Equity of Mental Health Services Coverage

source: bls.gov

source: bls.gov

Public Health in the National News – As part of the fallout from the recent school shootings and outbreaks of gun violence, the Obama administration promised to improve mental health services. One of the 23 executive actions taken to reach this goal was to issue the final rule to fully implement the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Overall, the MHPAEA does not require insurers to provide mental health and substance abuse benefits unless they are being offered through the state insurance marketplaces as defined by the 10 essential health benefits implemented under the ACA. However, if benefits are offered, the final rule signals significant changes to large group health insurance plans by requiring that benefits for mental health and substance abuse services be treated equally to other types of health services, including treatment limitations, financial requirements, and annual or lifetime dollar limits. In addition, the ruling ensures access to intermediate levels of care for residential treatment and outpatient mental health services and clarifies plan participant disclosure rights (i.e., explanation of comparable deductible and visit limits for both mental and general health care). It also requires insurers to charge similar co-payments for mental health treatments and services as they would for physical health problems.  In addition, the final rule also clarifies that the Affordable Care Act trumps parity law by not allowing annual or lifetime limits on essential health benefits, which for mental health and substance use disorder services include behavioral health treatment (e.g., counseling and psychotherapy), inpatient services, and treatment for substance use disorders. The combination of these recent policy changes means improved access to behavioral health services for millions of Americans.

For further information:

General Resources for Mental Health


The Insurance Marketplace and Mental Health and Substance Use Services


Fact Sheet on the Mental Health Parity and Addiction Equity Act


Full Text of the Final Rule for the Mental Health Parity and Addiction Equity Act


This article was written by Kelly Shaw-Sutherland, MPA, a health data analyst in the UNMC COPH Department of Health Services Research and Administration, and Jim Stimpson, PhD, director of the UNMC COPH Center for Health Policy and an associate professor in the UNMC COPH Department of Health Services Research and Administration.

Surveillance Testing for Influenza Virus

source: ct.gov

source: ct.gov

Public Health in the National News – During the recent government shutdown, news media frequently mentioned that the Centers for Disease Control and Prevention (CDC) had stopped surveillance testing for the influenza virus. What is surveillance testing and why is tracking influenza outbreaks important? The Nebraska Public Health Lab’s assistant director, Anthony Sambol, and state training coordinator, Karen Stiles, help shed some light on the process recommended by the CDC.

The Nebraska Department of Health and Human Services Office of Epidemiology has had a comprehensive, statewide influenza surveillance testing system in place since 1999. This system actively tracks the type and incidence of influenza infections in our state. When a  patient is diagnosed by the Rapid Influenza Detection Test as having an influenza virus type “A” or “B” or other influenza-like illness under the state surveillance program, the specimen is sent to the Nebraska Public Health Laboratory (NPHL), located in the Department of Pathology and Microbiology at the University of Nebraska Medical Center, for further testing and confirmation. If the sample is confirmed positive at the NPHL by methodologies provided by the CDC, the NPHL sends the sample to the CDC for further antiviral susceptibility testing as well as strain characterization. This process is followed by other states as well.

The surveillance system is important because it provides real-time data on the prevalence of influenza within Nebraska, allowing health officials to issue reminders about getting vaccinated as well as social distancing and treatment if an individual is infected. The data is also important on several levels as it provides information on the target group that is coming down with the most cases of influenza, the virulence of the disease strain, the course of the disease within the state, and the efficacy of the vaccine for the general population.

Additionally, not all strains of influenza virus can be treated with the same antiviral medication. The data can be used to make recommendations on where shipments of influenza vaccine should be delivered and the age group targeted for vaccination, so the most affected communities receive increased numbers of doses to be used.

Besides surveillance on a state level, the CDC tracks influenza infections on a national level. They monitor for the different strains of influenza circulating in the environment as well as the antiviral patterns seen in these strains. By doing this type of surveillance, the CDC can send out information to all health care providers, as well as the general public, about how the influenza season is progressing, the need to continue to get vaccinations, and the use of antiviral medication that can be taken to help alleviate symptoms if infected with influenza.

The importance of surveillance testing of influenza virus was demonstrated in the May 2009 outbreak of a new strain of Influenza A, H1N1, that occurred first in Mexico and then spread rapidly in the United States and the rest of the world. Without the CDC surveillance system, people would have had no medical guidance to help fight the diseases. To read more about this topic, please go to http://www.cdc.gov/flu/index.htm

This article was written by Anthony R. Sambol, MA, SM (NRM), SV (ASCP), assistant director NPHL, and Karen Stiles, MT (ASCP) SM, state training coordinator NPHL.

Herd Immunity?

U.S. and Mexico Vaccine Preventable Disease Outbreaks 2008-2013, Council on Foreign Relations. LEGEND: Red = measles, Brown = mumps, Green = Whooping Cough, Yellow = Other

U.S. and Mexico Vaccine Preventable Disease Outbreaks 2008-2013, Council on Foreign Relations. LEGEND: Red = measles, Brown = mumps, Green = Whooping Cough, Yellow = Other

Public Health in the National News – If you mention “herd immunity” to someone in the agricultural belt of the United States, your conversation will likely turn to livestock. For infectious disease experts, the term means something similar, but it is used in reference to large groups of humans rather than animals. “Herd immunity” and immunization have played a historic role in combating human disease and stabilizing human populations.

History gives us many examples of contagious diseases that decimated populations, for example the plague outbreak in the mid-1300s that came to be known as the “Black Death,” which killed an estimated 30%-60% of Europe’s total population. In the modern era, however, vaccines have helped reduce infectious disease pandemics and stabilize populations. Widespread immunization programs have led to what infectious disease experts refer to as “herd immunity,” meaning that an entire group of people is protected when a large percentage of group members are immune to a particular disease agent. Herd immunity applies to a disease if the following conditions are met:

1) The disease agent is restricted to a single host (i.e., humans)

2) Transmission is relatively direct from person to person

3) Solid immunity against the disease agent is obtained from vaccination or previous infection

The recent surge in outbreaks of vaccine-preventable disease highlights the complexity and challenges public health agencies face in helping communities achieve herd immunity. Since 2009, there have been over 90 vaccine-preventable outbreaks in the United States alone, accounting for 381 Measles cases, 160 Mumps cases, and over 44,000 cases of whooping cough [1,2]. Roughly 80% of outbreak-associated cases are unimmunized, indicating populations of unvaccinated individuals are a key element of these outbreaks [3].

Barriers to child vaccination include practical issues such as a lack of transportation or money to access vaccinations, and personal concerns such as parents with personal or religious beliefs that oppose vaccinations [4,5]. Emotional or psychological concerns, for example a now-disproven theory that vaccines cause autism, may also cause parents to decide against vaccinating their children. Additionally, a significant number of parents don’t understand the importance of vaccinating their children, are overwhelmed by complex immunization schedules, or find it difficult to make time to complete a full course of vaccinations [6,7].

It is important for care providers and public health practitioners to recognize that people interact with information through their experiences and social settings. Educating parents involves more than providing the facts about the importance of immunization to prevent their children from contracting these infectious diseases and to maintain herd immunity. We must also be ready and willing to address the fears and concerns parents have with vaccinations.

This article was written by John Lowe, PhD, assistant professor in the UNMC COPH Department of Environmental, Occupational, and Agricultural Health, and by KM Monirul Islam, MD, PhD, assistant professor in the UNMC COPH Department of Epidemiology.

[1] Council on Foreign Relations, (2013). Vaccine-Preventable Outbreaks
[2] CDC (2013). Measles – United States, January 1-August 24, 2013. (2013). MMWR Morb Mortal Wkly Rep, 62(36), 741-743. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a5.htm
[3] CDC (2013). Notes from the field: measles outbreak among members of a religious community – Brooklyn, New York, March-June 2013. MMWR Morb Mortal Wkly Rep, 62(36), 752-753.
[4] Dorell, C., Yankey, D., Kennedy, A., & Stokley, S. (2013). Factors That Influence Parental Vaccination Decisions for Adolescents, 13 to 17 Years Old National Immunization Survey–Teen, 2010. Clinical pediatrics, 52(2), 162-170.
[5] Dubé, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. A. (2013). Vaccine hesitancy: An overview. Human vaccines & immunotherapeutics, 9(8), 0-1.
[6] Wick, J.  (2011). Removing Barriers to Childhood Immunization. Pharmacy Times. August.
[7] Leask J. (2011). Target the fence-sitters. Nature. 473:443-445.

Winter Weather Safety (already?)!

GBsnowPublic Health in the National News – Did you know that Omaha averages 28 inches of snow per year, Des Moines averages 33 and Chicago 38? Going west Scottsbluff averages 40 inches, Denver 60, and Cheyenne 55?  The National Oceanic and Atmospheric Administration (NOAA) is predicting that a ‘wavering’ El Nino will mean a warmer and drier winter for the Midwestern US. Good news, right?

It is good news, but don’t let this early prediction fool you. Ice and snow can be dangerous, and it’s a good idea to think about it before you run into bad weather. In fact, the National Weather Service recommends that we prepare well before the first snow starts to fall. Keep this in mind when you are planning travel for this fall if you’re headed to states that have white winters.

One way to stay safe and healthy this winter is to put a winter weather kit in your car. Start putting your kit together now, so you can spread the expense over several months. The kit should include:

  • Phone charger and/or an extra battery

  • First aid kit

  • Shovel and tow rope

  • Battery booster cables

  • Blankets, extra clothes, hats, mittens, etc.

  • High calorie, non-perishable food

If you should get temporarily stranded in your car, stay inside until help arrives (unless you are stalled in the middle of the street, of course). In most cases, you are safer staying in your car.

You should also have some supplies in case you get stranded at home.  Stock up on non-perishable food before the storm. And, be particularly careful with alternate heat sources like fireplaces and some space heaters. The risk of fire and carbon monoxide poisoning increases when these sources are used. Do NOT run generators in your house!

When the snow and ice stop and you can finally venture outside, be sure to stay as dry as possible; cover all exposed body parts and layer your clothing. Also, be sure to eat and drink enough to keep your energy and prevent dehydration.

The National Weather Service provides the latest weather forecast, including potentially hazardous conditions. NOAA has teamed with the Red Cross to provide a  preparedness guide for winter weather. Many state Departments of Transportation (or Department of Roads) also provide information on road conditions. Or you can call 511 in most states for information as well. There are also a multitude of weather-related phone apps that provide up to the minute forecasts and warnings.

Winter can certainly be a wonderland. Just be sure you don’t underestimate the power of ice, cold, snow and wind. Be safe and enjoy the season!

Keith Hansen, MBA, is the assistant director of the Center for Preparedness Education, a joint endeavor between the UNMC College of Public Health and Creighton University School of Medicine, and an instructor in the UNMC COPH Department of Health Services Research and Administration.

Affordable Care Act Supports for Nursing Mothers in the Workplace

gb nursingmothersPublic Health in the National News –  Passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 improved the picture for breastfeeding women in the workforce. PPACA amends Section 7 of the Fair Labor Standards Act (FSLA) of 1938 by adding provisions requiring employers to provide reasonable break times for nursing employees to express milk and that they provide a place, other than a bathroom, shielded from view and free from intrusion in which to express milk (Section 7(f) of the Fair Labor Standards Act – Break Time for Nursing Mothers Provision).

This provision is the first federal law to explicitly require accommodation for mothers who wish to continue breastfeeding while working outside the home (Murtagh & Moulton, 2011).  By using the FSLA as the legislative vehicle for these provisions, Congress made accommodation for breastfeeding mothers an integral part of the US labor laws and thus provided protections for women in states that do not offer legal accommodation for breastfeeding employees.

While passage of the breastfeeding provisions in the PPACA was cause for celebration among breastfeeding advocates, there are still concerns. The provisions apply only to hourly wage workers and not to salaried employees or to certain classes of employees such as school teachers and agricultural workers (Murtagh & Moulton, 2011). The act also applies only to expressing breast milk or pumping and not feeding the child at the breast, a perspective that assumes pumping is the preferred option and insulates employers from developing alternatives that would allow mothers to feed their child at the breast while at work. Small employers with fewer than 50 employees are exempt if they can demonstrate hardship in complying with the law (Murtagh & Moulton, 2011).

The wording of the law is vague and does not provide guidance on what constitutes reasonable break time nor what a place other than a bathroom that is shielded from view and free from intrusion looks like. What constitutes hardship for small employers is also not clearly defined.

As with other vaguely worded legislation that could be interpreted as supporting nursing mothers in the workplace, the courts will become the final arbiter of how the provisions in the PPACA are implemented. The courts’ track record in supporting nursing mothers in the workplace is not good, but breastfeeding advocates hold out hope that the provisions of the PPACA are the start of a new perspective.

Murtagh, L., & Moulton, A. D. (2011). Working mothers, breastfeeding, and the law. Am J Public Health, 101(2), 217-223. doi: 10.2105/ajph.2009.185280

Section 7(f) of the Fair Labor Standards Act – Break Time for Nursing Mothers Provision.   Retrieved July 29, 2012, from http://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

This article was written by Lea Pounds, MBA, instructor in the UNMC COPH Department of Health Promotion, Social and Behavioral Health.

Organ Donation


source: donatelife.net

Public Health in the National News –  The statistics are sobering: 118,288 people are waiting for an organ as of June 10, 2013; 18 people die each day waiting for an organ. The statistics are also hopeful: 1 organ donor can save up to 8 lives; 1 eye and tissue donor can enhance the lives of as many as 50 people. The percentage of transplant recipients who are still living 5 years after transplant ranges from 54.4% for lung transplants to 74.9% for heart transplants.

Anyone, regardless of age or medical history, can sign up to be a donor. Every state provides access to a donor registry where its residents can indicate their donation decisions. When matching donor organs to recipients, the computerized matching system considers issues such as the severity of illness, blood type, time spent waiting, other important medical information, and geographic location.

Behind the facts are the people. One member of the UNMC College of Public Health (COPH) family has firsthand experience with organ donation. Fran Neff’s husband, Leonard, was diagnosed with end stage renal disease while they were dating. Fran is an office associate in the UNMC COPH Office of the Dean. Her husband’s kidney disease-related health issues have been a part of their daily lives. Leonard has had 3 cadaveric kidney transplants since 1989, with the third one in August 2012. Fran says, “It’s humbling to know that with the joy and happiness of each transplant Leonard has received there is sorrow too, a person has died and given the ultimate sacrifice for him—the gift of life.”

Fran points out that a common misunderstanding is thinking organ transplantation is a cure and not just a temporary form of treatment for the disease. All transplant patients take immune suppressant drugs and possibly steroids for the life of the transplanted organ. The drugs can cost from $2,000 to $4,000 a month and carry serious side effects. In addition, the patient undergoes considerable lab work. “You’re never far from that ‘leash’ to the Diagnostic Center and the transplant team,” Fran says.

When asked what one thing is most important for readers of The GroundBreaker to know, Fran says “Awareness! Even with all of the medical miracles we have, people continue to die every day waiting for a transplant. I encourage you to become an organ and tissue donor. Talk with your family and let them know your wishes now so there are no last minute struggles concerning your donation wishes.


US Department of Health and Human Services (June 6, 2013). Retrieved from http://organdonor.gov/index.html

Gluten and Health

source: niaid.nih.gov

source: niaid.nih.gov

Public Health in the National News – The relationship between gluten and health is currently receiving quite a bit of attention. Gluten is a major storage protein component in wheat, rye, and barley. Celiac disease (CD) is an autoimmune disease triggered by ingestion of gluten. It is estimated that 1% of the population in the United States is affected by CD. In this disease, the immune system reacts to gluten by attacking the lining of the small intestine (villi) in genetically susceptible individuals, leading to an inability to absorb certain nutrients and consequently to some nutrient deficiencies. Digestive symptoms of the disease include abdominal pain, indigestion, gas, diarrhea, weight loss, and tiredness. In some cases, there are nondigestive symptoms such as skin rash, tingling or numbness in the hands or feet, depression, and mood changes. A recent study revealed that the number of individuals with CD has increased in the United States. This increase has been attributed to better diagnostic methods or to environmental factors. However, the exact reason for the increase is unknown. Blood tests and intestinal biopsies are necessary to confirm the diagnosis of CD, as symptoms may vary from one person to another. In addition, some individuals may be intolerant or sensitive to gluten and have milder symptoms, but not have CD (ie, the small intestinal villi are not attacked).

A gluten-free diet is the primary treatment for CD and gluten intolerance. People with CD and gluten sensitivity should avoid wheat, rye, barley, and their derivatives. Foods that contain gluten include bread, muffins, cakes, pies, cookies, pancakes, couscous, and pasta. Wheat, rye, and barley derivatives include hydrolyzed vegetable proteins and soy sauce (wheat); artificial seafood present in sushi (wheat); soups and broth (wheat); meatballs (wheat); beer (barley); and Rice Krispies and corn flakes, which contain malt made of barley. Cross contamination with gluten-containing products can also be a problem. Examples of possible sources of contaminants include oil from frying breaded products, and shared toasters, strainers for pasta, and grills used for pancakes.

Gluten-free substitution foods include breads, cakes, pies, and muffins made of potato and rice flour. However, these food products are low in fiber, calcium, vitamin D, and iron. Therefore, gluten-free vitamin and mineral supplements are usually necessary for people with CD and gluten sensitivity. High fiber, gluten-free, whole grain products are also available. These products include brown rice, wild rice, quinoa, corn, popcorn, and gluten-free oats. Gluten-free foods that are high in fiber include fruits and vegetables, legumes, soybeans, uncoated nuts, and seeds. Calcium-rich gluten-free foods include fortified milk substitutes such as rice milk, almond milk, and soy milk. Iron-rich foods include unprocessed meat, poultry, and fish; whole grains; fortified gluten-free cereal; fortified rice; legumes; and green leafy vegetables. For optimal health, there are naturally gluten-free foods including fruits, vegetables, poultry, fish, and plain meat. Also, check the food label for the ingredients and for gluten-free products, and when in doubt, contact the food manufacturer.

Useful Resources:



Restaurants with gluten-free menus:


This article was written by Ghada Soliman, MD, PhD, RD, LMNT, an associate professor in the UNMC COPH Department of Health Promotion, Social and Behavioral Health.