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The Politics of Women's Health

National Health Care: Interview with Presidential Candidate Hillary Clinton

Judy Norsigian: So that would be one thing to mention, and the other would be the specific issues of expanding access to midwifery care.  A few of the chiefs of OB/GYN I know who are quite supportive of this quietly and privately tell me that the problem they have in some cases is with their colleagues, or in some cases with a system that doesn't support access to midwives.  And it's not that they need to be convinced that that isn't an incredibly sort of positive way and an optimal way to go. 

Laurie Rubiner: Well, you know, there's no question that we need to make better use of all of the range of healthcare professionals that we have in the system now.  That's not only a quality issue, that's a cost issue as well, and there are many, many women who prefer to use a midwife than to use a standard OBGYN, and we agree that we should try to find ways to accommodate that.

Kiki Zeldes: Byllye, do you want to take the next question?

Byllye Avery: OK, yes, I wanted to raise a question about Senator Clinton's plan, which sounds a lot like the one we have here in Massachusetts.  One of the problems that we're experiencing with mandated health insurance is that a large number of people who make too much money to be on the federal programs who are low income, many of them women, who are being penalized because they are unable to afford private insurance, to afford the fees of the available health insurance plans, and here everybody has to have insurance.  And I just want to know -- how does she plan to avoid the problem of that nationwide? 

Laurie Rubiner: Well, clearly you cannot have an individual mandate, it won't work if you don't make insurance both accessible and affordable for individuals.  You can't demand that people have something that they can't afford or don't have access to.  So her plan, probably the provision that's most on point is that we would have refundable tax credits so that they, nobody would be required to spend more than a certain percentage of their income on their healthcare premiums, and if the healthcare premiums cost more than that they would be subsidized by the federal government.

We also have a requirement that employers either continue to provide coverage to their employees if they're doing that now, or alternatively they would be required to contribute toward the cost of their employee's health insurance.

So, we clearly see this financial concern as key to making this individual mandate, and therefore universal coverage, successful, and we would ensure that people would not have to spend more than a set percentage of income to purchase the healthcare. 

Byllye Avery: And you would have that so that they could get that money up front?  Not that they would have to put it out because the people won't have the money to put out in the first place?

Laurie Rubiner: That's right.  It's refundable for people that don't have a tax at the end of the year, but it's also what we call advanceable which is the way the EITC is structured now. 

Kiki Zeldes:  Thank you.  Judy, do you want to take the next question?

Judy Norsigian: Sure.  This is something that a number of us on this call have worked on, and that's the question of misleading prescription drug advertising.  You all know that the specific brand name drugs highly advertised drive up costs and in many cases don't confer additional benefits.  Something like 10 of the top brand name drugs account for 40 percent of the DTC ad costs.  And of course there's a problem with exaggerating benefits and downplaying risk so that many consumers now are misinformed when they go into the doctor's offices.  And there have been plenty of studies by physicians -- Jerry Avorn here, Marcia Angell, John Abramson -- folks who've studied this who are really finding a lot of frustration on the part of physicians who have to defend the use of generics or point out that there aren't necessarily good data. 

In particular I point out the statin drug issue, because we've got this astounding situation where women who have no active heart disease or diabetes are being told to get on statins simply because of elevated cholesterol levels.  We actually don't have data to support that as a widespread practice, and we have an NIH funded study going on right now that Dr. Beatrice Golomb at UCSD is doing that's going to really give us more data here. 

We wanted you to address that issue, and I know you're familiar with the legislation that just passed, and then the other issue of fast tracking new drugs and what's happened as a result of some drugs getting on the market prematurely.  This specific measure that got sliced out of that recent bill that passed that Senator Kennedy supported, which would have had a two-year moratorium on DCT ads for newly approved drugs, is something that Senator Edwards recently endorsed himself.   I'm wondering if Senator Clinton is planning to do the same?

Laurie Rubiner: Well, let me take the first part of your question first, Judy.  Senator Clinton shares your concern about the impact of direct to consumer advertising on patients, and as part of the cost containment proposal that she outlined in May -- because I mentioned she put out a 10-point plan to reduce costs -- she announced this best practices institute that I referred to earlier that would build on comparative effectiveness research provision that she secured in the Medicare part D legislation that passed in 2003.  She has long been a proponent of evidence-based practice of medicine and she agrees with you that patients, providers, and payers would benefit from getting better information on what works in healthcare and how treatments compare to one another.  And you know, as you alluded to, in the past decade there's been an 80 percent growth in the number of drugs prescribed, 100 percent growth in new device patents, and 300 percent growth in teaching hospital procedures.

So the goal with our best practices institute is to get right at this issue that you just described which is to compare the effectiveness of alternative treatments such as pharmaceuticals, devices and surgical interventions.  One example is that information supplied by organizations like the Drug Effectiveness Review Project has been used in North Carolina to educate providers and improve quality of care, and it's saved the state an estimated $80 million in 2003, and we think similar research could facilitate the development of quality and outcomes measures.

On the specific direct to consumer advertising question that you raised, you know she's not a big fan of it.  Our country is the only one that treats prescription medications like a commodity, you know you advertise it like Coke or deodorant or a car.

Judy Norsigian: We and New Zealand, which is another one.  New Zealand's just like us. 

Laurie Rubiner: But, you know, the problem with banning direct to consumer advertising is that it raises freedom of speech questions and so she's been supportive of efforts to link increased and more effective consumer information being delivered as part of direct to consumer advertising, so that consumers who see these ads are more aware of the risks of the drugs, including the fact that newer drugs may have a less established safety record.

So, we're not quite where Senator Edwards is yet, but we're still trying to get at the same problem without raising the specter of the freedom of speech issue.

Judy Norsigian: Is she concerned that the two-year moratorium does invoke this sort of commercial freedom of speech problem, even when you have some good data that show that a very large proportion of the problems we've just had since DTC advertising and fast tracking of drugs has been instituted, that that's been a big piece of the problem so that a strong public health argument could be made for the need?

Laurie Rubiner: Well, it's untested in the courts whether or not that would prevail.  So I think we'd have to see how that came out in court.  I mean I think she let me put it this way, she agrees with the premise.  The question is the solution, we may have to get at the solution in a slightly different way, but I think she would like to get there.

Judy Norsigian: Well, you know, it's exciting that she wants to promote that information.  We've been watching the efforts of Cochrane Collaboration folks and university-based efforts and folks like Dartmouth and all the consumer groups like some of us represented here, and there are some valiant efforts and all of that generally is a drop in the bucket next to the $5 billion -plus a year spent on DTC ads.  And I don't think the government is going to spend even 20 percent of that on this effort.

Laurie Rubiner: Right.

Judy Norsigian: So one of the things we really want Senator Clinton to think creatively about is -- How do you offset that enormous impact of $5 billion-plus dollars a year in DTC ads?

Laurie Rubiner: Right, and it's a huge challenge so I appreciate that.

Judy Norsigian: OK, great.  We can go on.

Cindy Pearson: This is Cindy Pearson again.  Your central message about healthcare is one that I think makes sense to women in a very common sense sort of way -- many women think they're one job or one divorce away from no health insurance, and moving to a system that insures everybody they're not one job away, but also women that they're not one divorce away is going, it sounds great.

Now, most of us have the experience with our older relatives that Medicare is like that.  Medicare is there for virtually everybody over age 65; what was the Senator's thinking on why not to use the Medicare for all approach?

Laurie Rubiner: Well, it's pretty straightforward, Cindy.  She learned some lessons from the last time she tried to do this, and one of them was that the American public is not prepared to take on so much change at one time, particularly with something as delicate as their healthcare.  And the reality is that even if people have healthcare they hate, they still like the devil they know better than the devil they don't know, and we just felt very strongly that the public was not ready to take on this idea of moving to a completely new system.

One of the central premises of her plan is that if you have healthcare that you like, you can keep it and nothing will change.  And we felt that that was a very important message to people because it's one of the things that brought down her plan the last time around.   I think one of the things that shows true leadership is being able to learn from the mistakes you've made in the past and use those lessons in a constructive manner as you're moving forward to try to solve a problem.  And that was one of the central lessons that she learned.

I will say that in creating this sort of regional pool of plans that we model on the Federal Employee's Health Benefits plans that everybody would have access to the same kinds of plans that we, federal employees and Congress, have, a Medicare-like plan, a public plan would be one option.  So if people wanted to buy into a Medicare-type plan and they wanted to choose that, they would be able to, but we're not going to require everybody to go into a public plan because we just don't think that's what people want.

Cindy Pearson: OK. 

Byllye Avery: Well, I don't know if it's not what people want, but I think that we have other forces out there like the pharmaceutical and the insurance industry who definitely don't want it.  But people are not necessarily dissatisfied with their healthcare; they're dissatisfied with the system.

Laurie Rubiner: Right, I understand that.

Byllye Avery: The system is what people want changed and from what we hear, we've done town meetings all over the country and people are just really fed up and really want change.  So I hope that -- I kind of see it as an increment.  I know we can't all do it all at one time, but that we could at least take steps toward making sure that people have universal coverage so that people don't feel like if they lose their job or if they get really sick they can go into bankruptcy because they can't pay for it.  That's what people don't want to have.

Laurie Rubiner: Right, and this is a bold plan; it's not an incremental plan.  This is a plan to provide universal coverage to all Americans, so all 47 million people who are uninsured would have insurance under this plan.  It's just that in choosing the way that we insure people, our sense what that it was better to give people choices and let them keep the plan they have if they like the health insurance they have, and not force them to make a change if they're not ready, willing, or able to do that.

Cindy Pearson: OK, thanks Laurie.  

Kiki Zeldes:  Byllye, do you want to add, go to your next question?

Byllye Avery: I was really concerned about the environmental exposures, especially on the health of women and girls.  You know, we're seeing young girls going into puberty much younger and definitely a rise in breast cancer rates.  What plans does she have in addressing these environmental problems?

Laurie Rubiner: Well, as you probably know she sits on both the health committee and the environment committee, and this issue is right at the nexus of the two and she's had a long-standing interest in the ways in which the environment impacts healthcare.  She's introduced a couple of pieces of legislation -- one is the Coordinated Environmental Public Health Network Act, which would establish a national health tracking network to link information about environmental hazards with information about long-term chronic diseases. 

She's also been working to enact the Breast Cancer and Environmental Research Act.  She's been working very hard on this for many years, which would establish centers of excellence to research the links between pollution and the increased incidence of breast cancer.  And she strongly believe that with a better understanding of the ways in which environmental pollutants adversely impact human health that we'll be better able to implement measure to reduce exposures to toxins and the diseases that are linked to them.  So she shares your concern and has been looking at those issues closely.

Judy Norsigian: Laurie, can I ask if Devra Lee Davis has been advising the campaign at all?

Laurie Rubiner: You know she very well may be.  There's so many people now, I don't know who

Judy Norsigian: She used to be at NIH years ago, but she's been so prominent in this area, and she just put out a new book which is getting widely reviewed, and she was the keynote speaker at the Theresa Hines annual conference on women, health and the environment a few weeks ago.

Laurie Rubiner: Oh, well we will definitely, what is her name? 

Judy Norsigian: Devra Lee Davis. It's A Secret History of the War on Cancer.  I think it's a very big, thick book which is really the result of her 30 years-plus of incredible research and knowledge in this area. She's quite solid and quite knowledgeable. So it's someone that everybody who's running for president should be tapping in terms of the wealth of knowledge and her expertise in this area.

Laurie Rubiner: Great, well I will definitely take a look at her work and I'll make sure that the people on the campaign do as well.

End of Interview.

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Last revised: 11/29/07

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