- Kaiser Health News Original Stories 2
- Thousands May Have Been Shorted On Insurance Subsidies After Calculation Error
- Americans Are Drinking More Heavily, Especially Women
- Political Cartoon: 'Teen Angst?'
- Health Law 2
- Obamacare Satisfaction Scores Top Traditional Plans
- Tenn. Gov. Says Federal Approach To Medicaid 'Feels Awfully Heavy Handed'
- Public Health And Education 1
- Dr. Oz Fires Back After Other Doctors Call for His Ouster From Columbia Med School
- State Watch 2
- Even As Prescription Drug Overdose Death Rates Soar, States Fail To Take Simple Preventive Step
- State Highlights: N.H. Explores Why Its Health Care Costs Are High, Rising; Calif. Lawmakers To Weigh Open Health Care Data
From Kaiser Health News - Latest Stories:
Some families likely received lower subsidies than they were entitled to or were denied Medicaid coverage because of faulty calculations related to children who receive Social Security income. (Michelle Andrews, 4/24)
The first study to track drinking patterns at the county level finds that women are driving big increases in heavy drinking. (Barbara Feder Ostrov, 4/23)
Kaiser Health News provides a fresh take on health policy developments with "Political Cartoon: 'Teen Angst?'" by Gail Machlis.
Here's today's health policy haiku:
TOUGH TALK FOR A TV DOC
Critics say Dr.
Oz cashes in on “quack” cures.
Don't they know words hurt?
If you have a health policy haiku to share, please Contact Us and let us know if you want us to include your name. Keep in mind that we give extra points if you link back to a KHN original story.
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Summaries Of The News:
A study by J.D. Power offers the first comprehensive look at the Department of Health and Human Services's efforts to improve the customer experience in the second year of the health lawr.
Study: Satisfaction With ObamaCare Tops Traditional Plans
People who bought coverage through ObamaCare are generally more satisfied than those with other types of insurance, according to a new national survey. ObamaCare customers rated their satisfaction over the last year as 696 out of 1,000, compared to the 679-point rating by customers with employer-based plans, according to a large survey by the consumer research firm J.D. Power. (Ferris, 4/23)
California, Washington Shine During Special Obamacare Sign-Ups
Now that's a West Coast offense! Two states that run their own Obamacare markets—California and Washington—are blowing away the much-larger, federally run HealthCare.gov when it comes to signing up customers during a tax season grace period. That special enrollment offer is open to people who only just learned they owe a fine for not having health insurance last year. Through last Friday, a total of more than 38,700 people selected health plans during special enrollment in California and Washington, officials said. (Morgan, 4/23)
And state lawmakers in California reject a proposal that would have required them to get their insurance through Covered California, while uninsured Floridians find ways to get care -
Los Angeles Times:
Democratic Lawmakers Reject Switching Their Health Coverage To Obamacare
Democratic state lawmakers on Thursday shot down a proposal that would have required all California state legislators to get their health insurance from Covered California, the benefits exchange set up to implement Obamacare in the state. The Assembly Rules Committee split along party lines, with seven Democrats opposing AB 1109 and three Republicans in support of the bill by Assemblyman Scott Wilk (R-Santa Clarita). The measure would have forced lawmakers to give up the taxpayer-subsidized health plans provided by the Legislature and individually sign up for Covered California. (McGreevy, 4/23)
Health News Florida:
Selling Hard Boiled Eggs For Medicine: Tradeoffs People In The Gap Make For Health Care
Every Tuesday, a giant blue bus parks in front of the Pentecostal Tabernacle Church in Miami Gardens. Inside looks like a doctor’s office with a reclining exam chair and anatomical charts. You only know that it’s not a traditional office when it shakes as people get on and off. Cynthia Louis comes to this free mobile health clinic about twice a month to work with Doctor Fred Anderson and various medical students on mitigating the constant aching in her joints. Louis is one of the 850,000 Floridians in the health care “coverage gap”—she earns too little to get help buying health insurance under the Affordable Care Act but doesn’t qualify for Medicaid. (Sayre, 4/23)
The recent announcement that federal officials will tie special hospital funding for uncompensated care to states' decisions on whether to expand Medicaid is raising some concerns. Meanwhile PolitiFact examines Medicaid claims in Florida.
Haslam Questions Fed Health Care Funding Review
The federal government's review of how much money it spends to help pay for the hospital costs of low-income people in Tennessee and other states that didn't expand Medicaid feels like a threat to Gov. Bill Haslam. "The way they're approaching this feels awfully heavy handed: OK, well if you don't do that, then we're going to restrict the pool of money that we give you for indigent care," Haslam told reporters Thursday. (Boucher and Fletcher, 4/23)
Related KHN coverage: Tennessee, Kansas Also Get Warning: Expand Medicaid Or Risk Hospital Funds (Galewitz, 4/21)
Republican Governors May Pay Price For Refusing To Expand Medicaid Under Obamacare
Because of special arrangements that predate Obamacare, four states that haven’t expanded Medicaid have been getting billions each year in extra funding to pay for the care of people who are uninsured. That’s about to change. On April 14, the Centers for Medicare and Medicaid Services (CMS), which manages federal funding to the states for health programs, alerted Florida officials that CMS plans to let the $1.3 billion the state gets annually to help hospitals cover the cost of treating uninsured patients lapse at the end of June. (Tozzi, 4/23)
Fact-Checking Claims About Medicaid In Florida
A feud over Medicaid expansion that stretches from Tallahassee to the White House means the Florida Legislature may not pass a budget by the time the session ends on May 1. PolitiFact Florida has been fact-checking the fight over whether more poor Floridians will be able to qualify for heavily subsidized health insurance. The federal government is offering billions if Florida expands Medicaid, paying 100 percent of the expansion at first and gradually downshifting to 90 percent in later years. The program currently eats up a sizable portion of the state budget. (Gillin and Sherman, 4/23)
The program was supposed to shorten waiting lists by allowing patients to switch to private-sector doctors. Meanwhile, a Florida congressman has introduced legislation that would make it easier to fire Veterans Affairs employees.
The Associated Press:
Few Vets Getting Care Through $10B VA Program
A new program that was supposed to get patients off waiting lists at Veterans Affairs medical centers by letting them switch to private-sector doctors is proving to be an even bigger disappointment than initially thought. The Veteran's Choice program launched on Nov. 5 with $10 billion in funding and the expectation that it would instantly relieve backlogs at VA hospitals and clinics. But after a hurried rollout that has led to confusion as to exactly who is eligible and what they need to do to coordinate treatment, officials now say only 37,648 medical appointments have been made through April 11. (Caruso, 4/23)
The Washington Post:
After A Year Of Frustration, New Bill Would Make It Easier To Fire VA Employees
One year after the largest scandal in the Department of Veterans Affairs history, a congressman says he will introduce the VA Accountability Act, which would give the new VA secretary sweeping authority to fire corrupt or incompetent employees. Rep. Jeff Miller’s (R-Fla.) bill comes in response to increasing frustration from lawmakers and veterans service organizations over the slow pace of reform in holding VA employees accountable for a litany of problems, from patient wait times to delays in benefits. (Wax-Thibodeaux, 4/23)
The San Jose Mercury News:
VA And Congressional Leaders Spar During Hearing Examining Problems At Oakland Office
During a tense congressional hearing Wednesday looking into problems at the Oakland and Philadelphia Veterans Affairs benefits offices, Rep. Phil Roe, a Tennessee Republican, said he often hears frustrated vets say that maybe the VA is "just waiting for me to die." (Emmons, 4/23)
A growing number of state legislatures are weighing bills to force drug makers to disclose their costs to justify price increases. Meanwhile, Quest Diagnostics reports revenue growth while AstraZeneca's profit falls as a patent expires on its bestselling heartburn drug.
The Wall Street Journal:
Drug Prices Trend Up, And States Want To Know Why
Should drug makers be required to disclose their costs to justify rising prices? This is what a growing number of state legislatures are considering. Over the past several weeks, lawmakers in a handful of states stretching from California to Massachusetts have introduced bills in a bid to force the pharmaceutical industry to conduct an economic striptease. (Silverman, 4/23)
The Wall Street Journal:
Quest Diagnostics Revenue Grows 5.3% As Business Environment Improves
Quest Diagnostics Inc. said Thursday that revenue grew 5.3% in its first quarter as the laboratory-testing company benefits from growth in its diagnostics business and an improving environment. Core profit narrowly topped Wall Street expectations, while revenue was in line. (Dulaney, 4/23)
The Associated Press:
AstraZeneca Profit Falls As Patent Expires On Heartburn Drug
Anglo-Swedish drug-maker AstraZeneca PLC reported a 7 percent fall in net profit for the first quarter of 2015, as cheaper copies of one of its bestsellers ate into sales. Sales were hit by the U.S. patent expiring on heartburn drug Nexium. The patent on cholesterol drug Crestor, another big seller, expires next year. (4/24)
The Health and Human Services secretary made that promise during a Senate hearing. Meanwhile, about half the physicians and other providers eligible to participate in the incentive program did so in 2013, according to an administration report.
HHS Chief Says She'll Work With Senate On E-Health Problems
The chairman of the Senate Health, Education, Labor and Pensions Committee on Thursday secured a commitment from Health and Human Services Secretary Sylvia Mathews Burwell to work to address problems with electronic health records. At a Senate Labor-HHS-Education Appropriations Subcommittee hearing, Lamar Alexander, R-Tenn., expressed concern about the amount of federal funding spent subsidizing the shift from paper to electronic records while doctors continue to resist, even in the face of penalties for non-participation, and express dissatisfaction with the systems. Alexander and Patty Murray of Washington, the top Democrat on the HELP panel, have formed a bipartisan working group to identify five or six problems with electronic health records that can be addressed administratively or legislatively. (Attias, 4/23)
Half Of Eligible Docs Were In 'Meaningful Use' Program, CMS Says
About half of the physicians and other eligible professionals who could participate in the federal electronic medical records incentive program did so in 2013, according to a report that the Obama administration planned to release Thursday. The number of providers participating rose by 47 percent from 2012 to 2013. (Adams, 4/23)
Ten doctors wrote a critical letter that included references to his promotion of "quack treatments" on his television show. He has since launched a vigorous public defense.
The Associated Press:
Dr. Oz Mounts Spirited Defense Against Critical Letter
Dr. Mehmet Oz says last week's attack by 10 doctors who accused him of promoting "quack treatments" on his TV show was spurred by his vocal support for labeling genetically modified foods — a stance he says some if not all of those accusers oppose. (Moore, 4/24)
The Washington Post:
Dr. Oz Fires Back At His Critics: ‘We Will Not Be Silenced’
Dr. Mehmet Oz, the embattled medical-advice peddler and cardiothoracic surgeon, devoted numerous segments of his popular, eponymous show on Thursday to blast his critics as "mysterious doctors" with "conflict-of-interest" and "integrity" issues. His response included a carefully produced broadside against the 10 doctors who last week called for his ouster from Columbia University's medical school. (Izadi, 4/23)
The New York Times:
Dr. Oz Responds To Critics On His Television Show
During an episode of his syndicated daytime talk program, “The Dr. Oz Show,” that was broadcast on Thursday, Dr. Oz said his critics were attacking his freedom of speech. “I vow to you right here and right now, we will not be silenced,” he said. Dr. Oz, who is the vice chairman of Columbia’s surgery department, also defended the advice he shares on his show. “My life’s work has been built around one simple message: You have a right and a responsibility to become a world expert on your own body,” he said during the show, which was taped Tuesday. “And the way you do that is by having access to the best, most current information; multiple points of view; and diverse opinions.” (Ember, 4/23)
Dr. Oz Accuses Critics Of Having Conflict Of Interest
Dr. Mehmet Oz's rebuttal to his critics aired on local stations across the country Thursday, part of a public relations blitz that includes an essay in Time magazine and an interview on NBC's "Today" show. (Stetzer, 4/23)
Stateline reports on how states could make it more difficult for doctors to prescribe one of the most dangerous narcotics. In other news, Illinois lawmakers are considering legislation to fight drug abuse and a new study details Americans' heavy alcohol use at a county level. Meanwhile, Alabama continues to address problems associated with a recreational drug known as Spice.
Most States List Deadly Methadone As A 'Preferred Drug'
As prescription drug overdose deaths soar nationwide, most states have failed to take a simple step that would make it harder for doctors to prescribe the deadliest of all narcotics. Methadone overdoses kill about 5,000 people every year, six times as many as in the late 1990s, when it was prescribed almost exclusively for use in hospitals and addiction clinics where it is tightly controlled. It is four times as likely to cause an overdose death as oxycodone, and more than twice as likely as morphine. In addition, experts say it is the most addictive of all opiates. (Vestal, 4/23)
Kaiser Health News:
Americans Are Drinking More Heavily, Especially Women
Whether quaffing artisanal cocktails at hipster bars or knocking back no-name beers on the couch, more Americans are drinking heavily – and engaging in episodes of binge-drinking, concludes a major study of alcohol use. Heavy drinking among Americans rose 17.2 percent between 2005 and 2012, largely due to rising rates among women, according to the study by the Institute for Health Metrics and Evaluation at the University of Washington, published Thursday in the American Journal of Public Health. (Feder Ostrov, 4/23)
Illinois Lawmakers Consider Bills To Fight Drug Abuse
What started with a Vicodin prescription to deal with a particularly difficult kidney stone spiraled into a painkiller addiction for Bartlett resident Nicholas Gore, one he said made him so desperate to score pills that he'd raid medicine cabinets at real estate open houses. Ultimately, he started using heroin. After five years in and out of rehab, jail time on drug charges and the loss of family, friends and what was once a promising hockey career, Gore says he's been sober for three years. (Hellmann, 4/23)
The Washington Post:
Inside Alabama’s Deadly Spice Craze
For the small southern city of Anniston, 2011 seemed like a summer of madness. First came the cicadas, woken from their 13-year-slumber by some ineffable urge. Then came the reports of a new drug in town. It was called Spice, and all the kids were trying it. Then came the suicides. (Miller, 4/24)
News outlets cover health care issues in New Hampshire, California, New York, Missouri, Texas, Arizona, Georgia, North Carolina, Illinois and Maryland.
The Associated Press:
Insurance Department Explores Health Care Payment Reform
The New Hampshire Insurance Department is bringing together health care providers and insurers to explore why spending on health care is high and rising, and what can be done to change that. New Hampshire ranks in the top 10 states in health care spending per capita, and consultants hired by the department say health care costs are growing rapidly in the state largely because health care providers are charging more. The state has little competition among hospitals, which own many physician practices. The insurance market is highly concentrated, as well, and the consultants say the dominant insurers appear to be focused on maximizing their profits rather than using their market power to help consumers. (4/24)
Legislature's Turn To Consider Open Data
Last month, California HHS embraced the open data movement in health care with a decision to make more data available to the public online. Now it's the Legislature's turn. (Lauer, 4/23)
The Associated Press:
New York AG Files Suit Against 2 Tanning Salon Chains
New York's attorney general has filed suit against two tanning salon chains, accusing them of downplaying health risks while playing up the allure of bronze skin. Attorney General Eric Schneiderman filed the lawsuits against Portofino Spas and Total Tan Thursday. He says both franchises falsely advertise the health benefits of indoor tanning by promoting it as a safe alternative to tanning outdoors. (4/24)
The Associated Press:
Missouri House OKs Allowing Aspiring Doctors To Retake Exam
A Republican lawmaker who is an orthopedic surgeon says a measure moving forward in the Legislature would help alleviate the shortage of physicians in the state. The Missouri House on Thursday approved a measure by a vote of 110-36 that would remove the prohibition on physicians seeking licensure in the state from taking an exam more than three times. (4/24)
The Texas Tribune:
Texas Health Agency Bill Pulled Amid Heated Abortion Debate
Debate on legislation to re-evaluate a state health agency morphed into a fight over abortion in the Texas House on Thursday, and the bill was pulled down after a pair of anti-abortion amendments were added to the bill over the author's objections. The amendments, authored by state Rep. Matt Schaefer, R-Tyler, included one that would ban abortions of fetuses with genetic abnormalities after 20 weeks. Democrats and the bill's author, state Rep. Four Price, R-Amarillo, had objected, complaining the amendments weren't relevant to the bill. House Bill 2510, would streamline services at the Department of State Health Services. (Walters and Ura, 4/23)
The Texas Tribune:
Texas House Approves Protections For Breast-Feeding Moms
The Texas House on Thursday gave preliminary approval to a measure that would require public employers to provide accommodations for mothers who need to pump breast milk while at work. House Bill 786, by state Rep. Armando Walle, D-Houston, easily passed on Thursday on a voice vote. The measure would require public employers — state agencies, local governments and public schools — to support the practice of expressing breast milk and make “reasonable accommodations” for female employees to do so. (Ura, 4/23)
The Arizona Republic:
4 Arizona Hospitals Get Top Ratings In Patient Survey
Four Arizona hospitals scored the highest ranking of five stars based on the new, simpler measure of patient satisfaction unveiled last week by the federal Centers for Medicare and Medicaid Services, or CMS. (Alltucker, 4/23)
Georgia Health News:
Grady Settles With State In Overbilling Case
Grady Health System has agreed to pay $2.95 million to settle charges that it improperly billed Medicaid for treatment to neonatal intensive care (NICU) patients, the Georgia attorney general announced Thursday. (Miller, 4/23)
The Charlotte Observer:
Carolinas HealthCare Expands Access To Virtual Visit
Carolinas HealthCare System has expanded its Virtual Visit service to anyone. Launched last fall, the service provides live, 24-hour access to medical providers via camera-enabled smart phones, tablets or computers. Until now, it was offered only to patients who had established relationships with doctors in the Carolinas HealthCare network. (Garloch, 4/23)
The Chicago Tribune:
Rauner Takes Budget Ax To Health Care For The Poor
A month ago, new Republican Gov. Bruce Rauner and state lawmakers agreed to $300 million in cuts as part of a plan to fix a budget passed last year that didn't have enough money to cover 12 months of spending. On Thursday, a few details of what those cuts are started to emerge at the Capitol, though the Rauner administration declined to provide a full list of what's been chopped. (Garcia, 4/23)
USA Today/The (Westchester County, N.Y.) Journal News:
N.Y. Law Protects Against Surprise Medical Bills
Dana Roberts was raising two children in Yonkers and suddenly found herself wasting hours on the phone fighting insurers and medical offices over a $1,500 bill. She had to track down her medical records, talk to a lawyer and research similar cases. At one point, Roberts said she started recording conversations about settling the unexpected charge. Her distrust seemed appropriate. Roberts, 33, said she was unconscious when the $1,500 was tacked onto her surgery cost. ... Thousands of similar complaints by New Yorkers — many involving bills from specialists used unbeknownst to patients — prompted a state law seeking to protect against surprise medical charges. State regulators reported receiving at least 10,000 complaints about the problem. (Robinson, 4/22)
Los Angeles Times:
Should Doctors Be Allowed To Ask Patients About Their Gun Habits?
Physicians acknowledge that they ask their patients questions that, in any other context, would be considered nosy and meddlesome. They expect to get some pushback. But when physicians in Florida ask whether a patient -- or a young patient's parent -- has a gun in the home, they are now bracing for a call, and possibly a letter of discipline, from their state's medical board. Physicians in Indiana and Texas are on notice that for them, too, such questions may soon be limited by law. (Healy, 4/23)
Howard County Times:
New Howard Bill Would Set Nutritional Standards, With More Exceptions
New healthy food and drink standards could be coming soon to Howard County's vending machines. Four months after County Executive Allan Kittleman repealed a policy that banned sugary drinks and limited high-calorie snacks for sale on government property, County Councilman Calvin Ball is introducing legislation that would adopt a similar set of nutritional guidelines aimed at "promoting health and choice." (Yeager, 4/23)
St. Louis Public Radio:
What Options Do Police Have When Interacting With Those With Mental Health Issues?
Do police do enough to de-escalate encounters with people who may be mentally ill? Why do police use guns against a person with possible mental health issues who is armed with only a knife? These are questions that seem to crop up after any incident in which police use deadly force against someone who seems to suffer from mental health issues. They arose last week after the fatal police shooting of a man with a history of mental illness in Jennings, and after the death of Kajieme Powell last year in St. Louis. (Lecci, 4/23)
A selection of opinions on health care from around the country.
The Washington Post:
Insurance Coverage For Mammograms Jeopardized By New Guidelines, Congresswoman And Breast Cancer Survivor Says
Earlier this week, the U.S. Preventive Services Task Force (USPSTF), an independent group of doctors and health-care experts, issued draft recommendations on mammography for women at various ages. Their recommendations could lead to insurance companies dropping coverage of mammograms for women under age 50, as well as other preventive techniques that would help protect young women from getting breast cancer and help those who do have it. This is a wrong and dangerous path to take. (Rep. Debbie Wasserman Schultz, D-Fla., 4/23)
The New York Times:
Zombies Of 2016
[N.J. Gov. Chris Christie] thought he was being smart and brave by proposing that we raise the age of eligibility for both Social Security and Medicare to 69. Doesn’t this make sense now that Americans are living longer? No, it doesn’t. This whole line of argument should have died in 2007, when the Social Security Administration issued a report showing that almost all the rise in life expectancy has taken place among the affluent. The bottom half of workers, who are precisely the Americans who rely on Social Security most, have seen their life expectancy at age 65 rise only a bit more than a year since the 1970s. Furthermore, while lawyers and politicians may consider working into their late 60s no hardship, things look somewhat different to ordinary workers, many of whom still have to perform manual labor. (Paul Krugman, 4/24)
Health and Privacy
The most common way for health data to leak isn’t when hackers steal it. It’s when you give it away click by click. Just as marketers put bits and pieces of online information together to predict what toothpaste you buy, doctors and hospitals are using the same techniques in the hope of improving your health on the basis of stuff you haven’t told them. The rise of electronic health records, wearable devices and smartphone apps tracking your every breath, meal and heartbeat can only speed the spread of health information. (Shannon Pettypiece, 4/23)
The (Norfolk) Virginian-Pilot:
Again: Missing Target On Medicaid
Part of the reason reform is so difficult is that Medicaid is much bigger and more complex than partisans are willing to acknowledge. ... Medicaid isn't just free health care for poor people; it actually consists of two distinct programs. One is managed care, which helps lower-income Virginians. That's the most cost-effective Medicaid program, and the one that the federal Affordable Care Act calls for expanding. The other -- long-term, critical care for the disabled -- accounts for two-thirds of Medicaid's budget, despite serving only one-third of Virginia's Medicaid recipients. For years, the General Assembly -- led by Republicans -- has been shoveling money toward the biggest driver of Medicaid's growth. That program is inefficient and almost entirely the source of fraud cases. (4/23)
Columbia Medical Faculty: What Do We Do About Dr. Oz?
A recent letter from 10 physicians to the Dean of the Faculties of Health Sciences and Medicine at Columbia University College of Physicians & Surgeons states that [Dr. Mehmet Oz] is "guilty of either outrageous conflicts of interest or flawed judgments" and that because of this "Dr. Oz's presence on the faculty of a prestigious medical institution unacceptable." ... We are members of the Columbia faculty who recognize that the Dr. Oz Show performs a public service by bringing alternative therapies which are generally under-researched and under-regulated into the public forum. However, a 2014 report in The BMJ (formerly the British Medical Journal) reported that less than half of the recommendations on his show are based on at least somewhat believable evidence. This report raises concerns that Dr. Oz's presentations of anecdotal therapies as "miracle cures" occur in the absence of what we see as obligatory discussions of conflicts of interest, possible side-effects and evidence-based medicine. (Michael Rosenbaum, Joan Bregstein and 6 Columbia Faculty Members, 4/23)
The Unborn Can Be Murdered, Too
The Colorado legislature is now considering a bill to fill the gap in the law, so that the state would treat attacks on pregnant women as having two victims. That is already the practice of 37 other states and the federal government. NARAL Colorado, the state affiliate of the national organization that favors legal abortion, ... says that the bill is a stealthy attempt to enact the kind of personhood legislation that Colorado voters have repeatedly rejected .... It says that such laws have led to the imprisonment of pregnant women in other states. And it says that the bill is unnecessary, because Colorado already has tough laws on crimes against pregnant women. ... All three arguments are weak. (Ramesh Ponnuru, 4/23)
Principles And Challenges In Access To Experimental Medicines
Efforts by patients to obtain early access to experimental medicines have increased as novel therapies provide new evidence of their potential to treat or cure life-threatening diseases. As drug discovery efforts, particularly for cancer and orphan diseases, are increasingly based on molecular targets, success rates improve, generating further interest in early access to experimental drugs. Devising “expanded access programs” (EAPs), however, presents challenges. Fairness and ethical issues need to be addressed as do practical matters, such as efficient conduct of clinical trials, adequate drug supply, finances, and geography. ... This Viewpoint outlines general principles to help balance the competing interests of individuals facing life-threatening illness with practical concerns and broader societal interests. (Michael Rosenblatt and Bruce Kuhlik, 4/23)