Virginia is for (all) lovers

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The 4th Circuit Court of Appeals in Richmond, VA ruled in favor of same-sex couples’ freedom to marry today, upholding a marriage ruling out of Virginia from February. The landmark ruling follows a similar ruling from the 10th Circuit Court of Appeals, which held that banning same-sex couples from marriage in Utah and Oklahoma is unconstitutional. It is the 29th consecutive ruling in favor of marriage for same-sex couples in the past year.

The decision reads:

We recognize that same-sex marriage makes some people deeply uncomfortable. However, inertia and apprehension are not legitimate bases for denying same-sex couples due process and equal protection of the laws. Civil marriage is one of the cornerstones of our way of life. It allows individuals to celebrate and publicly declare their intentions to form lifelong partnerships, which provide unparalleled intimacy, companionship, emotional support, and security. The choice of whether and whom to marry is an intensely personal decision that alters the course of an individual’s life. Denying same-sex couples this choice prohibits them from participating fully in our society, which is precisely the type of segregation that the Fourteenth Amendment cannot countenance.

The 4th Circuit opinion also will affect marriage laws in other states within its jurisdiction, including West Virginia, North Carolina and South Carolina; however, separate orders would have to be issued for affected states in the region outside Virginia.

Gay and lesbian couples in Virginia cannot marry in the state for at least another three weeks, giving the time for another appeal to be filed on enforcement.  The decision on an appeal is not clear as Virginia Gov. Terry McAuliffe and Virginia’s attorney general have refused to defend the ban in court as is tradition, leaving it to other state officials to make the case.

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Marriage equality moves to Miami

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Yesterday, another judge in Florida overturned that state’s ban on same-sex marriage – this time in Miami-Dade County.  It is the second such ruling in florida after Monroe County Circuit Judge Luis Garcia struck down the ban for the Florida Keys.  Circuit Judge Sarah Zabel found the constitutional amendment approved by Florida voters in 2008 discriminates against gay people, saying it violates their right to equal protection under the law guaranteed by the U.S. Constitution’s 14th Amendment.  She writes,

Preventing couples from marrying solely on the basis of their sexual orientation serves no governmental interest.  It serves only to hurt, to discriminate, to deprive same-sex couples and their families of equal dignity, to label and treat them as second-class citizens, and to deem them unworthy of participation in one of the fundamental institutions of our society.

Garcia’s earlier ruling was put on hold when Republican Attorney General Pam Bondi filed notice of appeal. Zabel also stayed the effect of her ruling indefinitely to allow time for appeals, which could take months, and Bondi promptly followed up Friday by filing an appeal notice in the Miami-Dade case.

Both judges were appointed by former Republican Gov. Jeb Bush and have been re-elected.

The legal battleground will next shift to the Miami-based 3rd District Court of Appeal for both cases, and most likely after that to the state Supreme Court.

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Where do we come from?

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Whether or not Americans think so, the United States is still the land of opportunity.  More than 40 million immigrants, the US is still the top destination in the world for people moving from one country to another.

The Pew Research Center put together a map of where each state’s largest immigrant population was born.  For 2010 (the last time the US Census was conducted), the answer for most states was Mexico.  One hundred years earlier, the answer would have been Germany.  Take a look and see where the majority of your state’s immigrants come from.

origin of immigrants by state

 

Marriage equality in Colorado

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Earlier today, U.S. District Judge Raymond P. Moore ruled against Colorado’s constitutional amendment banning marriage equality.  His ruling has been stayed until August 25 to allow the state time to appeal to the U.S. Court of Appeals for the Tenth Circuit, the same court which has already struck down bans on marriage equality in Utah and Oklahoma.

Moore’s ruling is particularly important for Colorado, where clerks in several counties began issuing marriage licenses to same-sex couples after lower court rulings that deemed marriage bans unconstitutional.  The Colorado Supreme Court last week ordered Denver County clerks to stop issuing the marriage licenses, however today the same court declined the state’s request to force the Boulder County clerk to stop issued licenses.

The state of Colorado has not yet indicated whether it plans to appeal Judge Moore’s decision.

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Minimally Invasive Health Reform

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Earlier this month, well known surgeon Dr. Marty Makary wrote an opinion piece for the Wall Street Journal titled “A Minimally Invasive Approach to Health-Care Reform.”  In the article, Dr. Makary touts the benefits of minimally invasive surgery as a cost-effective way of reducing health care costs in the United States.  Complications following surgery cost roughly $25 billion annually, and Makary posits that minimally invasive surgery, with it’s lower overall complication rates, could save billions of dollars each year.  He further notes that by avoiding larger incisions, patients spend less time in the hospital, have less pain, fewer infections, lower medication use during recovery, overall faster recovery, and lower risk of needing subsequent surgery.

However, Makary bemoans the fact that minimally invasive surgery is not the standard of care in hospitals across the United States.  In fact, many patients are never even offered a minimally invasive approach.  Furthermore, in a study conducted by Makary and colleagues at Johns Hopkins, they found little if any correlation between the use of minimally invasive procedures and the location, size or affiliation of a hospital.  He correctly notes that the disparity likely comes from difference in culture between hospitals as well as the training of the surgeon, as some surgical training programs have heavier focuses on minimally invasive techniques.  Makary continues to say that “standardizing minimally invasive and open technical training should be a priority for residency programs, rather than emphasizing on approach over the other.”  He goes on to say that a hospital’s surgical outcomes should be transparent and available to prospective patients, and he even claims that a hospital’s rate of using minimally invasive surgery for specific operations should be considered a new quality measure.  After all,

If there were a new medication that greatly reduced surgical infection rates, lowered pain medication use, and quickened recoveried, policy makers and health-care professionals nationwide would be asking one simple question: Why aren’t people getting it?

I agree with Dr Makary on many points in his article, but as he well knows, that question and the answers to it aren’t so simple.  Dr Makary is correct with his contention that surgical training should be more standardized.  Furthermore, publishing surgical outcomes and making those outcomes transparent to patients has been heavily argued for in the not so distant past – an idea that hospitals and physicians vehemently oppose and one that the Affordable Care Act is slowly trying to address through Medicare.  And yes, minimally invasive techniques have an overall lower complication rate than open procedures, when performed by skilled surgeons.

But Dr Makary misses the mark on many levels, most importantly with regard to cost.  First, minimally invasive techniques are more costly than open techniques; there is the added cost of specialized equipment, and in general, minimally invasive techniques take longer to perform, leading to higher operating room costs.  Much of that added cost is recovered by the hospital with shorter lengths of stay and recovery times for patients undergoing minimally invasive techniques as compared to open procedures.  But what Dr Makary fails to mention is that if we converted every open procedure currently being performed to a minimally invasive one (where feasible), we would certainly save money from less complications – but only if the number of procedures performed remained unchanged.  Let me explain.

Minimally invasive techniques revolutionized medicine quite some time ago, with laparoscopic cholecystectomy (minimally invasive gallbladder surgery) being the best example.  Prior to the introduction of laparoscopy, patients were forced to undergo painful open surgery which often necessitated hospitals days of 3-5 days or more, and the recovery time after leaving the hospitals was even longer.  Open cholecystectomy was therefore reserved for patients with true emergencies; patients suffering from gallstones or biliary colic (occasional pain from the gallbladder) were told to change their dietary habits and take analgesics in order to avoid a painful operation and prolonged recovery period.  Laparoscopic changed all of that by reducing risk, shortening hospitalizations, reducing pain, and decreasing recovery times.  Proponents posited that despite the higher cost of performing laparoscopic cholecystectomy, the operation would greatly save money for hospitals and the health care system as patients no longer required hospitalization post procedure.  They were right – but the number of gallbladder operations skyrocketed, as patients no longer wanted to deal with their gallstones and biliary colic.  The result was that even though costs to hospitals decreased, overall health care costs increased due to the higher number of procedures performed.  Minimally invasive approaches to nearly every other operation have likewise increased overall health care costs due to the higher number of procedures performed.

Finally, Dr Makary fails to mention that even though there may be a minimally invasive technique for a given procedure, not all operations are amenable to minimally invasive approaches.  Partial colectomy (removal of a part of the colon) can be performed laparoscopically, but the minimally invasive technique is not always appropriate.  And with regard to his prime example of appendectomy, the surgical literature still does not support that laparoscopic appendectomy is superior to the open technique.

There are many reasons to perform minimally invasive procedures, however, cost is not one of them.  If Dr Makary’s intent is to improve the quality of care, then he’s right on the mark.

Sooner State marriage equality

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This is starting to become redundant, but the US Court of Appeals for the Tenth Circuit issued another ruling today, affirming the decision by US District Judge Terence Kern, that Oklahoma’s constitutional amendment banning same-sex marraige violates the US Constitution.  The 2-1 decision was authored by Judge Carlos Lucero, who was joined by Judge Jerome Holmes – a President George W. Bush appointee.

The same court previously affirmed a similar ruling regarding the state of Utah’s marriage ban.

Same-sex marriages will be put on hold pending an appeal by the state of Oklahoma.  The state now has the option to request an en banc appeal before the full bench of the Tenth Circuit, which decides whether or not to grant that request. It may also bypass an en banc session and appeal directly to the U.S. Supreme Court.  The Utah attorney general announced earlier this month that he would appeal the Tenth Circuit’s ruling to the Supreme Court.

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Marriage equality in the Sunshine State

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Earlier today, a judge in a state court struck down Florida’s ban on marriage for same-sex couples, deeming the ban unconstitutional.

Chief Circuit Judge Luis Garcia ordered the Monroe County Clerk to stop enforcing Florida’s anti-marriage constitutional amendment, saying that marriage licenses should begin being issued in Monroe County on July 22.

In his ruling, Judge Garcia writes:

It is our country’s proud history to protect the rights of the individual, the rights of the unpopular and the rights of the powerless, even at the cost of offending the majority. … The Constitution guarantees and protects all of its citizens from government interference with those rights. All laws passed by the legislature or by popular support must pass the scrutiny of the United States Constitution, to do otherwise diminishes the Constitution to just a historical piece of paper.

Of note – the ruling only applies to Monroe County, home to the Florida Keys.

 

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Marriage equality moves forward in Colorado

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A District Court judge today struck down Colorado’s ban on same-sex marriage, marking the 24th consecutive ruling in favor of the freedom to marry (with no rulings against) since June 2013. The ruling has been stayed for now, pending an appeal.

In the ruling, District Court Judge C. Scott Crabtree explained how civil union – which Colorado has had in effect since 2013 – is a lesser, unequal form of family status that does not compare to marriage. He writes:

The fact that the State has created two classes of legally recognized relationships, marriages and civil unions, is compelling evidence they are not the same. If civil unions were truly the same as marriages, they would be called marriages and not civil unions. If they were the same, there would be no need for both of them. The fact that Colorado denies same gender couples the same right to apply for federal benefits that it grants to opposite gender couples is a violation of the Equal Protection Clause.

In other marriage equality news, Utah’s Attorney General will be filing an appeal of the 10th U.S. Circuit Court of Appeals recent decision to overturn the state’s ban on same-sex marriage.  Attorney General Sean Reyes will be filing the appeal directly to the US Supreme Court rather than asking for a review by the entire 10th US Circuit Court of Appeals.  The Supreme Court is under no obligation to hear the appeal.

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10 years later…

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Anniversaries are supposed to be happy occasions, a remembrance of important life events like a weddings, college graduations, or years spent at a career. Anniversaries are supposed to make us reminisce and remember with joy, to remind us of how much we’ve grown and changed over the years.

Today marks an important ten year anniversary for my family, however, it is one that fills our hearts with sadness instead of job. Ten years ago, today, the most important man in my life left it too early, becoming an angel in heaven far too young.

Our dad fought a valient 5+ year fight against lung cancer, all the while continuing to take care of his family. He was the most honest, hard working, and loving man I’ve ever known. When I think on everything our family has gone through since – a daughter married, my graduation from medical school, the birth of several grandchildren, and the loss of my grandmother – it aches even more knowing what he has missed and how much he is missed.

Ten years later, and it’s becoming harder to remember his walk, his talk, his strong presence, and his passion.  A decade later, it’s still hard, and it still hurts.  When it gets to that point, I cling to the hope that somewhere he is watching over us, and that he’s probably looking down and smiling along with his mom and dad.  I hold on to the fact that we only hurt because we we care, and that our pain is a testament to how important someone was to us.  It’s a pain and a hurt shared with my mom and sisters, and a similar feeling with other family and friends.

What I wouldnt give anything to have him here for even just an hour, just to chat and impart his wisdom.  Yet I know that’s not possible.  Instead, I will hold my family close and my memories closer.

I carry your heart with me.  I carry it in my heart.

World Cup tweet

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So it turns out that Americans love football.  And by that I mean Americans really love soccer.  Ratings for the World Cup have hit all time highs in the United States, and have continued even after Team USA was eliminated.  Perhaps we could get behind some other things that the rest of the world enjoys?

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