Rewriting the competency rules for children: full recognition of the young person as rights-bearer

The rules regarding the competency of children to consent to medical treatment have traditionally focused on the child's understanding of the proposed treatment. This article argues that this focus has perpetuated an unjustifiably paternalistic attitude to the treatment of children that is inconsistent with obligations under the Convention on the Rights of the Child and the common law's preference for upholding personal autonomy. A new test is therefore proposed, abandoning the presumption of incompetency for adolescents and focusing on the understanding of the right to make medical decisions. The application of the proposed test is examined both from a general point of view and with regard to a particularly vulnerable group of young people: those suffering from mental illness.

Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts?

BACKGROUND

Most countries in the world have become States parties to one or more international human rights treaties, thus creating an obligation by the State to its people towards the realisation of the right to health, which includes access to essential medicines. But whether such access is enforceable in practice is unknown.

METHODS

We did a systematic search to identify completed court cases in low-income and middle-income countries in which individuals or groups had claimed access to essential medicines with reference to the right to health in general, or to specific human rights treaties ratified by the government. We identified and analysed 71 court cases from 12 countries in which access to essential medicines was claimed with reference to the right to health.

FINDINGS

In 59 cases, access to essential medicines as part of the fulfilment of the right to health could indeed be enforced through the courts, with most coming from Central and Latin America. Success was mainly linked to constitutional provisions on the right to health, supported by the human rights treaties. Other success factors were a link between the right to health and the right to life, and support by public-interest non-government organisations. Individual cases have generated entitlements across a population group, the right to health was not restricted by limitations in social security coverage, and government policies have successfully been challenged in court.

INTERPRETATION

Skilful litigation can help to ensure that governments fulfil their constitutional and international treaty obligations. Such assurances are especially valuable in countries in which social security systems are still being developed. However, redress mechanisms through the courts should be used as a last resort. Rather, policymakers should ensure that human rights standards guide their health policies and programmes from the outset.

Medicare program; revision of the deadline for submission of emergency graduate medical education affiliation agreements. Final rule

This final rule responds to comments on and revises the deadline for submission of the 2006 emergency Medicare graduate medical education (GME) affiliation agreements. The deadlines to submit the emergency Medicare GME affiliation agreements for the 2005 through 2006 and 2006 through 2007 academic years are changed from on or before June 30, 2006 and July 1, 2006, respectively, to on or before October 9, 2006.

Women's access to health care: The legal framework

The Millennium Development Goals set ambitious targets for women's health, including reductions in maternal and child mortality and combating the spread of HIV/AIDS. The law, which historically has often obstructed women's access to the health care they require, has a dynamic potential to ensure women's access that is being progressively realized. This paper identifies three legal principles that are key to advancing women's reproductive and sexual health. First, law should require that care be evidence-based, reflecting medical and social science rather than, for instance, religious ideology or morality. Second, legal guidance should be clear and transparent, so that service providers and patients know their responsibilities and entitlements without litigation to resolve uncertainties. Third, law should provide applicable measures to ensure fairness in women's access to services, both general services and those only women require. Legal developments are addressed that illustrate how law can advance women's equality, and social justice.

The political evolution of mental health parity

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.

Reducing disparities in the burden of cancer: the role of patient navigators

Many racial and ethnic minority patients with cancer face barriers related to access to health care and information. Patient navigators, say the authors, could help to overcome these barriers.

Welfare reform, employment, and drug and alcohol use among low-income women

In 1996 welfare reform legislation transformed income assistance for needy families by imposing work requirements, time-limited benefits, and explicit provisions allowing states to sanction recipients who fail to meet program requirements. Though they represent a minority of the welfare population, women with substance use disorders (SUDs) experience multiple, and more severe, employment barriers than other Temporary Assistance to Needy Families (TANF) recipients. This review of welfare reform, substance abuse, and employment documents the evidence to date regarding the employment patterns of women with SUDs before and after welfare reform, and proposes several topics for further research. Based on higher rates of unemployment, less work experience, and lower earnings when working, women with SUDs have worse employment records than other TANF recipients. Despite elevated employment barriers, women with SUDs left TANF after 1996 as fast as, or faster than, other women. Since the 1996 welfare reform, women with SUDs have increased their employment and earnings, but by less than similar women without SUDs. Future research should describe how specific state welfare policies relate to employment of low-income women with SUDs, how the well-being of these women and their children changes with employment, and how welfare and employment interact to affect access to health insurance among this population.

Moving toward assured access to treatment in microbicide trials. Global Campaign for Microbicides

Anna Forbes discusses the Global Campaign for Microbicides' consensus statement on access to treatment and standards of care in microbicide trials.

Prenatal care initiation among very low-income women in the aftermath of welfare reform: does pre-pregnancy Medicaid coverage make a difference?

OBJECTIVES

To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy.

METHODS

The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage.

RESULTS

Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively.

CONCLUSIONS

Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.

Recent developments in health law in the Netherlands

This article gives a few examples of recent developments in Dutch health law, namely equal access to health care, compulsory placement and treatment in a psychiatric hospital, and end of life decisions. They are outstanding examples of trends in health legislation that require to be followed closely.

The impact of parity on major depression treatment quality in the Federal Employees' Health Benefits Program after parity implementation

BACKGROUND

Since the 1990s, parity laws have been implemented to reduce inequities in mental health coverage compared with that for general medical conditions. It is unclear if parity under managed care is associated with improvements in mental health treatment quality. Major depressive disorder (MDD) is a prevalent but often undetected and undertreated and thus could potentially benefit from parity implementation.

OBJECTIVE

The objective of this study was to examine the association between parity implementation and changes in MDD treatment quality in the Federal Employees' Health Benefits (FEHB) Program.

METHODS

We conducted retrospective analyses of insurance claims data. Logistic regression models estimated quality changes for MDD-diagnosed enrollees from pre- to postparity.

SUBJECTS

Subjects included MDD-diagnosed FEHB insured enrollees, aged 18-64, across multiple states and 6 FEHB plans before (1999-2000) and after (2001-2002) parity implementation.

MEASURES

Measures included receipt of any antidepressant or psychotherapy within a given calendar year of diagnosis; receipt of appropriate psychotherapy frequency/intensity and duration; and pharmacotherapy duration during acute-phase treatment episodes.

RESULTS

Postparity, several plans improved significantly in the likelihood of receiving antidepressant medication. In the acute-phase episodes, the greatest improvement was seen in the likelihood of follow up >or=4 months. Few or no other changes were observed in the acute-phase treatment intensity or duration quality measures.

CONCLUSIONS

Parity under managed care was associated with modest improvements. The observed improvements were consistent with secular trends in MDD treatment. Whereas mental health parity is an important policy goal, these results highlight its limitations: improving the financing of care may not be sufficient to improve quality.

Side effects: a dose of competition and access to care

The Federal Trade Commission and Department of Justice 2004 report Improving Health Care: A Dose of Competition argues in favor of increasing competition among health care providers. Several of the proposals within the report, however, may pose risks for access to care. The report urges that the current system of implicit cross-subsidies for indigent care be replaced with insurance expansions that provide coverage to individuals. Such a substitution would certainly enhance access, but would be very costly and likely require considerable government intervention in the health care system. In the absence of a substantial expansion in coverage, reductions in cross-subsidies could limit access to care through the existing safety net. The report argues that insurance mandates limit access to care by driving up cost and reducing choice. In some cases, such as mental health and substance abuse, however, the unregulated market may not cover a benefit at all, leaving people with less coverage and less choice. Finally, the report stresses the importance of linking costs to quality. Such a linkage is likely to lead to a health care system in which poor people obtain poor-quality care at low prices--a result that many would find disturbing.

The Effects of State Parity Laws on the Use of Mental Health Care

OBJECTIVE

We used a quasiexperimental research design to measure the effect of state parity laws on the use of mental health care in the past year.

METHODS

We pooled cross-sectional data from the 2001, 2002, and 2003 National Surveys on Drug Use and Health. Our sample included 83,531 adults 18 years of age or over with private health insurance stratified by the level of mental and emotional distress experienced in the worst month of the past year. We used a state and year-fixed effects approach to measure the effect of parity. Similar to a difference-in-difference analysis, the effect of parity was measured by comparing pre-/postchanges in mental health service use within states that switched active parity status to changes in service use within states that did not change parity status in the same calendar year. For each subgroup, we report predictions of the percentage point change in any mental health care use, prescription drug use, and outpatient care use resulting from parity laws.

RESULTS

Depending on the time window used to define active parity status, we found that parity increased the probability of using any mental health care in the past year by as much as 1.2 percentage points (P<0.01) for the lower distress group and by as much as 1.8 percentage points (P<0.05) in the middle distress group. We found no statistically significant changes in service use for the upper distress group. Whether measured differences were attributable to changes in the use of prescription drug or outpatient care also depended on the definition of active parity status.

CONCLUSIONS

Overall, the results of this study suggest that state parity laws succeeded in expanding access to mental health care for those with relatively mild mental health problems.