Category: Blog

Over the past twenty-five years, the United States has experienced an increasingly devastating opioid crisis.  According to the Department of Health and Human Services (HHS), in the late 1990s, pharmaceutical companies offered reassurance to the medical community that patients would not become addicted to opioid pain relievers, leading healthcare providers to begin prescribing them at greater rates.  Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive.  

The Centers for Disease Control and Prevention (CDC) outlines the rise in opioid overdose deaths in three distinct waves.  The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999.  The second wave began in 2010, with rapid increases in overdose deaths involving heroin.  The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl.  The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.  In 2017, HHS declared a public health emergency to address the national opioid crisis and announced a five-point strategy with the following priorities: improve access to prevention, treatment, and recovery support services; target the availability and distribution of overdose-reversing drugs; strengthen public health data reporting and collection; support cutting-edge research on addiction and pain; advance the practice of pain management. 

The COVID-19 pandemic has created a devastating public health crisis and has posed significant challenges for health care delivery, including opioid use disorder (OUD) treatment.  Like the opioid crisis, the COVID-19 pandemic has had a disproportionate impact on racial and ethnic minority groups, particularly those who use drugs.  For example, one recent study showed that Black people with OUD are not only at significantly increased risk for COVID-19, but also have greater odds of hospitalization and mortality.  This reflects how Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality.

Methadone has been successfully used for over forty years to treat OUD and must be dispensed through specialized opioid treatment programs.  To receive the treatment, individuals have to show up every day for ninety days to receive their dose.  Only after that, are they able to take home a weekly bottle.  To get a full month’s worth of take-home methadone, individuals need to have been going to the clinic for two years.

Buprenorphine reduces cravings without becoming addictive itself and has been found to have similar effectiveness as methadone for treating OUD when given at a sufficient dose and for sufficient duration.  However, unlike methadone, buprenorphine can be prescribed by certified health care providers.  This eliminates the need to visit specialized treatment clinics, thus expanding access and providing an option for individuals with OUD who are unwilling or unable to attend a licensed methadone treatment program.

While both methadone and buprenorphine have been shown to reduce opioid misuse compared to abstinence-only interventions, buprenorphine has the greatest potential for widespread dissemination due to its relative ease of use and safety.  However, findings from several studies suggest buprenorphine and methadone treatment rates are correlated with race and ethnicity.

The following recommendations have been proposed by public health professionals and, if adopted, could help address the racial disparities in access to medications for OUD.  First, the requirement that a health care provider must complete a course before they are able to prescribe buprenorphine should be lifted. Second, newly diagnosed OUD patients should be offered both buprenorphine and methadone as treatment options.  Furthermore, patients currently receiving methadone should be offered the option to transition to buprenorphine.  Third, policies and regulations should be changed to allow pharmacy-led methadone dispensing.  Steps such as these must be taken to ensure all Americans, regardless of race or ethnicity, have equal access to health care.  Otherwise, this would be a missed opportunity to improve public health. 

In 2000, the National Institute of Justice (NIJ) came together with the Center for Disease Control and Prevention (CDC) to perform a study to better understand the breadth of abuse, stalking, and other violent behaviors on women in the US. Previously, other studies showed that arrests of abusers upon report tended to have a positive effect in reducing future violence. However, research hadn’t yet captured the sheer extent and magnitude of abuse directed against women in the United States. 

In the study performed by the CDC and the NIJ, researchers surveyed 8,000 women and 8,005 men through a process of randomly selecting phone numbers of households across the US. Of the women that responded to the survey questions, 17.6% had been victims of rape, 8.1% had been victims of stalking, and 22.1% had been assaulted by an intimate partner. But while these statistics were significant in and of themselves, the most surprising finding of the study was the primary source of violence against women: intimate partner violence. “64.0% of the women who reported being raped, physically assaulted, and/or stalked since age 18 were victimized by a current or former husband, cohabiting partner, boyfriend, or date” compared to only 16.2% of men.” 

Additional studies have been conducted that also demonstrate the endemic nature of intimate partner violence and the need to classify it as a major public health crisis. In the wake of this kind of research, various lawmakers in Congress, including then Senator Joe Biden, pioneered the passage of the “Violence Against Women Act” (VAWA) in 1994 and since renewed and strengthened in 2000, 2005, and 2013. On Wednesday, March 16 2022, President Joe Biden signed the fourth reauthorization of the law, which provides a variety of further enhancements to the bill: increased resources and support for survivors of underserved and marginalized communities, establishing a federal cause of action for individuals whose intimate images are disclosed without their consent, increasing support for the Rape Prevention and Education Program, implementing trauma-informed policies for law enforcement responding to domestic violence reports, among others.

Of these various updates, the bill also specifically provides for strengthening the healthcare system’s response to domestic violence and sexual assault. Title V of the bill provides various grants to states for conducting surveys of healthcare systems with the intent to gauge the effectiveness and availability of medical forensic examination. Medical forensic examination is the process whereby a health care provider examines a victim of sexual assault to address any of the victim’s immediate injuries but mainly to collect any bodily evidence that may assist in a future prosecution of an abuser. The bill’s prompting of further research about the effectiveness of these tests is purposed to result in states forming specific action items to improve the process in their jurisdictions. 

Studies have demonstrated that victims receiving these examinations feel roughly handled. Other studies, often conducted on a somewhat small scale, have demonstrated that victim-blaming mentalities actually pervade many forensic examiners’ approaches to conducting examinations. In an article titled, “‘Silly Girls’ and ‘Nice Young Lads’: Vilification and Vindication in the Perceptions of Medico-Legal Practitioners in Rape Cases,” authors Lesley McMillan and Deborah White discuss the findings of surveys they performed of various practitioners. Strikingly, of the various responses recorded to questions about the different rape cases practitioners had dealt with, many repeatedly echoed the idea that they had dealt with some “real” rape cases, often referencing rapes by a stranger, and other less real cases of “silly girls getting drunk and getting caught by their boyfriends” (285). As the authors highlight, these ideas about rape stand in violent contrast to the reality of how most rapes of women occur—at the hands of intimate partners. Hopefully, the funding provided in the reauthorization of the VAWA will result in meaningful changes to the process of conducting forensic medical examinations so that victims are better dealt with and just convictions are more common.

Under the Affordable Care Act (ACA), private health insurers cannot deny a person coverage or charge them a higher premium because of a pre-existing condition or because of their health status. 

Is being unvaccinated for Covid-19 a pre-existing condition? If it isn’t, the unvaccinated could be denied healthcare coverage, but perhaps they should be. 

The health care market is characterized by a significant cost-shifting problem. Right now, healthy, vaccinated individuals are paying the collective cost of the unvaccinated population’s Covid-19 related healthcare. The Covid-19 vaccine has been widely available for almost a year and has proven to be highly effective for preventing costly hospitalization and for mitigating “long-covid” symptoms, which can be very costly. It is so effective that while the unvaccinated population represents only 15% of adults in the U.S., it incurs more than 90% of the nation’s Covid-19-related healthcare costs. It is widely understood that those who remain unvaccinated are far more likely to be hospitalized for Covid-19, and require more specialized – and thus, more expensive – medical care. 

Even before the Covid-19 pandemic, there was a major cost-shifting problem burdening the healthcare system. Before the passage of the ACA, the insured population was essentially carrying the cost of the uninsured. While the ACA’s individual mandate has helped mitigate the issue, another ACA provision poses a new problem in the context of Covid-19. Because insurers cannot deny coverage based on a pre-existing condition, they have been unable to deny coverage to the unvaccinated. 

The unvaccinated population is incurring billions of dollars in healthcare costs, and insurance companies spread these costs evenly among policy-holders, whether they are vaccinated or not. Why should a policyholder who makes the responsible choice to get vaccinated have to pay the price of the unvaccinated patient’s bad decision through higher premiums?

Health insurers in the individual marketplace have interpreted the pre-existing condition provision of the ACA to mean that they can’t impose penalties for not being vaccinated, but some private and public employers have taken the step of penalizing unvaccinated employees to address this cost-shifting problem. 

Delta Airlines, rather than imposing a vaccine mandate, took the usual step of charging unvaccinated employees a $200 monthly penalty, essentially a higher insurance premium, to address the expectation of higher healthcare costs. 

Insurers themselves have also re-instated copays and deductibles for Covid-related costs that were waived at the beginning of the pandemic and before the widespread availability of the vaccine, but these affect both the unvaccinated and vaccinated. 

So long as vaccination status is considered a pre-existing condition for the purposes of health insurance, employer-imposed penalties seem to provide the best path forward for addressing the cost-sharing problem posed by the unvaccinated population’s disproportionately high healthcare costs. 

Around the world, the United States is admired and followed as the globe’s leading superpower. However, the continuously high rates of maternal mortality in the United States greatly distinguishes it from its international counterparts.

The Center for Disease Control and Prevention (CDC) defines maternal mortality as “the death of a woman during pregnancy, at delivery, or soon after birth.” In the United States, about 700 women die each year as a result of pregnancy or delivery complications. While most of the complications that arise during pregnancy are preventable or treatable, the United States struggles to decrease its maternal mortality rates as women’s lives, especially women of color, are consistently put at risk. 

Throughout the country there are people, and more importantly policymakers, who believe healthcare is a privilege rather than a right. The right to healthcare is not explicitly mentioned anywhere in the United States Constitution, making policy decisions around how to access it a source of tension between political parties and lawmakers. Furthermore, access to maternal healthcare tends to suffer as a result of this political tension. The difficulty in improving maternal healthcare is further compounded by the fact that reproductive health is a subset of healthcare that predominately impacts women, making it a less funded and researched area of healthcare. 

Looking to legislative history to examine the steps taken forward to help improve these disheartening facts, the Affordable Care Act (ACA) stands out as a beacon of hope. The ACA expanded Medicaid to reduce the amount of uninsured women who are of a reproductive age and new mothers in the year after delivery. The ACA also forced insurers not to charge women higher health premiums than men, which used to be a common practice as women were expected to have more healthcare costs during their childbearing years. Additionally, reimbursement for midwives was increased to the amount physicians receive for performing the same service- an incredibly important addition for expanding access to personnel who can safely perform births. Though legislation such as this exists to improve maternal mortality rates in the U.S., devastating statistics around this issue continue to occupy the country and disproportionately impact women of color.

According to the CDC, black women are three times more likely to die from a pregnancy-related cause than their white counterparts. This is largely due to social determinants of health that historically and continuously place women of color at a disadvantage when receiving healthcare through structures of systemic racism and implicit bias. In Washington D.C., 95% of pregnancy-related deaths occurred among black women between 2013-2017. In 2017, United Medical Center’s Obstetrics unit in Washington D.C. closed due to lack of revenue and malpractice, leaving nowhere to give birth for women living in Wards 7 and 8 which are primarily occupied by black residents. Women living in these Wards are forced to travel to Maryland or cross the Anacostia River to safely deliver their babies. This reality is sadly not unique to the nation’s capital as high maternal mortality rates continue to plague the U.S. even with legislative victories like the ACA. 

Unfortunately, the hope once raised by the passage of the ACA now appears to be overshadowed by the impending United States Supreme Court decision set to overturn Roe v. Wade this summer with Dobbs v. Jackson Women’s Health Organization. This upcoming decision is bound to disproportionately impact women of color as they will be forced to carry unwanted pregnancies to term and then give birth in a system that is already causing them irreparable harm. This upcoming decision has the power not only to increase the U.S.’s maternal mortality rate, but also change the course of how women’s rights and specifically their place in the healthcare system is respected in this country. Furthermore, how do we move forward in a society where after almost fifty years of progress from Roe v. Wade, our fate rests in the hands of a court who fails to recognize how a decision regarding women’s access to abortion will inevitably have a devastating impact on women of color accessing maternal healthcare? 

On March 20, 1981, John W. Hinckley, Jr. shot President Ronald Reagan and three others, and the following year, the jury found him not guilty by reason of insanity largely because of the presentation of scientific evidence during trial. During trial, Hinckley’s defense team introduced a computerized axial tomography (CAT) scan that suggested he had an atrophied brain, which is a common feature among those with schizophrenia. While the CAT scan did not prove that Hinckley had schizophrenia, it was enough to convince the jury to find Hinckley not guilty by reason of insanity. Nearly 41 years later, the incorporation of neuroscience into law, known as “neurolaw”, has dramatically expanded, particularly within the courtroom.   

Currently, neuroscience is used in the courtroom through several methods, such as presenting medical history, brain scans, and neurophysiological tests at trial. When medical history is presented at trial, judges are required to consider its information when reaching a verdict. Given that approximately 25% of defendants suffer from a mental illness, this is especially relevant when determining a defendant’s competency to stand trial. A second example is through brain scans, which can help determine correlations between activity in particular brain regions and human behavior. Lastly, neurophysiological tests are a current way to assess a defendant’s mental health by evaluating whether they had the requisite mental state to be held responsible for a crime.  

Generally, mentally ill defendants are sentenced to jail or a psychiatric hospital. If a defendant is found guilty but mentally ill, they are typically placed in a mental hospital and treated for their illness, rather than imprisoned. Sometimes, the defendant is neglected mental health treatment and placed in a jail. If a defendant is found not guilty by reason of insanity, oftentimes they are placed in a psychiatric hospital. While found not guilty, this verdict does not mean that the defendant is free to return to society. Incarceration without treatment has been linked to worsening a defendant’s mental health. In a Bureau of Justice Statistics survey, defendants were asked about their mental health 30 days before being incarcerated; 14% of those surveyed said they were having severe psychological distress. This rate doubled to 26% when defendants were asked about their mental distress while in jail. In jail, individuals face isolation and demoralization, which is not productive to those suffering from mental health issues. If these individuals are released after incarceration, they are more likely to reoffend. In contrast, individuals that received treatments for their illness were less likely to reoffend when released. For these reasons, neurolaw can aid in giving mentally ill individuals the proper treatment and punishment.

There are several advantages to expanding the field of neurolaw, including the actual treatment for mentally ill offenders, the use of risk prediction for crime prevention, and early inmate release. Using neuroscience in criminal cases would highlight treatment needs for mentally ill offenders, giving them a chance at recovery and management rather than just being sentenced to jail time. Risk prediction and assessment in neurocriminology can be used for prevention of future crimes and prediction of the offender’s likelihood to reoffend. Neuroscience can be used to help predict and therefore prevent crimes before they occur. This use of risk assessment could be integrated into prisons and mental health hospitals and act as a tool to release those offenders who are not considered a threat. 

Often times, mental history is overlooked, and defendants are punished without a chance of rehabilitation. When these offenders are released back into society, their chances of recidivism are even higher. Neuroscience methods, specifically the use of medical history in the courtroom, would allow judges and juries to understand the scope of a defendant’s mental history, allowing them to make more informed decisions about where to place a defendant if determined guilty. Ultimately, the merging of science and law provides diverse ways of thinking that can be used as an advantage to greatly improve the criminal justice system. While the use of neuroscience in the courtroom in determining sentencing has significantly expanded over the last few decades, there is still room for considerable expansion as technology continues to advance.

The intersection between health care and prison reform has arguably never been more publicly visible than through the inhumane living conditions endured by the detainees at the D.C. county jail. This jail has consistently come under scrutiny regarding its conditions including, but not limited to, extreme confinement lasting more than 400 days and a class action lawsuit pertaining to proper COVID protocols. Unfortunately, this is just one example of the many jails, prisons, and detention centers in America that force detainees to suffer through uninhabitable conditions.

An impromptu inspection in October of 2021 revealed that the D.C. jail’s roughly 1,500 detainees are forced to live in systemic, inhumane and unsanitary living conditions. Notedly, many of these detainees have yet to be found guilty and are currently awaiting trial. These egregious conditions range from denial of food, water, and showers for punitive reasons, cells filled with sewage and blood, water leaks, mold, roaches, and lack of access to necessary medical care. There is no question that long term exposure to these conditions leads to physical and psychological trauma, which increases the likelihood that they will require future medical care.

Many representatives have likened the jail’s conditions to unconstitutional, cruel and unusual punishments. Even Marjorie Taylor Greene drew attention to the matter by visiting the January 6th defendants and claimed they face conditions worse than the homeless and prisoners of war. The roughly 40 January 6th detainees, however, are located in the Correctional Treatment Facility (CTF). They are isolated from the jail’s general population with more sanitary conditions, and thus they will not be transferred immediately. In fact, many of the jail’s other detainees have filed emergency motions to transfer into CTF.

A 2015 report on D.C. prisoners’ living conditions proves that authorities were notified of these inhumane living conditions. These conditions, however, are nothing new to the Black detainees who make up 87% of the jail’s populationand have repeatedly complained throughout the years. It is no surprise that U.S. media attention and legal action began to rise due to complaints made by the mostly white, January 6th defendants. Recently, a U.S. judge held D.C. jail officials in contempt for delaying medical treatment to a January 6th defendant that broke his wrist in custody and required surgery. This judge further recommended that the Department of Justice investigate potential civil rights violations at the jail.

Following the 2021 inspection and recent legal actions, the U.S. Marshal ordered the transfer of all sentenced inmates beginning November 8, 2021. Unfortunately, many of these inmates will be transferred to a prison in Lewisburg, PA where living conditions are not much better and inmates will likely have less access to their lawyers. “The notion that Lewisburg is an improvement over the D.C. jail points to the degree of human suffering occurring right now,” said the D.C. Public Defenders Office. The rest of the detainees will remain in D.C. until their upcoming hearing dates where they will either be released or quarantined before being transferred to Lewisburg or federal prison. 

A silver lining can be found in the midst of these civil and constitutional rights violations, notwithstanding what it took to get them formally recognized. D.C. officials were forced to address these inhumane living conditions due to the influx of complaints, media attention, investigational reports, and legal actions. A local task force created and expedited a plan to replace the D.C. facility, which will be completed by 2027. This new facility will presumably be equipped with the safe, sanitary living conditions that these inmates deserve. 

In addition to human rights violations, it is also interesting to note the financial impact that systemic treatment of inmates across the U.S. has on the American economy and individual taxpayer. The Supreme Court previously determined that inmates have a constitutional right to medical care while in custody. Although inmates may retain pre-incarceration private insurance coverage, a majority qualify for Medicaid and Medicare. Those programs, however, often refuse to pay for health care during incarceration leaving states responsible for covering the cost in order to avoid constitutional violations. Thus, it is in the federal, state, and local governments’ best interest to maintain livable jails and prisons to reduce financial costs in addition to constitutional and civil rights violations. It is imperative that safer living conditions are incorporated in the discussion of prison reform; our nation’s incarcerated, taxpayers, and government will be better off for it.