Sandy Hook report: Preventing school shootings

On Dec. 14, 2012, Adam Lanza of Newtown, Conn., used this Bushmaster semi-automatic rifle in the mass killing of 26 children and educators at Sandy Hook Elementary School. The weapon, which is a civilian version of the M-16 military assault rifle, was equipped with a pair of 30-round ammunition magazines. /Law enforcement image

In the United States, few issues are more polarizing than guns. Even the fatal shootings of 20 young children and six educators at Sandy Hook Elementary School in Connecticut two years ago has failed to generate a consensus on ways to curb gun violence.

This week, the commission formed to advise Connecticut authorities about preventing school shootings issued its final report. The premise of the report is indisputable:

"There is at least one place, other than a home, in which every person, whether a child or an adult, should feel absolutely safe and secure from harm: school. Short of transforming our schools into gated communities or prison-like environments, however, no school can be freed entirely from the risk of violence. Nevertheless, through safe school design and operation strategies, and through closer coordination with our educators, local law enforcement, fire departments, EMS, public safety personnel, security experts and mental health professionals, our schools can become much safer environments."

The recommendations in the commission's report fall into three categories: safe school design and operation; law enforcement, public safety and emergency response; and mental and behavioral health.

While the shooter in this mass killing had been diagnosed with severe mental illness, the commission's report makes a key point about the role of mental illness in gun violence: "People with mental health challenges are far more likely to be victims of violence than perpetrators." In my opinion, improving the quality and availability of mental health services in the United States would decrease the risk of mass shootings; but the primary benefit would be boosting the productivity and quality of life for those suffering from mental illness and their loved ones. 

After reviewing the commission's 277-page report, I hope widespread support can be established for these recommendations, which have been edited to remove jargon and verbose prose:

• Requiring classroom and other safe-haven areas to have doors that can be locked from the inside. 
• All exterior doors in K-12 schools should be equipped with hardware capable of implementing a full perimeter lockdown.
• School custodians should be included as members of school security and safety committees. Custodians have a wealth of knowledge and experience to share about the physical school building and grounds.
• Mandatory background checks on the sale or transfer of any firearm, including long guns, at private and gun show sales.
• A ban on the possession or sale of all armor-piercing and incendiary bullets.
• Evaluate the effectiveness of federal law in limiting the purchase of firearms via the Internet to only those individuals who have passed background screening.
• Prohibit the possession, sale or transfer of any firearm capable of firing more than 10 rounds without reloading. This prohibition would extend to military-style firearms as well as handguns. Law enforcement and military would be exempt from this ban.
• To allow, at a judge's discretion, the opportunity to temporarily remove any firearms, ammunition, and carry permits from a person who is the subject of a restraining order, civil protection order or family violence protective order, at the time of the issuance of that order.
• Recognizing that mental health is more than the absence of mental illness, build systems of care that go beyond treating mental illness to foster healthy individuals, families and communities.
• Build a mental health system that targets detection and treatment while building stronger communities of care.
• Addressing a fragmented and underfunded behavioral health system tainted by stigma requires building a comprehensive and integrated approach to care. This approach should stress family involvement and community resilience. Care should be holistic and involve pediatric and adult medical facilities from birth to adulthood, with efforts to ensure continuity of care.
• Many students and their families live under persistent and pervasive stress that interferes with learning. There are many potential resources such as school-based health centers that should provide access to preventive care.
• Schools should form multidisciplinary teams to assess and support children who may pose a risk to others or themselves due to toxic stress, trauma, social isolation or other factors.
• For many children, schools offer the only access to health assessment services. Schools should increase the availability of guidance counselors, social workers, psychologists, and other health professionals during and after school.
• Increase the behavioral health workforce.
• Funding decisions about behavioral health must look beyond the model that has prevailed over the past several decades to embrace psycho-social interventions, services directed toward the achievement of functional skills, and other efforts to engage the whole person, which frequently offer the best prognosis for recovery.
• Commercial health insurance should cover the full range of services available through the public behavioral health system, including programs that provide housing and occupational support for individuals struggling with severe mental illness. 
• A diagnosis of mental illness does not have to mean an end to achieving one‘s life goals. Systems of care that promote wellness generally and recovery for those who struggle with behavioral health challenges and the effects of traumatic stress can help to diminish stigma and its effects.
• For adolescents and adults facing mental health diagnoses, effective psycho-education of both individuals and families can decrease stigma. Psycho-education involves teaching individuals and families about mental illness and its treatment, as well as strategies for handling typical challenges that might arise with a particular condition. The goal of such programs is to recognize that someone considered "different" or "odd" may need professional help.

Obamacare Curse: Healthcare politics tide turning

Kevin Counihan, CEO of the federal health insurance exchange operated in 37 states, ran the Romneycare exchange in Massachusetts and launched the successful state-operated exchange in Connecticut. /NPR image

There is a reason why the last major healthcare reform initiative, Medicare, was adopted 50 years ago: Revolutionizing healthcare is difficult in a country as large and diverse as the United States.

As the blush cools on the Republican triumphs in the fall's mid-term election, a huge healthcare storm is gathering over the Grand Old Party. With power comes responsibility, and who in their right mind would want responsibility for the fate of the U.S. healthcare industry?

No matter who is pulling the levers of power in Washington for the foreseeable future, the healthcare industry is going to be a tumultuous and expensive sector of the U.S. economy. The transformations envisioned under Obamacare such as expanded access to care through the new public insurance exchanges are propelling into full swing, fueling hope and trepidation among healthcare stakeholders.

My wife loves a folksy conundrum: "better the devil you know than the devil you don't know,"

Obamacare is the devil we know: a patchwork and ironically market-based approach to boosting access to healthcare while maintaining quality and constraining costs.

A Republican repeal-and-replace deal for the Patient Protection and Affordable Care Act is the devil we don't know: Scuttling Obamacare midstream would be disruptive, and the Republican cure for PPACA ills could be far worse than actual PPACA diseases,

It was easy for Republicans to snipe at Obamacare over the past five years: They did not have any ownership over the pressing need to reform the healthcare industry, which is spending about $1 out of every $5 generated in the U.S. economy. In an ominous political portent, one of the first GOP alternatives to the PPACA proposed in Congress this yearnhas gained no momentum, despite the sponsorship of three veteran Republican senators: Tom Coburn of Oklahoma, Orrin Hatch of Utah and Richard Burr of North Carolina.

Put yourself in the shoes of the 2016 GOP presidential candidates as the early contests in Iowa and New Hampshire loom large a year away. Would you want any of this healthcare action:

• Obamacare has garnered health insurance coverage for about 20 million Americans, but at least another 20 million citizens remain uninsured or underinsured.
• The U.S. healthcare industry has the best technology and pharmacology in the world, but there are vast disparities in the distribution of these assets and medications, particularly in rural and economically disadvantaged communities.
• Marrying provider service and payment models: The "fee-for-service" payment model is widely viewed as a source of quality-blind cost pressure in healthcare. Traditional Medicare is based on a fee-for-service payment model -- beneficiaries get sick, they go to their doctors for healthcare services, then Medicare pays for those services. Under traditional Medicare, doctors have no monetary incentive to help keep their patients healthy. They have the opposite incentive: the sicker their patients get, the more services they can bill and the more money they can make. The key to healthcare reform is marrying value-based redesign of provider services with value-based payment models, such as physicians providing more preventive care for seniors and Medicare finding new ways to pay for preventive care. Marrying provider service and payment models that are geared to generate health value rather patient volume requires change on a grand scale. The healthcare industry's mindset needs to focus on health, not healthcare services. By the way No. 1: The marriage of value-based healthcare service models with value-based payment models cuts to the heart of every healthcare industry organization's business model, and wedding-day jitters are rattling boardrooms across the country. By the way No. 2: Healthcare providers and payers have had bitterly adversarial relationships for decades.
• Detroit native Otis Brawley, MD, of the American Cancer Society is a top healthcare disparity researcher. He believes every human being has a fundamental right to basic healthcare services. Millions of American -- mostly in rural and socio-economically disadvantaged communities -- do not have access to basic healthcare.
• The status of American health poses an elephantine challenge. More than one-third of Americans are obese, according to the Centers for Disease Control and Prevention. Obesity is directly linked to three of the deadliest diseases in the United States: diabetes, heart disease and cancer. Without changes in the American diet and level of physical activity, no amount of reform contortion in the healthcare industry will improve care at a sustainable cost.
• In the real world of healthcare reform, acceptable performance would not be considered tolerable in nearly any other industry. The open enrollment period that just concluded on the Obamacare exchanges is a case in point. The federal exchange website, HealthCare.gov, crashed less often than the glitch-plagued first open enrollment a year ago, but an income verification feature failure on Valentine's Day prevented about 500,000 people from enrolling; the HealthCare.gov call center was overwhelmed with would-be beneficiaries over the entire Valentine's Day weekend; and the income verification glitch and long call center wait times prompted federal officials to extend the open enrollment period for one week. The open enrollment extension is a blow to health insurance carriers, which are struggling to make the "back end" of the exchanges work, including cumbersome enrollment verification and data sharing processes. Despite these fumbles, health plan enrollment has nearly doubled on the exchanges to more than 11.4 million people. This is what success looks like in the realm of healthcare reform, but it's not the kind of clear-cut success on which political empires are built.  

Looking ahead, many Republicans are rubbing their hands together gleefully at the prospect of a Supreme Court blow to the Obamacare exchanges. But a nervous few in the GOP ranks are sitting on their hands hoping they will not have to clean up a healthcare train wreck.

Next month, the high court is set to hear oral arguments in King v. Burwell, which could strip federal healthcare coverage subsidies from Obamacare insurance exchanges in 37 states. This year, those federally operated exchanges are on track to help provide about 8 million Americans healthcare coverage. The vast majority of the people who purchase health insurance on the exchanges receive subsidies, which are a key affordability leg in the Patient Protection and Affordable Care Act.

If the Supreme Court rules against the Obama administration in King v. Burwell, how will Republican lawmakers fix the damage associated with millions of Americans no longer being able to afford their health insurance? How much will it cost to fix the damage?

The first blood-letting in Republican efforts to unravel Obamacare passed relatively quietly this winter: the bankruptcy of the Iowa-based PPACA insurance cooperative, CoOportunity. The GOP put a fatal financial squeeze on CoOportunity in December. U.S. taxpayers are now on the hook for as much as $145 million in federal loans to the failed insurance cooperative, and 96,000 people in Iowa and Nebraska have been forced to purchase new health coverage from other carriers.

In the 2016 election cycle, playing politics with healthcare is not going to be fun for anyone.

Bullwork of democracy never rests

North Korea hacks Sony, November 2014 - January 2015

With the launching of a blatant cyber attack on Sony over the release of "The Interview," Kim Jong-un's regime revealed its greatest weakness: the truth.

North Korea took a significant risk hacking Sony, weighing exposure of the country's cyber warfare capabilities against the threat to Jong-un's cult of personality. The inevitable retaliation from abroad was a built-in bonus for the pariah country's Stalinist government.

ISIS poses grave threat

The aftermath of George W. Bush's war in Iraq was always a matter of how bad the outcome would be for the United States and the Middle East. This is about as bad as it gets.

The most prescient critics of the Iraq War compared the U.S.-led invasion to plunging a fist into a hornets nest. Now, Iraq is a nearly failed state, with a dysfunctional army; Iran is ascendant; and the region is buzzing with violence and reeling under the crushing weight of religious extremism reminiscent of The Crusades.

The Islamic State of Iraq and Syria, aka Islamic State of Iraq and the Levant, is so vicious that even disgraced Syrian President Bashar al-Assad is a palatable partner in the fight to defeat them. Mass executions and immolation of prisoners are never good hallmarks of social movements.

Rudy Giuliani plays with weapon of mass political destruction

It's like the script to an apocalyptic science-fiction movie about a society developing weapons of mass destruction that careen out of control. Republican should be careful what they ask for, they just might get it.

Former New York Mayor Rudy Giuliani beat the lowest drum of Republican politics last week, accusing President Obama of lacking love for his country and harboring hostile intent in his heart for America because of his upbringing.

Socialism reality check: Obama has been as friendly to Wall Street as any Republican president. The Hawaii native let the perpetrators of the 2008 financial meltdown skate.

Top 10 Healthcare Quotes: HealthLeaders Year 1

These are the most precious pearls of healthcare wisdom I have gathered since joining Danvers, MA-based HealthLeaders Media a year ago: 

David Hare, National Health System Confederation, London 

"The hospital is the symbol of healthcare, and we need to change that."

James Weinstein, DO, Dartmouth-Hitchcock Health, Lebanon, New Hampshire

"We need to create a sustainable health system, not a sustainable healthcare system. ... The model needs to focus on health, not healthcare."

Anita Goel, MD, PhD, Nanobiosym, Cambridge, Massachusetts

"Our consciousness in the healthcare industry is very much rooted in a centralized paradigm dating back to the Industrial Revolution in the 1700s. ... Just as Google disrupted the information industry and a country like India went from a few hundred thousand land lines a little over a decade ago to over 900 million cell phones today, I believe we are at the tipping point of a similar impending disruption in the healthcare industry."

David Burton, MD, Former CEO and Chairman, Health Catalyst, Salt Lake City, Utah

"In this early, adolescent stage of shared risk, you're going to have people operating in an immature manner. It's a lot harder than it looks. Providers end up doing it less efficiently than a third party payer. ... You do, in fact, need someone to do the administrative aspect of an ACO."

Rebecca Katz, Master Chef, San Francisco Bay, California

"It's looking at food and cooking food in a way that's delicious and nutritious: food you like and cooking you like. It's not just a diet, it's a way you live your life."

Otis Brawley, MD, American Cancer Society, Atlanta, Georgia

"There is basic healthcare that every human being has a fundamental right to."

Mike Beebe, Former Governor, State of Arkansas

"These states that are just saying 'no' to [Medicaid expansion] are just paying for the rest of us and not getting anything in return at the expense of their people and their hospitals. ... You're hurting your own people."

Kevin Counihan, CEO, Federal Marketplace, Washington, DC; former CEO, AccessHealthCT

"We think that retail is the future, the consumer is the future. The days of group coverage are waning. In five to 10 years, you're going to see a major change. People want more choices. They want more flexibility."

Michael Yuhas, President and CEO, Integra ServiceConnect, Owings Mills, MD

"This is not a healthcare intervention we're talking about. We've been taught historically that when something breaks, you bring the patient in to fix it. But once you find [a health plan beneficiary with a behavioral health condition], that is not enough. You have to engage them. You have to let them know you are friend and not foe. We've created a science of finding people, engaging them, and connecting them to the services they need."

Earl Ferguson, MD, PhD, Cardiologist, Ridgecrest, California

"We need to recognize that primary care can't do everything alone. Primary care providers must be the coordinators of comprehensive care, but specialty care is essential to assist them in the ongoing management of many of their patients."

MLK holiday: 'Tame the savageness of man'

On April 4, 1968, Sen. Robert F. Kennedy delivered one of the greatest speeches in U.S. history.

Kennedy was in Indianapolis for a campaign event in his run for the presidency. At the rally, the New York senator and brother of a slain president delivered timeless remarks about civil rights icon Martin Luther King Jr., who had been assassinated earlier that evening.

This speech overflows with wisdom, but I do have a favorite gem of sage advice:
"Dedicate ourselves to what the Greeks wrote so many years ago: to tame the savageness of man and make gentle the life of this world."

American journalism's secrets revealed

 

Objectivity is declining in U.S. journalism, which is in danger of turning back the clock more than a century to a time when nearly every city in America had newspapers aligned with the Democratic and Republican parties. /Fox News image

American journalism was once widely known as the Fourth Estate, an elite sector of American society responsible for keeping an eye on the government and helping to inform the citizenry.

Now more commonly known as members of The Media, U.S. journalists walk a very fine line. Despite the necessity of a free press to serve as a bulwark of democracy, Americans are virulently skeptical about elites. There is little love for the fat cats of corporate boardrooms, political power mongers, ivory tower dwellers, or an arrogant know-it-all of any ilk.

It is hard to imagine a more public enterprise than journalism, but it is amazing how little the public knows about the inner workings of the Fourth Estate. In the spirit of benevolent know-it-allism, here is a glimpse of the newsroom's secret society:

• Headlines are the high art of journalism, whether they appear in print, online, television graphics, or at a radio broadcast's "top of the hour." The best headlines are promotional without overselling. Headline writing is a mysterious craft. The masters of this art are nameless and faceless editors, not the reporters seen on the street or working the phone gathering the news.
• Prior review of news stories has always been rare and is nearing extinction. Allowing people who serve as sources of news to review a story before publication or broadcast is a cumbersome process. When gathering news, a reporter assembles notes, video footage or audio snippets into a story format, then at least one editor massages the material into a final form. For prior review to be meaningful, it must occur after the editing process. One of the harsh realities of journalism is that only the most financially successful news magazines have the time and resources to accommodate prior review.
• Deadline pressure is intense in news media organizations. The sense of urgency is at least two-fold: avoiding the possibility of a competitor beating you to the punch and the fundamental truth that the best news is new not stale. As is the case in any industry, deadline pressure is one of the prime drivers of media errors.
• In America, journalism is a business, particularly if a news media organization produces quality content. Even in the blogosphere, which has been a democratizing force for the Fourth Estate, production of high-quality journalism is a high-cost venture. The public rightfully gravitates toward expertise and eye-catching presentation when consuming news. Expertise requires formal education or years of experience, neither of which comes cheap in America. Attractive presentation requires a knowledge of design and mastery of technology, which also come with a price.
• Story selection is a constant source of consternation in the public, but it reflects one of my best friend's favorite adages: be care what you ask for, you just might get it. Editors have always known sex and violence sells. With the rise of the Internet as a journalism medium, now editors have data that shows conclusively the kinds of stories that draw the public's interest. There are media outlets that consistently present important stories about government policy and community affairs, but there are many more that pander to prurient page clicks.
• Trust is the secret sauce of journalism. Reporters have to establish a level of trust with their sources to gather information that is often sensitive in nature. Editors have to trust their reporters are gathering accurate information and representing it truthfully. The public is best served when it can turn to trustworthy news organizations for information that affects individuals, families, communities and the country.

Ebola bares hospital training, disease control flaws

Nina Pham, a critical care nurse at Texas Health Presbyterian Hospital Dallas, is the first American to contract Ebola on U.S. soil. /Image via pbs.org

Despite confident statements from the federal Centers for Disease Control and Prevention, America's first test treating an unexpected case of Ebola teetered on the brink of total failure.

Missteps at Texas Health Presbyterian Hospital, insufficient CDC protocols, and an apparent shortfall of preparedness across the public health spectrum have exposed gaping holes in capabilities to stave off potentially cataclysmic biological threats. As the crisis deepens, a moment of truth looms for U.S. health care.

Beyond containing the outbreak in Texas, there are colossal challenges in the weeks and months ahead:

• Rearranging the CDC's national response to Ebola on the fly
• Boosting preparedness at more than 4,000 acute care hospitals
• Restoring confidence in hospitals, both among caregivers and the general public

Russian Big Lie Watch: Lost Paratroopers in Ukraine

After Russian paratroopers were captured in Ukraine in late August 2014, they were quickly swapped for Ukranian prisoners of war. /AFP image

Big Lie: Ten Russian paratroopers captured recently in Ukraine "really did participate in a patrol of the Russian-Ukranian border, crossed it by accident at an unmarked section, and as far as we understand showed no resistance," the Russian Defense Ministry said according to the BBC.

Closer to the truth: "This wasn't a mistake, but a special mission they were carrying out," a Ukranian military spokesman said.

Ukraine bulwark against Russian aggression

A resident reacts to shelling damage in Donetsk, eastern Ukraine, in August 2014. /CTV News image

Ukraine is a fledgling democracy, and young governments of the people are more imperfect than their mature counterparts such as Australia, Switzerland and the United States.

Vladimir Putin's Russia is imperfection incarnate.

The Russian president, ex-KGB officer, Judo expert and all-star power monger has pushed his James Bondesque villain game to an Ivan the Terrible level. In 2014, Putin has racked up a string of stains on humanity, from exterminating dogs at Sochi during the Winter Olympics to launching an aggressive war against Ukraine.

Putin's Russia, which ranks as an authoritarian regime in indexes of democracy, appears determined to re-establish key elements of the Soviet Union, including large chunks of Ukraine.

This is starting to look a lot like Stalin's Russia.

Russian tanks are invading an Eastern European country and the Kremlin has dusted off a propaganda tool imported from Nazi Germany during World War II: The Big Lie. Joseph Goebbels, who operated Hitler's propaganda machine, was the master of the WWII whopper: "If you tell a lie big enough and keep repeating it, people will eventually come to believe it."

For weeks, the Russians have been deploying The Big Lie about their military activity on Ukrainian soil. Foreign Minister Sergei Lavrov shamelessly fired up the propaganda machine, claiming NATO satellite photos showing heavily armed Russian military units conducting operations inside Ukraine had "turned out to be from video games."

NATO satellite imagery reportedly shows Russian military units operating inside eastern Ukraine.

Ferguson reminder about race in America

Police in riot gear confront protesters in Ferguson, Mo. The fatal police shooting of an unarmed African American teenager on Aug. 9 inflamed racial tensions in the St. Louis suburb. /Image via npr.org

Many Americans want racially charged issues to go away.

But the final steps in the country's 400-year-long journey through the pitfall-strewn landscape of racial injustice have yet to be taken.

Whether it fits into your view of the United States or not, the racially charged violence sparked by the police shooting of 18-year-old Michael Brown in Ferguson, Mo., is an ugly reminder about the country's struggle to overcome centuries of bias against African Americans.

As long as African American teenagers walking down the street are at high-risk of being shot to death, America has more steps to take.

As long as white men think it is acceptable to drive around in their pickups with battlefield Confederate flags flying from the truck bed, America has more steps to take.

As long as nearly half of the people incarcerated in the United States are black, America has more steps to take.