most aspects of the ACA. But the battles will certainly continue—both politically and judicially.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights.

About The JAMA Forum:  JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Access to Online Medical Records May Increase Use of Medical Services

Ted E. Palen, MD, PhD, MSPH, and colleagues from Kaiser Permanente’s Institute for Health Research in Denver found that patients with online access to their medical records used more health care services than those without access. Image: Kaiser Permanente

Patients with online access to their medical records used more health care services than did patients without online access, found a study published in JAMA today.

Electronic medical records and other new technologies have been proposed as tools to help improve the efficient delivery of medical care. So far, however, studies have had mixed findings, particularly with regard to whether these technologies reduce costs or use of health care services.

Kaiser Permanente Colorado, which provides health care services to more than 535 000 members in the state, has had an integrated electronic medical records system in place since 2004 and added an online portal called MyHealthManager in 2006 that allows patients to view their own medical records. To probe the effect of using the portal on patients’ use of health care services, scientists from Kaiser Permanente’s Institute for Health Research in Denver conducted a retrospective cohort study of Kaiser members who used the portal and a matched group of members who didn’t. Compared with Kaiser members who did not use the portal, those who did increased their use of a number of health care services, including office visits per year (an additional 0.7 visits per member per year, on average), telephone consultations (an additional 0.3 telephone consultations per member per year), visits to after-hours clinics (an additional 18.7 visits per 1000 members per year), emergency department visits (an additional 11.2 per 1000 members per year), and hospitalizations (an additional 19.9 per 1000 members per year). Continue reading