Beginning tomorrow, women's health care will get a big boost, thanks to the Affordable Care Act.

Insurance companies will have to pay for women's well-care with no out-of-pocket costs for women. That includes screenings for cervical and breast cancer, contraception, breastfeeding counseling and supplies and more.

Until the ACA, insurance companies could deny full coverage for birth control and women could be forced to pay co-pays (or full charge in the case of high-deductible plans) for mammograms and PAP tests.

While opponents are still fighting for the "right" to deny women coverage for birth control, most plans will cover it.

The US Department of Health and Human Services recommends screenings and counseling for sexually transmitted diseases, Hepatitis C, HIV/AIDS, for high blood pressure and cholesterol and diabetes and for obesity and domestic violence.

The good thing about all of this is that breast and cervical cancers will be caught earlier, when they are most curable. Until now, women with high-deductible health insurance plans were as likely as uninsured women to have their cancers discovered at later stages and more likely to die from them.

Women in violent relationships can get help getting out before their abusers kill them instead of feeling helpless and trapped.

New mothers will get help in breastfeeding, which is better for both mother and baby -- and far less expensive than formula.

Not only was denial of these services inhumane, it was incredibly expensive. Cancer is hideously expensive to treat -- chemo can cost hundreds of thousands of dollars, while a mammogram costs about $100 to provide. Even if an early cancer is discovered, a lumpectomy and perhaps one round of chemo are far less expensive than finding a cancer after it has spread, both in dollars and in human cost.

Allowing women no-cost access to these tests and services will save thousands of lives every year. Mothers, grandmothers, sisters, aunts, daughters and friends will survive because of it, and our overall medical costs will decline.

Sounds like a win-win to me.

Presidents Johnson and Truman, 7/30/65
Medicare turns 47 today, and I'm old enough to remember it -- I was almost 13 at the time and more politically aware than most people my age.

Like the Affordable Care Act, Medicare was denounced as a socialist program (actually, many called it Communist). It was the first step on a slippery slope.

Medicare was conceived by Harry Truman, who advocated a universal system, but he was willing to start by caring for the elderly. As soon as he proposed it in 1952, the American Medical Association denounced it and worked to stop its passage.

In 1958, Democratic Congresswoman Aime Forland of Rhode Island, introduced it again, and the AMA squashed it again with a massive campaign.

In 1960, a bill was passed creating a health care plan for indigent elderly, but it wasn't a so-called entitlement program that would cover everyone who paid into it, but even this was too much for opponents.

In 1961, a new bill that was closer to Medicare as we know it, was vehemently opposed by the AMA and its affiliates. The Woman's Auxiliary of the AMA launched Operation Coffee Cup -- a series of small gatherings in communities across the country -- to oppose it; the AMA bought full-page ads in newspapers and took to the airwaves to denounce the bill, known as King-Anderson.

Ronald Reagan made a recording to be played at anti-King-Anderson gatherings, which featured an 11-minute impassioned plea from Ronald Reagan to help him stop this socialist threat:

"One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project. . . . "

If Medicare became law, according to Reagan, we were headed straight for totalitarianism:

 ... From here it's a short step to all the rest of socialism, to determining his pay. And pretty soon your son won't decide, when he's in school, where he will go or what he will do for a living. He will wait for the government to tell him where he will go to work and what he will do.

He urged good Americans to write to their members of Congress and ask then to vote against this travesty. Otherwise:

And if you don't do this and if I don't do it, one of these days you and I are going to spend our sunset years telling our children, and our children's children, what it once was like in America when men were free.

This time around we have the histrionics of the Tea Party calling for a stop to "Obamacare."  The problem is the same, though. In the 1960s, the anti-socialist frenzy was whipped up by doctors; today it is whipped up by the Koch Brothers and Dick Armey, who can afford their health care and who don't want to help pay for yours.

Medicare has saved thousands and thousands of lives, offering access to care for people who otherwise wouldn't be able to afford it through our for-profit system. Medicare is one of the most efficient, effective single-payer programs in the world. It is not going broke -- or at least it won't if we can get our national priorities back in line.

A generation or two from now, most Americans will ask what the big deal was about "Obamacare."

I moved to North Carolina almost 11 years ago to take a job as health reporter for the Citizen-Times. Soon afterward, I began covering mental health "reform," which pretty much involved the implosion of a system that had been working OK.

Even before the new system went live it was easy to see where it would fail, and it did. It was poorly planned and policies were poorly written. It depended on private service providers who were supposed to be eager to take on this population but who never materialized in big enough numbers to meet the need.

Rules and regulations changed so quickly it was impossible for service providers to keep up. There was no standardization of forms so providers found themselves filling out dozens of forms with the same information for various state and federal agencies.

Where people knew where to go for help and services before the change -- the area program was one-stop -- no one seemed to know what to do afterward.

Former state Department of Health and Human Services Secretary Lanier Cansler declared reform over three years ago and began to work on rebuilding the system, but there was no funding, and he couldn't coax anything out of the GOP-led General Assembly in Raleigh. Eventually, he stepped down rather than preside over the gutting of DHHS.

Then last year, the federal government sent word it would enforce a Medicaid rule about adult care homes that has been on the books for more than a decade, and which North Carolina has been flouting.

Under the rule, facilities knows as IMDs (Institutions for Mental Disease) are not eligible for Medicaid -- residents' Medicaid is suspended while they live in the home. An IMD has more than 16 beds, with half or more of those beds occupied by people whose primary reason for being there is a mental illness.

But residents of adult care homes do get Medicaid, so homes want to be classified as adult care rather than IMD. The problem is that if more than half of the home's residents are there primarily for mental illnesses, the home has to be reclassified, and it loses Medicaid funding.

There are other methods of payment, including billing residents, who get money for living expenses each month from Medicaid, and from state and local funding sources. They are still eligible for personal services such as medication management, food planning and help with everyday tasks such as dressing or bathing, as long as they need help with two or more of these daily tasks.

People who live in adult care homes get the same services, plus Medicaid, and there is no responsibility for treatment of the mental illness other than issuing medications, so it is more profitable to be an adult care home.

But the federal government expects North Carolina to comply with the "50 percent rule," and it is ready to come down on the state for noncompliance.

"The federal government expects North Carolina to comply," said Vicki Smith, director of Disability Rights NC. "There's a lot of shuffling around of residents to get homes into compliance, but that won't work for long."

The state has to move to fix this problem, Smith said; otherwise the federal government could demand the return of all Medicaid funds that went to homes that are not in compliance.

"Believe me, the state will be aggressive on this because they don't want a payback," Smith said.

On June 1, a letter went out to a home in Madison County, informing the owners that the home was being reclassified and would no longer be eligible for Medicaid funding. That would mean the residents who are not in the home for mental illness also would be cut off from Medicaid funding, affecting the viability of the home and the well being of all the people in it.

Twelve more homes got the same notice, and were able to get a temporary restraining order as they move residents around to get under their number of people with mental illnesses down to below 50 percent. One home has moved several people to Virginia.

Counties' departments of social services and local management agencies are working to find placements for people who are being moved out of homes, but it is a scramble, and people will fall between the cracks.

"The owners of these homes are good at gaining sympathy," Smith said. "They talk about taking people out of the only homes they know and how sad that is -- and it is -- but they are not in compliance with federal regulations."

Unfortunately, the victims of the state's noncompliance are the people who have mental illnesses. It's likely many adult care homes will stop taking any people with mental illnesses, and we will see even more people on the streets.

The entire situation could have been prevented if the state had planned and put in place the services people need instead of trying to do mental health on the cheap.

The solution is the same one that the state seems to have rejected all along: help people with mental illnesses manage this chronic condition before there's a crisis, before they become sick enough so they can't maintain themselves in a home.

"The state finally, finally will have to start developing appropriate services," Smith said. "But in the meantime it's the person with a mental illness who will suffer."

Once again, our health care system comes up short.

A recent study by the Commonwealth Fund, "Oceans Apart," details the higher rate of women in the US not getting the care they need as compared to women from 10 other countries.

The figures, from 2010, show that nearly 19 million women ages 19-64 were without insurance in 2010, up by about one-third from 1000. Nearly 17 million more women had health insurance but had such high out-of-pocket costs that they couldn't afford care -- making them effectively uninsured.

In all, the survey showed, 43 percent of US women were not able to access the care they needed because of cost. Among women who were uninsured all year, that rate was 77 percent.

So much for the idea that the number of uninsured are inflated by people with plenty of money not buying insurance because they just don't want to.

These women skipped medications, decided to forgo mammograms, PAP tests and other tests and treatments, meaning that if they did have health issues, those problems were made much worse -- even deadly -- because of lack of access to care. That also makes care, when they do get it, far more expensive.

Now look at the numbers in other countries. None of them is perfect, but the rates of women not getting care because of cost are far, far lower. Look at the United Kingdom with its state-run system. Just 7 percent, and the Netherlands is at 8 percent.

I don't know the rates for men, who need screening for prostate cancer, blood pressure and cholesterol levels. But their insurance rates are lower -- in some instances 50 percent lower -- for the same coverage.

In 2014, our rates of uninsured will go down, thanks to the Affordable Care Act. How far depends on the willingness of states to expand Medicaid coverage to everyone with an income less than 133 percent of federal poverty level.

Health reform isn't finished, but we are starting to see improvements. Maybe in a few years we won't be coming in at the very bottom of every measure of care.




When I moved to Asheville, NC, 10 years ago, it had one of the best public health departments in the state, if not the nation. Its clinic saw everyone who had fallen through the cracks and its Project Access, operated through the Medical Society, helped uninsured, low-income people get free care from specialists and hospitals.

The Health Department had a program that offered free birth coaches to families in need.

Then, a few years ago, the county health department began to downsize. Today, the clinic is closed and a free clinic sees its patients --  at least those who know to go there. Project Access accepts only the neediest because the number of  uninsured has risen to such heights. The birth coach program is gone, although Life o' Mike has developed its own program, using the doula who ran the original program as an advisor.

But the same thing has happened across the country. One of the first places governments make cuts is in public health.  Across the country, Buncombe County's experience is mirrored -- or worse. Smoking cessation and prevention programs have been cut.

As the amount of money spent on anti-smoking programs decreases, the number of smokers is bound to increase again.

Public health is where we turn when diseases threaten -- such as antibiotic-resistant forms of tuberculosis or hepatitis outbreaks. Spending on public health protects us from these and other threats. It helps assure us that restaurants are safe to eat in. It helps pay for flu shots and other immunizations that keep epidemics at bay.

Funding for public health efforts had been falling steadily since the 1980s until the terrorist attacks and then the anthrax scare. Money poured into shoring up our crumbling public health system.

But we as a nation have a very short memory, and instead of raising taxes to pay to protect us all, governments have slashed public health funding once again.

Public health departments and personnel are paid for with tax money because they protect all of us. Without that money, epidemics and food-borne illnesses become more likely, and they will be a lot more expensive than paying for an adequate public health system.