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Thursday, May 17, 2018

People Are Dying in the US Because They Can't Afford Insulin-Required Action and Solutions


People are Dying in the U.S. because they can’t Afford their Insulin
Type 1 Diabetics (Type 1 D), whom acquire the disease as children or young adults are dying because they can’t afford the price of insulin in the United States. In 1972, three years after my brother, Russell was diagnosed with Type 1 D, a vial of insulin cost $9. Today, that same quantity is $275, nearly triple what it was in 2010. For an insulin dependent diabetic, whom must take one to two vials a day for survival, this can be a $50 per day expense. Suffice to say, most people cannot afford to pay that much for medicine, especially lacking insurance. And if someone has a chronic condition like diabetes, it may be more difficult to obtain and keep employment, especially a job with good medical insurance. How does someone buy their essential insulin without the means, in the U.S. they go to GoFundMe.com and ask for help.  But even with the relative success of this social media phenomena, many are still unable to pay their bills.  
One person in a family with diabetes impacts the whole family.
 My nephew, Jeremy, was diagnosed with Type 1 D before age 25, works fulltime, has a mortgage, wife and child and he struggles to pay for his insulin and supplies. Though he has insurance, his $4,000 deductible means his insurance company never pays for his diabetic supplies or insulin. This means he has to use less than optimal insulin types and glucometers, because of cost, not efficacy. A month of Humalog, which is manufactured by U.S. pharmaceutical giant, Eli Lilly, costs him $1,088 per month. If he were to use Novo Nordisk’s brand, Novolog it would run $800 to $1,000. Novo Nordisk does sell a generic insulin, which runs $25 for a supply, but it is not as fast acting as the newer formulas.  In addition to the insulin costs, the meter and sensors for checking blood sugar run $300 to $400 per month for the best versions and about $60 per month if you can make do with the older ones. In addition to these challenges, he obtains samples when he can and micromanages his diabetes as best he can through inconsistent types of insulin and diet.
For those whom have been insulin dependent for a long time, it can take a week to ten days to die without it.  Symptoms of ketoacidosis would include; extreme thirst and frequent urination, followed by abdominal pain, nausea and vomiting. A severe headache would ensue from brain swelling. These are signs your body is starved for essential hormones and is shutting down, which would be followed by diabetic coma.[1] At this point, death could occur at any time, but even if an emergency intervention occurs to prolong life, lasting damage to organs has ravaged the body, which may include kidneys, heart, and brain function.
My brother, Russell, was diagnosed with Type 1 Diabetes by age three and in fact, he experienced several symptoms of ketoacidosis. He did live for 42 years, but he experienced brittle diabetic symptoms, probably a result of the delay in his initial diagnosis. But in the 1970’s they did not have the advanced testing available through the Thymus or T cell tests to assess if a child is more likely to become diabetic.[2] At the time, he was one of six children and had been exposed to mumps and measles from older siblings, again because the time for many immunizations was in primary school and not earlier in childhood then.
By the time Russell was in his twenties, he was in renal failure and became covered under Social Security and Medicare once he was on dialysis. Prior to that, he worked as an electrician, in a state, which is largely nonunion, so I have no idea if he had continuous medical insurance. I suspect he didn’t and my mother or other family members probably paid for his insulin. I do remember my mother fretting about buying his insulin even at $9 a vial when he was a child. As a farm family we rarely had medical insurance and then only if my father had an outside job with benefits.
The Lown Institute just completed a Mother’s Day Campaign to educate the public on people whom have died because they can’t afford their insulin. Please join the Lown Institute’s campaign to change this gross inequity in our healthcare system at: https://rightcarealliance.org/cms/assets/uploads/2018/02/insulin-fact-sheet.pdf
 Here are some of their vitals:
Shane Patrick Boyle-Died $50 shy of what he needed to buy insulin-despite his Go Fund Me campaign.
Alec Raeshawn Smith-Died at 26, after he aged out of his parent’s insurance plan, because he couldn’t afford insulin.
Diabetes is the 7th leading cause of death in the United States and is thought to be under reported,[3] for those not yet diagnosed and based on death certificates which do not have to distinguish the disease which caused death, just the ultimate means of death. For example, when Russell died from ventilator acquired pneumonia due to a kidney transplant, his death certificate probably just said pneumonia, not diabetes. But the reason he was getting the transplant was because he was diabetic. Diabetics do not get the sympathy that cancer patients get, as the public blames diabetics for getting the disease. My three-year-old little brother did not exhibit any character failing which thus caused his diabetes. America needs to examine why we look the other way for some patients with chronic diseases and will do anything for others with more exotic conditions.  Rather the nation needs to take a personal inventory on our poor health policy and management of resources which allow adults and children to regularly die from this treatable disease.
Seven million people need insulin to survive in the U.S. and three million of those are Type 1 Diabetics. How many people must die because they can’t afford their medication? Why is this an acceptable phenomenon in one of the richest countries in the world, which just gave corporations (pharmaceutical firms) and the top 2% of the wealthiest a huge tax break. In fact, the top 1% based on income will gain 20% from the Republican Tax cuts.[4]
Type 1 Diabetes is an autoimmune disease which is managed through insulin and is not currently cure-able except through successful pancreas transplants. Benaroya Research Institute, a global health research nonprofit in Seattle, is working to change that. Current research shows genetic modification of T cells is likely to be the future cure for diabetics.[5] In other words, the cells that cause the pancreas to quit processing glucose or bodily sugar, will be modified to prevent diabetes from occurring.
Why Is Insulin So Expensive in the U.S.
A cabal of three global pharmaceutical firms control the world insulin market, with Novo Nordisk, a Danish company representing 41% of the world’s share of insulin products. The information below was drawn from a 105-page report published by a global healthcare nonprofit group.[6] This table shows the top three suppliers.
Novo Nordisk, Denmark
Sanofi, France
Eli Lilly, United States
41% global market share
32% global market share
20% global market share
Products-NovoLog, NovoRapid, NovoMix, Actrapid, Insulatard
Products-Apidra, Insuman, Lantis
Products- Humalog, Humilin
Price increases in the USA were 8% in 2017 [7] and 240% over the last 10 years
Lantis has increased prices by  240% over the last 10 years, old price $88.20, current price $307.20[8]
8% price increases in 2017 alone [9], 240% over the last 10 years, 800 to 1,000% since development
Novalog represented 23% of all diabetic market share profits (3.3 billion) in 2015, driven largely by access to U.S. market (Pharmaceutical Technology.com, 2016)
In 2015 Lantus was the world’s top selling insulin and generated 17% of all profits for Sanofi (6.86 billion)[10]
Humalog generated 2.84 billion in profits in 2015

What You Can Do
First, you should be contacting your state legislature and Congress about the price gouging big pharma is exacting from our nation, which is resulting in wrongful deaths. These people are not dying because of character flaws, they are dying for lack of $50 or $500. There are currently 11 patients suing the three largest insulin suppliers for price fixing in the U.S. and maybe that is what it will take as Congress seems to be unwilling to do a thing. Additionally, several states, including Washington, are suing the pharmaceutical companies for price fixing adversely impacting state Medicaid plans. Meanwhile, the profits of the three major drug companies who supply insulin to the world increased exponentially. (Committee, 2011) Here are some policy changes we can make which would create affordable medications again:

  1. Reauthorize production of older insulin formulas, to keep an affordable supply available. A 2011 World Health Organization study of outcomes tied to the newer analog insulin versus the older human insulin  formulas,  showed no evidence of a clinically significant outcome in morbidity or mortality. (Committee, 2011)
  2. Require Pharmaceutical companies to show statistical evidence of a population health benefit for new drugs and not just a scientific benefit.
  3. Ban all direct to consumer advertising for drugs in the United States-this isn’t about science but about developing market share.
  4. Stop allowing patent extensions for specious modifications which are minor and profit not patient motivated.
  5. Look at differences in regulatory access to markets, such as Finland and Estonia, which allow many more registered insulin producers than the U.S. Better access to affordable insulin will prevent health decline and reduce deaths from diabetes. The U.S. should be vigorously supporting this ethos as opposed to artificially supporting exorbitant profits for drug companies.
  6. Reform U.S. healthcare by allowing  the Centers for Medicare and Medicaid to negotiate with drug companies on price, just like all of the other countries do. This would have a price lowering impact across the private sector too.
  7. Continue to fund research into curing diabetes through the National Institutes of Health, not cutting the budget, as in the current administration.

Act Out
I am cycling 900 miles from Bremerton, Washington to Napa, California to highlight the need for a cure for diabetes as that is the only way we are going to get out of the clutches of big pharma. All of the money I raise goes to Benaroya Research Institute’s diabetes work, through the Virginia Mason Foundation. Because diabetes is a terrible disease, I wanted to do some suffering on my journey as well, and am biking the distance in eight days, which includes two days of 150 miles each. Throughout this journey I will reflect on my brother’s and nephew’s lives and how much we need to change our healthcare system. I will be speaking to the press and general public at each stop along the way. Please give to the inaugural Russell Ride so that something positive can come from the early deaths of these good people.

And this is the healthpolicymaven signing off encouraging you NOT to sign blank release forms when you are admitted to a hospital. DO specify that for which you consent and that for which you do not approve. If at all possible, bring an advocate to your admission. Do not go quietly into the night and make your concerns known, not just in your medical treatment facility, but with your local, state, and national representatives. All lives matter, not just the uber rich, regardless of what comes out of Washington these days.

Roberta Winter is a freelance journalist who has published this independent healthcare column for 11 years, without obligation to pharmaceutical, hospital, clinic, or medical supply companies. Please feel free to share this widely on social media.

Works Cited

Committee, W. H. (2011). World Health Organisation. Retrieved May 17, 2018, from http://haiweb.org/wp-content/uploads/2016/04/ACCISS_Insulin-Market-Profile_FINAL.pdf
Pharmaceutical Technology.com. (2016, March 29). The World's Top Selling Diabetes Drugs. Pharmaceutical Technology.com. Retrieved May 17, 2018, from https://www.pharmaceutical-technology.com/features/featurethe-worlds-top-selling-diabetes-drugs-4852441/







Wednesday, March 28, 2018

The Endangered American Family

How America Has Broken the Social Contracts for Our Children
Trump Administration Republicans are intent on cutting social contracts for middle-class and lower income Americans, by undermining funding, creating negative campaigns about publicly funded programs, and voiding enforcement of current regulations. This article examines these primary expenses for families; healthcare, childcare, housing, and education in the United States, as compared to other industrialized countries.
Healthcare
The cost of U.S. healthcare is higher than anywhere else, yet the benefits and access to care are at the bottom of industrialized countries. As discussed in my 2013, book and many articles over the past decade, this is primarily due to a system which has little cost controls and reimburses healthcare providers on the basis of volume. The Trump Administration has removed the tax penalty for nonexempt families who do not obtain health insurance, which will undermine participation in the ACA insurance exchange programs. Further, the current administration has threatened to remove the tax credits which enable middleclass and lower middleclass Americans to obtain insurance. According to the Kaiser Foundation, the average cost for health insurance for a family is now $18,301 for private plans through employers. (Kaiser Foundation State Health Facts, 2018) Republican plans to lower the cost of health insurance include; reinstating pre-existing conditions for people with health issues, excluding maternity coverage, and absurdly low maximum benefit levels.
Finally, the cost of healthcare, does not mean your insurance payments, it means the total cost of services, administration, out of pocket expenses, and of course the insurance premiums.  This link shows healthcare spending in 2015, using World Economic Forum data. https://www.pgpf.org/chart-archive/0170_international_health_spending_comparison

Childcare
The ability to afford childcare is fundamental to economic mobility. Countries which do not produce enough children have challenges filling jobs, supporting social programs for current beneficiaries of social programs, like Social Security, and maintaining public services. Excluding Monaco, which is primarily a retirement haven for the wealthy, as well as a small French protectorate off the coast of Newfoundland, and Andorra the adorable tax haven situated in the Pyrenees, Japan still leads the pack for the lowest birth rate. For this criterion, the U.S. is in the middle of the pack, ranking 158 out of 226 nations. (CIA Factbook-2017, 2017)  Of the industrialized countries, here are top child producers:

Rank
Industrialized Country
Birth per 1,000
1
India
19.0
2
Venezuela
18.8
3
Mexico
18.3
4
Israel
18.1
5
Argentina
16.7
6
Turkey
15.7
7
North Korea
14.6
8
Brazil and Ireland
14.1
9
Iceland
13.7
10
Chile
13.6
11
New Zealand
13.2
12
United States
12.5

The most expensive childcare is in the U.K., which includes England, Scotland, and Wales. The U.S. has the next most expensive childcare, consuming over 25% of family household incomes. (Organisation for Economic Co-operation and Development, 2016) Currently, the U.S. has no mandatory paid maternity or family medical leave policy. The Family Medical Leave Act, enacted in 1993, required employers with 50 or more employees to provide up to 12 weeks of unpaid leave for an employee or family member engaged in the care of a family member. Employees are entitled to this leave every 12 months. Though 66% of women work during pregnancy, there has been no change in this mandate.

Scandinavian countries provide families with subsidized high-quality childcare, free preschool, and a monthly stipend per child. Parents receive anywhere from 12 to 20 weeks of paid maternity leave. These generous social policies mean that most women are able to work and support themselves while having children, at living wage jobs, including single mothers. Even the UK now provides 15 hours of free childcare for all children (as of 2017). Virtually all European nations provide some type of childcare for working families and in Western Europe this is typically 15 to 30 hours per week. (Janta, 2010)

Home Affordability
In the United States there are many variables to housing costs, depending on a rural or urban location and the availability of employment, which can support housing costs. This is why housing indexes tend to measure housing costs in major metropolitan areas and not the sparsely populated ones. Though housing costs for home buyers tend to be more affordable here than in other nations, for renters, costs are out of control in many regions of the country. That said, housing is a key issue for families so here is a metric illustrating how the U.S. compares to other developed nations with the most expensive listed first. This chart includes data from 2017 for 2018 cost of living values. (Numbeo.com, 2018)

Ranking
City
Multiple of Income   Housing Affordability Ratio
1
Beijing
48.1
2
Shanghai
42.8
3
Hong Kong
41.08
4
Mumbai
28.7
7
Singapore
22.2
8
London
22.19
9
Rio De Janeiro
21.31
10
Rome
20.48
28
Paris
17.68
41
Vancouver, CA
16.02
58
Barcelona
13.99
63
Tokyo
13.68
79
New York
12.34
81
San Francisco
12.31
108
Helsinki
10.99

Rental Housing
However, when viewing housing affordability and rent, a 2015 Harvard study of 11 countries revealed the U.S. was the second most expensive for renters, after Spain. U.S. renters spend 34% of disposable income on housing and low-income households are much more likely to spend 50% of household income on rent (28% of U.S. renters spend >50%). The study found that the degree of income inequality, which is by far greater in the U.S. than these nations and the availability of housing allowances determined the level of affordable rentals. This exhibit shows the housing subsidies provided by European countries compared to the U.S. (Micheal Carliner, 2016)

Percentage of the nation Receiving Housing Allowance
Country
Value of Annual Housing Allowance in USD
55%
France
2,257
46%
United Kingdom
4,988
38%
Netherlands
2,170
20%
Sweden
5,324*
18%
Germany
Not listed
12%
Austria
4,200*
6%
Italy
Not listed
6%
USA
7,200
5%
Spain
2,952*
3%
Switzerland
Local funding
2%
Belgium
Local funding

*These values were drawn from other sources for the 2015 year, due to the way the Harvard article expressed the data. (Organisation for Economic Co-operation and Development, 2016)

Education
Though obtaining a university education is not a goal for all residents, it is considered a measure of upward mobility, not only for the individual but for generations of family members. Since the U.S. has continued to under fund public universities, universities have relied more on user’s fees, tuition increases, and private endowments to pay for higher education. Follow this link to a Forbes article citing the Organisation for Economic Co-operation and Development, which shows U.S. tuition costs compared to the world, based on 2017 data. (Organization for Economic Development, 2018)
  
Education policy changes under consideration in the Trump Administration include: eliminating PELL grants for low-income students, cutting back on federally subsidized student loans, eliminating loan forgiveness for those who go into public service roles like nursing or education, and turning loan programs over to for-profit entities, which will raise the costs for students. None of these changes would impact children of the wealthy, whom have already been gifted the biggest tax break under the Trump budget, since Ronald Reagan, only working-class people trying to better themselves.

Anyone with a pulse would conclude the U.S. is not a very easy place to raise children, with the highest rate of mass shootings in the world (the only places that come close are war zones), laws that allow employers to discriminate against working parents, and a nominal social safety net. Not only are these factors impacting highly skilled workers, where out migration has increased since George W. Bush, but the continued efforts by the Republicans to cut social safety-net funding jeopardizes future generations. The U.S. government doesn’t effectively track residents who move to other countries, but maybe it should learn why natives are fleeing the country. The number of Americans who have left the country is anywhere from two to nine million and those legions include retirees, professionals working elsewhere, and those who don’t want to raise their families in the U.S. If Trump wants to make America great again, why doesn’t he look at the adverse policies making it extremely expensive to raise children, who are after all, future tax payers. The proposed federal budget further increases the federal deficit to give tax breaks to the super rich further undermining the nation’s ability to meet Social Security and Medicare/Medicaid obligations. Let’s be clear, these are the only working class social programs for Americans and Trump, Ryan, and Mulvaney would like to get rid of them through program and funding cuts.

This article was written by Roberta Winter, an independent journalist and author of : https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

For the next three months I will be raising money for the inaugural Russell Ride, an epic 858 mile bicycle ride from Washington to California, in memory of my brother. All proceeds go to the Benaroya Research Institute to cure Type 1 Diabetes. For more information, follow these links:

https://give.everydayhero.com/us/team-roberta-e

https://www.benaroyaresearch.org/


References
Agency, U. S. (2017). CIA Factbook-2017. In C. I. Agency, The World FactBook 2017. Retrieved March 27, 2018, from https://www.cia.gov/library/publications/the-world-factbook/rankorder/2054rank.html

Janta, B. (2010). Caring for Children in Europe-How Childcare, Parental Leave, and Flexible Working Arrangements Interact in Europe. Rand Corporation.org. Rand Corporation-Europe. Retrieved March 28, 2018, from https://www.rand.org/content/dam/rand/pubs/research_reports/RR500/RR554/RAND_RR554.pdf

Kaiser Foundation State Health Facts. (2018, March 28). Kaiser Foundation State Health Facts. Retrieved from Henry J. Kaiser Family Foundation.org: https://www.kff.org/other/state-indicator/family-coverage/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22washington%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Micheal Carliner, E. M. (2016, September 1). Rental Housing-An International Comparison. Harvard University Joint Center For Housing Studies. Retrieved March 28, 2018, from http://www.jchs.harvard.edu/research/publications/rental-housing-international-comparison

Numbeo.com. (2018, March 27). Property Prices Index 2018. Retrieved from Numbeo.com: https://www.numbeo.com/property-investment/rankings.jsp

Organisation for Economic Co-operation and Development. (2016). Affordable Housing Database-Key Characteristics of Housing Allowances. Paris: Organisation for Economic Co-operation and Development (OECD). Retrieved March 28, 2018, from https://www.oecd.org/els/family/PH3-2-Key-characteristics-of-housing-allowances.pdf

Organization for Economic Development. (2016, December 22). These Are The Countries Where The Parents Spend The Most On Childcare. World Economic Forum. Retrieved March 27, 2018, from https://www.weforum.org/agenda/2016/12/childcare-cost-oecd/

Organization for Economic Development. (2018, March 27). Education At A Glance. Retrieved from Organization for Economic Development: https://blogs-images.forbes.com/niallmccarthy/files/2017/09/20170912_Tuition_Fees.jpg    


Sunday, March 11, 2018

Suicide-How Does Your State Compare


Washington State has been undergoing an outcomes-based, health systems improvement plan and a health outcomes scorecard is part of that process. While perusing the most recent health scores for the 2016 calendar year, I was astounded to learn that Washington has a much higher suicide rate which is 16 persons per 100,000 compared to the national average of 13 per 100,000. (Department of Health, 2018) In other words, there are 20% more suicides in Washington based on a population rate, than the average rate for the United States. Even more disturbing is the rate of suicide is increasing in Washington. This astounded me, so I reviewed national data from the Centers for Disease Control and here are the findings from the 2015 survey. (National Center for Health Statistics, 2018)

States posting the highest suicide rates per 100,000 lives were cold and sparsely populated outposts:
  1. 28.0-Wyoming
  2. 26.9-Alaska
  3. 25.3-Montana
States with the Lowest Suicide Rates per 100,000 lives were all on the east coast, which is a densely populated region with good health care access.
  1. 7.2-New Jersey
  2. 8.0-New York
  3. 8.8-Massachusetts

1    Despite all of the news coverage on murders, suicides outnumber murder in the U.S. two to one. It is estimated that there are 45 attempts for every suicide. A 2002 Harvard study of all fifty states found that where there are higher levels of gun ownership, suicide rates are higher. (Kiewra, 2008) For example, Wyoming has a 63% rate of gun ownership and the highest suicide rate in the country.

Comparing the U.S.’s Statewide Bipolarity of Suicide Rates to the World
Suicide is a global problem and though it is higher among poverty-stricken countries, even wealthy European nations have high suicide rates. In fact, the seat of the European Union, Belgium, has one of the highest rates of suicide in the world, with 20.5 deaths by suicide out of 100,000 in 2015. (World Health Organization, 2017) Eastern Europe led the pack for suicides, with Lithuanians doing the deed at a rate of 32.7 out of 100,000. In fact, Europeans collectively had the highest suicide rate in the world in 2015, according to the World Health survey. Even the beautiful country of France had a markedly higher suicide rate than the U.S. with 16.9 deaths per 100,000 people.
The highest suicide rate in the world in 2015 was in Sri Lanka with 35.1 deaths per 100,000, equal to the rate of deforestation of their tropical rain forests(49% loss of forests by 2005). Belgium was only in 2nd place, followed closely by Koreans at 32 deaths per 100,00 souls.
In the Americas, the U.S.A. ranked 6th for its overall suicide rate in 2015, with 14.3 suicides per 100,000 people. The worst suicide rate in the Americas was Guyana, with 29 self-inflicted deaths per 100K, followed by Surinam at 26.6, and Bolivia at 18.7. But even Cubans have a robust suicide rate of 14.1 deaths per 100,000. Amazingly, Canadians, the well-mannered neighbor to the north with national healthcare has a high suicide rate at 12.3 deaths per 100,000.
 In the Pacific, New Zealanders, in the dreamscape without predators, scored a relatively high rate of suicide as well, with 12.6 deaths per 100,000.
Good News
Now for the good news potential retirees, the least suicidal place in the world in 2015 was Barbados at  .40 or less than one half of a person per 100,000 very content souls. Brunei was next at 1.3 lives, followed by Jamaica at 1.4 lives lost to suicide per 100,000 happy folks.

Information on Which to Act
Given the prevalence of suicide, which occurs in both our youth and people in the prime of their earnings years (the Washington survey revealed that males aged 45-55 had the highest rate of suicide) this is a public health crisis. The most popular suicide method is a gun, causing 51% of the deaths. In a recently published study, examining 32 years of firearm ownership in households and suicide data across all fifty states these were the conclusions: (Michael Siegel)
  • ·         State levels of firearm ownership were associated with increased levels of firearm related suicide among males and females
  • ·         Higher levels of gun ownership were associated with increased rates of suicide by any means for males


Whites were found to have the highest suicide rates, followed by American Indians, Pacific Islanders, and Blacks. Speaking to gender, girls attempted suicide twice as often as boys, with Hispanic girls posting a 15.1% suicide rate, compared to 6.8% for White females. Further examination of methods to reduce this disturbing phenomenon is merited, but in the short term here are resources for those in need.

Washington State has a number of suicide prevention coalitions which may be found at:  https://www.doh.wa.gov/YouandYourFamily/InjuryandViolencePrevention/SuicidePrevention/Coalitions

Other Washington State Resources include a Suicide Prevention Resource Center at the capital in Olympia: https://www.sprc.org/states/washington

Harvard’s Injury Control Research Center created a campaign to reduce suicide called Means Matter, which educates the public to keep guns out of the hands of the vulnerable and youth.[1] Reducing access to guns can reduce suicide in the depressed. Other initiatives to reduce suicides in the U.S. include:

National Institute for Mental Health has a suicide hotline-800-273-TALK (2735)

American Foundation for Suicide Prevention has a support network for those with suicidal thoughts and their family members found at: https://afsp.org/find-support/

This is the healthpolicymaven signing off wishing you fully informed consent and a more positive outlook. The healthpolicymaven is a trademark, continuously in use since 2007, owned by Roberta E. Winter, a freelance journalist and healthcare analyst. Winter is the author of a consumer’s guidebook to the U.S. healthcare system, https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Department of Health, W. S. (2018). Washington State Public Health Survey 2016 Results. Washington State Department of Health. Retrieved March 11, 2018, from https://www.doh.wa.gov/DataandStatisticalReports/StateHealthAssessment
Kiewra, K. (2008). Guns and Suicide: A Fatal Link. Retrieved March 11, 2018, from https://www.hsph.harvard.edu/news/magazine/guns-and-suicide/
Michael Siegel, M. M. (n.d.). Firearm Ownership and Suicide Rates Among US Men and Women, 1981–2013. 106(7)(July 2016). doi:https://dx.doi.org/10.2105%2FAJPH.2016.303182
National Center for Health Statistics. (2018). Suicide Mortality By State. U.S. Centers for Disease Control, Department of Health and Human Services. Centers for Disease Control. Retrieved March 11, 2018, from https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/suicide.htm
World Health Organization. (2017). Suicide Mortality Rates in 2015. World Health Organization . World Health Organization. Retrieved March 11, 2018, from http://apps.who.int/gho/data/node.sdg.3-4-viz-2?lang=en