I want to thank all of you for your patience. Since my last post, I've worked on the medicaid expansion issue through the lens of a filmmaker. The series of Medicaid expansion posts I'm working on will be in part described through video. I'd like to share the trailer to the film I'm directing, producing and writing entitled, "Texas UnMedicaided". Would love to work on this project with others in the community, so if you are interested in standing for this cause and working on the film, send a message through the "contact" tab!

​-Leo

In an upcoming series of posts, I hope to present arguments, data, and expert opinion revolving around the issue of Medicaid expansion in Texas, keeping in mind the 500 word SJR parameter. 

It was struck down by the U.S. Supreme Court in 2012. It’s a vital piece of the Patient Protection and Affordable Care Act (PP&ACA) that provides coverage to the “working poor". It was designed for individuals whom do not qualify for traditional Medicaid, and whom struggle to afford premiums for private insurance. PP&ACA (Obamacare) is one of the most polarizing, political issues in recent history. It’s come to the House floor for repeal vote more than 40 times. The Medicaid expansion legislation is as divisive. I attended a physician-led advocacy day in 2013 when I was a second year medical student. We met with representatives at our state’s capitol in Austin, Texas. Several staffers met our group at the door and declared that a Medicaid expansion conversation was a non-starter. To this point, at least 15 states have not expanded Medicaid. Commonly presented arguments against expanding are the following:

“Traditional Medicaid is a broken system.”

“Medicaid will bankrupt the state.”

“Medicaid reimbursement is so poor, physicians are reluctant to treat patients with this coverage.”

“Medicaid leads to poor medical outcomes.”

These arguments exacerbate the discrimination of the poor and those in poverty. They paint caricatures of humble citizens as social leeches, moochers, and takers. These arguments are morally and economically bankrupt. Here is why:

A few points on the economic argument:
-The federal government would contribute nearly 100 billion dollars to Texas’ program over the next 10 years. 

-Blocking medicaid expansion would NOT lower individual’s federal taxes.

-$40 billion dollars are spent each year by hospitals in uncompensated care. You’ve probably encountered this on one of your rotations. Patients without insurance seek care at emergency rooms. This is an incredibly expensive way to do health care.These costs are covered by tax-payers and local institutions. Expanding Medicaid helps mitigate much of these costs and relieve the burden on local communities, while putting an emphasis on preventative care.

-Texas' economy would add over 200,000 jobs.

-After the first three years of the expansion, Texas' contribution would not exceed 10% of the cost to run the program.

Texas loses nothing by blocking Medicaid. Unless, of course, we consider the loss of billions of federal dollars, hundreds of thousands of jobs, countless lives, and our integrity. We are withholding resources from hard working families in Texas. This money was already paid into the system through taxes. The funds sit at the federal government waiting for the elected officials in Texas to claim for their people. We’ve built a bureaucratic fortress around health, wellness, and economic freedom and deny the working class access through the gates. If our state wanted to make a deal tomorrow to bring in these federal dollars and improve the lives of Texans, they could. But they won’t. I think back to Hughes, and contemplate the sick body. 

“A hungry body exists as a potent critique of the society in which it exists. A sick body implicates no one”, said Hughes. 

These words are more true now than ever. We must implicate those enabling the sick body and be critical of our society for this social injustice. 

Considerations:
What is your state representative doing to fix the traditional Medicaid program?

Why do you think your representative is blocking Medicaid expansion?

What reservations do you have about Medicaid and the expansion?

Have you worked with physicians who are reluctant to accept Medicaid patients? What was their reasoning? What are your thoughts on this?

What is your group doing to increase access to care and embrace health care as a human right? 

How have you been successful in having access-to-care conversations at your school or program?

​Readings and sources: 
How have states handled medicaid expansion?

Obamacare repeal votes

​Sebelius on the ACA

Texas and Medicaid expansion

Alternatives to medicaid expansion

Study looking at medicaid expansion

I’m from the Rio Grande Valley, where it isn’t uncommon to know someone serving time in prison. I'd even say it’s far more common to know someone who's served time than otherwise not to. Our area resides on the border between Texas and northern Mexico. It’s a region with many public health concerns ranging from a disturbingly high rate of childhood obesity to lack of basic access to quality health care. Underlying these issues are the conditions of poverty, illiteracy, and lack of economic opportunity. For many young people, dealing illicit drugs or joining the ranks of the neighboring Mexican drug cartels are enticing options for pulling themselves out of generational poverty. They inevitably cycle through the system as convicted felons for nonviolent, drug-related crimes. (For more, watch my 2013 short film Rio) As a young boy, I never reflected on what life was like for my peers; to be isolated from everyone and everything they’ve ever known. Through most of my life, I never felt sympathy for the prisoner. I never considered how their family suffered, much less how our community was affected by the incarceration of our neighbors. I was socialized to forget about the criminal once he/she was imprisoned. Friends whom once shared the hallways at school became vague memories. This is the paradigm that allowed the United States to become the most incarcerated country in human history.

I learned about Reagan’s war on drugs when I was a second-year undergraduate.
Over-policing. Mandatory minimum sentences. The prison-industrial complex. Mass Incarceration.
Criminal justice reformation is scaling the wall of priority for public health workers, human rights activists, and public servants alike. Michelle Alexander taught me more about the issue with her book, The New Jim Crow - Mass Incarceration in the Age of Colorblindness. She describes the inequalities in the criminal justice system that disproportionately impact people and communities of color. Recently, Vice produced a powerful piece covering mass incarceration and President Obama’s visit to a Federal Correctional Institution. While much of this work focuses on the incarcerated populations specifically, a study by The American Journal of Public Health published earlier this year, looked at how living in neighborhoods with high incarceration rates affects one’s health. Specifically, the study looked at the odds of developing psychiatric illnesses like major depressive disorder (MDD) and generalized anxiety disorder (GAD) if one lives in an area with high incarceration rates. (Read the study here ; May have to purchase) High incarceration rates were defined as roughly 5 prison admissions per 1000 adults in the community. After controlling for age, gender, "race", and income, the study showed that the odds of meeting criteria for a current diagnosis of MDD are 2.9 times higher for residents in communities with high incarceration rates (2.1 time higher for GAD). This is a glimpse of how mass incarceration extends beyond the walls of our prisons; an indication for public health urgency, action and further investigation. It's time for us to examine how the culture of mass incarceration developed and what we can do ameliorate the poor outcomes generated by it; how the war on drugs impacts our patients and our communities' mental and physical health. Dostoyevsky helped us measure the degree of civilization in our society by entering the prison. Now it seems we can make the same assessment by entering the 'hood.

Considerations:
-What do you think of the study? 
-Should physicians be more vocal regarding criminal justice reformation and it’s public health implications?
-When performing a social history, do you regularly ask about patients’ friends/families/neighbors who are imprisoned?
-Have you rotated or visited a prison during your training? What was that like?
-What is your group doing in terms of advocacy and action?
-Do you know someone in prison? 
-What is the war on drugs?
-What is the prison-industrial complex?

Recommended readings:
-The Collateral Damage of Mass Incarceration: Risk of Psychiatric Morbidity Among Nonincarcerated Residents of High-Incarceration Neighborhoods
-The New Jim Crow - Mass Incarceration in the Age of Colorblindness by Michelle Alexander
-Chasing the Scream: The First and Last Days of the War on Drugs by Johann Hari   

Welcome to the Social Justice Rounds Blog. This is a place where pre-meds, medical students and residents (anyone is welcome really) can read, engage, exchange ideas and contribute to conversations of social justice as they pertain to health disparities. While commenting on society, health, and culture, the goal is to spark a conversation in roughly 500 words.

Scholars have long studied outcomes driven by slavery, segregation, and racism on the social determinants of health and well being. We can easily talk at length about all the work being done in these fields. In short: The Black condition in America faces generations of systemic oppression that account for many of today’s severe economic, health, social, and educational disadvantages. Click here for historical reference. If you followed current events over the past year, you couldn’t have missed the socio-cultural impact of the Black Lives Matter movement. Black Lives Matter. Three words that, in the very least, represent for centuries of oppression, violence, and discrimination by the state towards a population based on skin color. For a year, we’ve watched the BLM movement spread across the country; educating us and demonstrating for justice. I’m captivated by how this movement demands recognition. Injustice paints a powerful, visual narrative. News coverage takes us to the front lines in Ferguson. We watched riots evolve in Baltimore. We connected with the characters involved, and names like Michael Brown and Eric Garner are now house hold names. The narrative took social media, television, and radio hostage. As a person of privilege, I can never truly appreciate the struggle, the history, of what Being Black in America means. But for this year, at least, I learned why Black Lives Matter.

Why I’m Interested:
I’m a family medicine resident physician. Still in training, idealistic, unjaded, and naive beyond measure. I want to learn about and contribute to serving populations facing severe disparity, like those suffering racial discrimination. As a medical student, I thought the clinic, the hospital, and the emergency room, were safe havens for all patients, peoples, colors, and creeds. Our clinic is a sanctuary where doctors check their racism, sexism, and xenophobia at the door, or so I thought. I was conditioned to believe the white coat was color blind. 

A study funded by the National Institutes of Health covering racial disparity was published last month. The study looked back at how doctors used pain meds to treat black children and white children with the same chief complaint - appendicitis. When adjusting for pain score, insurance status, age, and sex, this is what the researchers found:

-Black children were less likely than were white children to receive opioids for the treatment of appendicitis when they arrived in the emergency room.

-Only 25% of black children in severe pain received opioids for appendicitis pain compared to nearly 60% of white children.

I questioned the study. Was the data real ? What could explain such disparity? How could we allow children to suffer so needlessly in pain? We’ve long known about health disparity based on race/ethnicity in adults, but the idea of children being discriminated against so negligently gave me a nauseating turn. I’m curious to see how deep this runs. 

You can read the study, published in JAMA Pediatrics, here.

Quick Reflection:
-How are medical schools implementing unconscious bias into their curricula?

-How is physician prejudice checked at medical facilities?

-What is your experience with discrimination in the hospital/clinic?

-In your health/bioethics course, what is the conversation on race like? 

While these findings warrant further investigation, I anticipate strong pushes from medical-social justice groups like White Coats for Black Lives Matter. I hope to see the movement flood the emergency rooms across the nation, just as it did in Ferguson and Baltimore. However, making racial-health disparities palpable to the country won’t be as easy as say police brutality. I think back to Officer Michael Slager  and the shooting in South Carolina. The country watched in shock. Everything Black Lives Matter was demonstrating for was sadistically recorded for public viewing. BLM framed the conversation and demanded change. Can something like racial-inequities in medicine ever be presented to the public eye in the same way? We may not be gunning people down in the streets, but if the study stands, we are imposing cruel suffering onto black children by withholding pain-alleviating medication. Patient privacy and the physician-patient relationship is protected and held sacred. Methods like suiting doctors in body cameras obviously won’t happen.

Take Home Questions:
-How can movements like Black Lives Matter hold health care providers accountable?

-How do we take privileged encounters and perpetuate them to the masses as the fatal shootings of black men were?

-A robust, national discussion of racial health disparity is long over due. Will this study play a role in sparking change?