From Health and Fitness

Molina Healthcare, A Top Obamacare Insurer, Investigates Breach Of Patients’ Data

Molina Healthcare, a major insurer in Medicaid and state exchanges across the country, has shut down its online patient portal as it investigates a potential data breach that may have exposed sensitive medical information.

The company said Friday that it closed the online portal for medical claims and other customer information while it examined a “security vulnerability.” It’s not clear how many patient records might have been exposed and for how long. The company has more than 4.8 million customers in 12 states and Puerto Rico.

“We are in the process of conducting an internal investigation to determine the impact, if any, to our customers’ information and will provide any applicable notifications to customers and/or regulatory authorities,” Molina said in a statement Friday. “Protecting our members’ information is of utmost importance.”

Brian Krebs, a well-known cybersecurity expert who runs the Krebs on Security website, said he notified the company of the potential breach earlier this month and wrote about it on his website Thursday. Molina said it was already aware of the security vulnerability when contacted.

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Until recently, Krebs said, Molina “was exposing countless patient medical claims to the entire internet without requiring any authentication.”

Krebs said the information he saw online included patients’ names, addresses, dates of birth and information on their medical procedures and medications.

“It’s unconscionable that such a basic, security 101 flaw could still exist at a major health care provider,” Krebs said. “This information is more sensitive than credit card data, but it seems less protected.”

Krebs said he received an anonymous tip in April from a Molina member who stumbled upon the problem when trying to view his medical claim online. The tipster found that by changing a single number in the website address he could then view other patient claims, according to Krebs.

Krebs said the Molina member showed him screenshots of his own medical records and how when he changed the web address slightly it then displayed records of another patient. On Friday, the Molina website told customers that the online portal was “under maintenance.”

Health care companies, hospitals and other providers must report data breaches to U.S. officials. Molina emphasized that it was still investigating the matter so had not yet reported it. Federal regulators can levy significant fines for violations under the Health Insurance Portability and Accountability Act, also known as HIPAA.

Many security experts question the ability of health care companies and providers to safeguard vast troves of electronic medical records and other sensitive data, particularly at a time when cybercriminals are targeting medical information.

Molina, based in Long Beach, Calif., posted $17.8 billion in annual revenue last year.

Molina made news earlier this month with the surprise firing of its top two executives, who are sons of the company’s founder. Both CEO J. Mario Molina and his brother, finance chief John Molina, were ousted. The company’s board said Molina’s disappointing financial performance led to the management change.

Molina has grown more prominent during the rollout of the Affordable Care Act, as Medicaid expanded and state insurance exchanges launched. The company serves more than 1 million people through Obamacare exchanges across several states. It has nearly 69,000 enrollees in the Covered California exchange, or about 5 percent of the market.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Health Industry, Insurance

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An Effect of Climate Change You Could Really Lose Sleep Over

Trilobites
By JUSTIN GILLIS

Global warming caused by human emissions of greenhouse gases is having clear effects in the physical world: more heat waves, heavier rainstorms and higher sea levels, to cite a few.

In recent years, though, social scientists have been wrestling with a murkier question: What will climate change mean for human welfare?

Forecasts in this realm are tricky, necessarily based on a long chain of assumptions. Scientific papers have predicted effects as varied as a greater spread of tropical diseases, fewer deaths from cold weather and more from hot weather, and even bumpier rides on airplanes.

Now comes another entry in this literature: a prediction that in a hotter world, people will get less sleep.

In a paper published online Friday by the journal Science Advances, Nick Obradovich and colleagues predicted more restless nights, especially in the summer, as global temperatures rise. They found that the poor, who are less likely to have air-conditioning or be able to run it, as well as the elderly, who have more difficulty regulating their body temperature, would be hit hard.

If global emissions are allowed to continue at a high level, the paper found, by 2050 every 100 people in the United States may endure an extra six nights of insufficient sleep per month. By 2099, that would double to 14 nights of tossing and turning, in their estimation.

Researchers have long known that being too hot or too cold at night can disturb anyone’s sleep, but nobody had thought to ask how that might affect people in a world grown hotter because of climate change.

Dr. Obradovich is a political scientist who researches both the politics of climate change and its likely human impacts, holding appointments at Harvard and the Massachusetts Institute of Technology. He started the research while completing a doctoral degree at the University of California, San Diego.

He got the idea for the study while enduring a 2015 heat wave in an apartment in San Diego with no air-conditioner in the bedroom.

”I wasn’t sleeping,” he recalled. “My friends weren’t sleeping. My colleagues weren’t sleeping. The levels of grumpiness were higher than normal.”

To calculate the effect of warmer temperatures in the future, he turned to data collected by the Centers for Disease Control and Prevention, which asks people in a survey to recall their sleep patterns in the previous month. Sure enough, he found a correlation between higher temperatures in particular cities and disturbed sleep as reported by their residents. To make forecasts, he drew on computer estimates of how hot particular places will get if greenhouse emissions continue at a high level.

Dr. Obradovich acknowledged that a survey about sleep over the previous month was subject to the vagaries of memory. More definitive research would involve putting lots of people in a sleep laboratory and manipulating the temperature to see what happened. “Those ideal data don’t exist and would be prohibitively expensive to collect,” he said.

A bigger weakness in the study, perhaps, is that it is impossible to know what human society will look like 100 years from now. How many people will be without air-conditioning in that world?

Jerome M. Siegel, head of a sleep laboratory at the University of California, Los Angeles, who was not involved in the study, said the assumptions and data limitations gave him pause.

“It’s sort of a nice exercise — yes, this is something that might affect people,” Dr. Siegel said. “But this would be way down on my list of things to worry about with climate change, even though I’m a sleep researcher.”

A Busy Week For Health: Budget Cuts, CBO Scores And Mitch McConnell’s Cryptic Signal

https://kaiserhealthnews.files.wordpress.com/2017/05/052617_khn_hoth.mp3

It was a hectic week for people who follow news about health politics. Kaiser Health News’ veteran reporters Mary Agnes Carey and Julie Rovner sat down to discuss some of the major developments.

MARY AGNES CAREY: Hello, and thanks for joining us. I’m Mary Agnes Carey, partnerships editor and a senior correspondent for Kaiser Health News. Julie Rovner, KHN’s chief Washington correspondent, is here with me to talk about a very busy week in health care: Medicaid cuts in President [Donald] Trump’s budget plan and a new Congressional Budget Office analysis of the House passed ACA overhaul. We’ll also look at what Senate Republicans have in mind for their ACA replacement bill. Julie, let’s get started.

JULIE ROVNER: OK.

MARY AGNES CAREY: First the budget. President Trump released his fiscal 2018 budget plan this week. Federal spending on Medicaid and the Children’s Health Insurance Program would be cut. Can you take us through those changes.

JULIE ROVNER: Yes these Medicaid changes would be on top of what’s in the House-passed health care bill, which would be about $800 billion. What the administration says is that they’re going to let the amount that Medicaid goes up every year go up by less. So that would result in even more cuts. There’s a roughly 20 percent cut to the Children’s Health Insurance Program.

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This budget also includes big cuts to the public health infrastructure. It cuts the Centers for Disease Control and Prevention by about 17 percent. It would cut the National Institutes of Health by nearly 18 percent. It would completely eliminate the Agency for Healthcare Research and Quality and fold that into the NIH. So there’s been a lot of uproar from the medical and scientific community, although we should point out that this budget is unlikely to happen. Presidents’ budgets are mostly wish lists — that goes back decades. Congress basically decides who gets how much money.

MARY AGNES CAREY: Because they control the purse, right.

JULIE ROVNER: Absolutely.

MARY AGNES CAREY: All right. Let’s move on to the ACA. The Congressional Budget Office, or the CBO as we like to call it, released a new score or analysis for the House Republicans’ plan to replace the Affordable Care Act. What were the top takeaways for you?

JULIE ROVNER: Well, a lot of attention was paid to, you know, that sort of top line — that it would result in 23 million more people not having insurance after 10 years and then overall it would save about $119 billion from the deficit.

But what most of us were really looking at is what would happen as a result of that last-minute compromise that actually got the bill passed in the House. That was this amendment that would let states waive some of the requirements in the bill, like having a set of benefits and not charging people with preexisting conditions more. And interestingly, the CBO said that either under the Affordable Care Act or under the original House bill the market for individual insurance would probably be stable. But in those states that decided to take those waivers, it might well become unstable.

And the CBO didn’t say which states that would be, but they estimated that about one-sixth of Americans lived in states where that might happen. In those cases, people with preexisting conditions might be completely priced out of being able to get policies and even people who could get insurance might have to pay many, many thousands of dollars more because some benefits that they might need, like maternity care or mental health care, would no longer be covered. So it was not a ringing endorsement of that last-minute compromise.

MARY AGNES CAREY: And there’s also a big differential between if you’re younger or older, right?

JULIE ROVNER: That’s absolutely right. This is in sort of the original House bill. They would change the way tax credits are provided for people to help pay their premiums. Right now, they’re basically based on your income and how much insurance costs, so it doesn’t matter in different parts of the country if you’re sure insurance costs more. You only have to pay a set percent of your income.

The Republicans would change that, and they would link the tax credits more to age so older people would get more. Younger people would get less, but people would get less help overall. So for older people, premiums would spike dramatically. Sometimes you know more than $10,000 or $12,000. Some younger people, healthy younger people, would see a decrease, but it would not be nearly as large as the increase for older people.

MARY AGNES CAREY: So what does this CBO score mean for Senate Republicans as they try to draft their ACA replacement.

JULIE ROVNER: Well it certainly doesn’t help. The Senate had to wait for the Congressional Budget Office to deliver this score. That’s one of the requirements of the budget process that they’re using. But Senate Majority Leader Mitch McConnell did a couple of interviews this week where he basically said that they’re working hard on health care, but he doesn’t see a path to 50 votes, which is what they need to get this bill passed. That’s assuming Vice President [Mike] Pence could break a tie.

What we’re starting to see are conservatives saying they need to have these waivers — the ones that the CBO just said might destabilize the insurance market. Then you’ve got more moderates saying no we want fewer or no waivers. It’s hard to see where they’re going to come together. We’re told that staff is going to try to draft something next week while Congress is out for the Memorial Day break. But there’s no real anticipated timeline for this yet.

MARY AGNES CAREY: So Julie, why do you think Mitch McConnell would send such a public signal that he’s having a problem getting to 50 votes?

JULIE ROVNER: I really don’t know. I thought it was kind of curious. One of the things that it might be is that he wants to, you know, light a fire under his caucus, who are having all this disagreement, saying you know this whole thing could, you know, just dissolve if you don’t actually start coming to the table and compromising. Why else do you think he might do it?

MARY AGNES CAREY: Well you talk about how the calendar is working against him if he wants to get to tax reform. We’re at Memorial Day, and typically tax reform takes a lot of work, a heavy lift, maybe he just wants to move onto that.

JULIE ROVNER: So basically abandon the whole health reform idea?

MARY AGNES CAREY: I mean it sounds a little nutty. And obviously it’s a campaign promise they’ve all made. But also, as we’ve seen, there are problems in the marketplace. You do see insurers leaving over uncertainty. Perhaps they want to let that play out. I’m not sure.

JULIE ROVNER: Neither am I.

MARY AGNES CAREY: All right, well there you go. Thank you, Julie Rovner of Kaiser Health News.

Categories: Health Industry, Insurance, Medicaid, Public Health, Repeal And Replace Watch, The Health Law, Uninsured

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Carrie Underwood Has Learned to 'Cut Myself Slack' When It Comes to Working Out: 'I Fit It in When I Can'

This article originally appeared on People.com. 

Before having her son 2-year-old son Isaiah, Carrie Underwood would work out six or seven days a week, but she doesn’t put pressure on herself to maintain such an intense workout schedule anymore.

“It just happens if and when it happens,” Underwood, 34, told PEOPLE of her new approach to working out at the CALIA by Carrie Underwood Summer Kick-Off event in Malibu on Friday. “I’ve gotten a lot better at doing what I can when I can, but also cutting myself a little slack. You have to!”

That means squeezing in a workout when it’s doable.

RELATED: Carrie Underwood’s Trainer Erin Oprea Shares the 4 Best Moves to Tone Your Arms

“Now it’s like, ‘Okay, I have 20 minutes. What can I do in 20 minutes?’” she says. “I can go run for a little while, I can go do some tabata rounds, I can do something. Sometimes I’m like, my workout today is going be running around after my kid. If we’re going to go to the park, why not run there and push him in the stroller? Then I get a good cardio session to and from, and then he gets to play, so everybody wins.”

If she does have a little more free time, she’ll do a full tabata workout.

“I ‘play cards’ a lot — I assign different exercises to each suit, and I sit down at breakfast and plan out what each suit’s going to be,” she says.

Her other go-to activities are running and group exercise classes, like Barry’s Bootcamp.

“I love just putting headphones in and going for a run,” says Underwood. “I feel so good when I get home, especially when it’s hot. I’m one of those weirdos that likes to run when it’s super hot outside! Or classes. I find myself competing with other people in the room. I’m like, ‘Oh she’s good, I want to be like her!’ I try to ‘beat’ someone in the class. They have no idea we’re competing!”

RELATED: Carrie Underwood Works Out With New Gym Buddy: Her Son!

The singer says finding time for herself is possible thanks to family support.

“It helps having a supportive husband and a great unit around me,” she says. “You have to sit down and talk to those around you because I feel like I’m a better mom, a better wife, a better friend when I feel good about myself. It’s endorphins and all that stuff that’s being released, too. No bad things can come out of taking care of yourself!”

And having her own fashion line of workout gear is extra motivation to hit the gym.

“I used to go to the gym in ratty old sweats, but if you already feel good going into your workout, it just kind of gives you that little extra lift,” she says.

Underwood says her drive to work out comes from herself, and not from external pressures to look a certain way.

“It’s all about realizing why you do it,” she says. “I want to be a great mom and I want to be around for him for as long as I possibly can. I want to feel good about myself, I want to set that example for my child and make that a priority, because he’s watching. He’s a busy guy, so I need to keep my energy levels up to be able to play with him and chase him around. So it’s for me and my family and for feeling good about myself. Sometimes you have to remind yourself, but it helps to just say, ‘It’s not for everybody else, it’s for me.’ “

This 20-Minute Yoga Flow Can Help Relieve Back Pain

Anyone who struggles with back pain knows how distressing it can be. Whether it’s soreness that impedes your sleep or aches that hurt your productivity while you sit at your desk at work, back pain is hard to ignore no matter what position you’re in. 

The good news? Yoga can be a surprisingly helpful remedy. In this video, yoga expert and Retox author Lauren Imparato takes you through a 20-minute yoga flow designed to soothe and prevent back pain. Yes, please!

“How you sit, how you sleep, something you ate, how you moved,” can all contribute to upper or lower back issues, Imparato explains. And while treatment options do exist—such as massage and acupuncture—studies have shown that yoga may actually be more effective than these and other alternatives. Research from the Annals of Internal Medicine found that people with chronic lower back pain saw more improvement of their symptoms after a 12-week yoga class compared to those who only received medicine or physical therapy to treat their pain. 

RELATED: 4 Surprising Cures for Back Pain

Want to experience the same relief? In this video, Imparato will first help you release tightness and tension in your back by guiding you through classic stretches like cat and cow. Next, she’ll show you how to do a quick, equipment-free flow that works to stabilize the spine and strengthen the muscles in your core that support it. (Hi, toned abs!) Watch the clip above for a yoga routine that not only reduces back pain but crafts long, lean muscle at the same time. 

Viewpoints: Taking Stock Of Genetic Privacy; What About Those Medical Misfits?

A selection of opinions on health care from around the country.

The New England Journal Of Medicine: Undermining Genetic Privacy? Employee Wellness Programs And The Law
Genetic information is becoming ubiquitous in research and medicine. The cost of genetic analysis continues to fall, and its medical and personal value continues to grow. Anticipating this age of genetic medicine, policymakers passed laws and regulations years ago to protect Americans’ privacy and prevent misuse of their health-related information. But a bill moving through the House of Representatives, called the Preserving Employee Wellness Programs Act (H.R. 1313), would preempt key protections. Because the bill, which was sent to the full House by the Education and the Workforce Committee in March, would substantially change legal protections related to the collection and treatment of personal health and genetic information by workplace wellness programs, it should be on the radar screens of physicians, researchers, and the public. (Kathy L. Hudson and Karen Pollitz, 5/24)

The New York Times: Where Will The Medical Misfits Go?
People with health insurance tend to think of safety-net hospitals the way airline travelers think of the bus: as a cheaper service they would use only if they had to. But without these essential hospitals — which specialize in the care of our country’s most medically and financially vulnerable, particularly the uninsured — our entire health care system would be in danger. (Nuila, 5/26)

RealClearScience: Alternative Medicine Is Not The Answer To The Opioid Epidemic
America’s opioid epidemic is not manufactured hype; it’s real. Prescription painkillers are now more widely used than tobacco. Opioids were to blame for 31,000 overdose deaths in 2015, a 300 percent increase from 1999. Of the top ten drugs involved in overdose deaths, half are prescription opioids. (Ross Pomeroy, 5/25)

The New England Journal Of Medicine: Accelerated Approval And Expensive Drugs — A Challenging Combination
For serious or life-threatening disease, the Food and Drug Administration (FDA) can approve drugs on the basis of surrogate end points that are “reasonably likely to predict clinical benefit,” through its accelerated approval review track. This pathway, which dates back to the early 1990s, was designed as a response to the demand for faster drug development in the context of the HIV/AIDS crisis. Since then, the accelerated-approval program has expanded to include oncology products and drugs for other diseases, now accounting for about 10% of new drug approvals. (Walid F. Gellad and Aaron S. Kesselheim, 5/25)

San Jose Mercury News: Mentally Ill Kids Shouldn’t Languish In Juvenile Halls
California’s mentally ill children need clearer laws when going through the juvenile court system… While competency laws exist for juveniles suffering from mental illness, there are no clear, prescriptive guidelines for juveniles on the delivery and duration of services like those that exist in the adult system. Because of this gap in the law, these very vulnerable children languish in juvenile halls, unable to receive the mental health treatment they desperately need. (Mark Stone and Laura Garnette, 5/25)

Cleveland Plain Dealer: Continued Federal Investment In Science Is Critical For Lake Erie And The Region
Scientific research is a critical national investment, providing strong economic and societal benefits that improve our quality of life. In Northeast Ohio, investments in scientific research and environmental protection have helped spur the growth of our local biotechnology and fuel cell industries, enhance our world-leading hospitals and universities, and revitalize the Cuyahoga River and Lake Erie. Yet the White House’s budget proposal seeks to walk away from these investments, threatening our nation’s ability to ensure a more prosperous future, healthy people, and a healthy environment. (Anne Jefferson, 5/26)

Health Affairs Blog: The Burgeoning “Yelpification” Of Health Care: Foundations Help Consumers Hold A Scale And A Mirror To The Health Care System
From flashy tech start-ups in Silicon Valley to modernized insurers in New York, everyone wants to “disrupt” health care. In practice, this is immensely more challenging than it sounds. Electronic health records (EHRs), more than a decade ago, were expected to revolutionize how health information is stored and shared. Yet, even today, 36 percent of office-based EHRs don’t permit secure messaging between patients and physicians, and 37 percent do not even allow patients to view their records. (Paul Howard, Yevgeniy Feyman and Amy Shefrin, 5/25)

RealClear Health: Health Heart 101
For millennia the heart was thought to be the seat of emotions — the source of love, of course, but also kindness and courage. To lose heart is to lose the fight, and perhaps even one’s life. In a literal sense, a weak heart means death. Unfortunately, sudden cardiac arrest is the leading natural cause of death in the United States. (Kamal Patel, 5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Perspectives On The Trump Budget: Examining The Charged Language Used To Respond To It; And What Does That Budget Say About Trump And His Voters?

Opinion writers take on a variety of fiscal issues advanced by President Donald Trump’s budget proposal, including how it treats Medicaid and Social Security’s disability program.

The New York Times: It’s All About Trump’s Contempt
For journalists covering domestic policy, this past week poses some hard choices. Should we focus on the Trump budget’s fraudulence — not only does it invoke $2 trillion in phony savings, it counts them twice — or on its cruelty? Or should we talk instead about the Congressional Budget Office assessment of Trumpcare, which would be devastating for older, poorer and sicker Americans? There is, however, a unifying theme to all these developments. And that theme is contempt — Donald Trump’s contempt for the voters who put him in office. (Paul Krugman, 5/26)

Boston Globe: Baby Boomers Beware: GOP’s Medicaid Cuts Could Hurt You Later
But there’s a giant hole in Medicare coverage, a hole that many aging American seniors eventually fall into: Nursing home care isn’t generally covered, and neither is full-time assistance at home. But if you live to 65, there’s a 40 percent chance you’ll enter a nursing home in the future. And it’ll cost you $80,000 to $90,000 a year on average. So where does that money come from if Medicare won’t pay? The answer is Medicaid, the other government insurance program, the one more often associated with the poor than the elderly. About 60 percent of nursing home residents rely on Medicaid. Which means that if the Republican plan to slash $834 billion from Medicaid goes forward, it could have a devastating impact on seniors with critical health needs. (Evan Horowitz, 5/25)

Chicago Tribune: Social Security’s Disabling Disability Program
Whhen the White House unveiled its 2018 budget on Tuesday, plenty of Democrats were quick to characterize it as stingy and cruel. Among the exhibits for the prosecution was the plan for Social Security Disability Insurance, whose projected outlays the administration would cut by 5 percent by 2027. White House budget director Mick Mulvaney started the argument in March. “It’s the fastest growing program,” he asserted. “It grew tremendously under President Obama. It’s a very wasteful program, and we want to try and fix that.” He was promptly accused of factual sloppiness and heartlessness, and some of the criticism was justified. But Mulvaney is onto a real problem that demands attention. (5/25)

The Kansas City Star: Truth From Mick Mulvaney
Cutting health care for the poor is a dream come true for many congressional Republicans. And that’s not an exaggeration, but a direct quote: “So Medicaid, sending it back to the states, capping its growth rate, we’ve been dreaming of this” since college, House Speaker Paul Ryan said in March. So, what are food stamp recipients who do work but don’t earn enough to feed their families to do? Get “the right mind-set,” says HUD head Ben Carson, since poverty is largely “a state of mind.” (Melinda Henneberger, 5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Different Takes: The Politics Of Repeal, Replace And Reform

Editorial pages across the country include thoughts about the political risks in play as Congress and states confront efforts to dismantle Obamacare.

Bloomberg: Exposing The Obvious About The GOP Health-Care Bill
The gory details of the Congressional Budget Office’s report on the House legislation to “repeal and replace” Obamacare are, in many ways, superfluous. The bill’s flaws, substantive and otherwise, have long been evident. Less clearly understood, though equally disturbing, is the larger political context. (5/25)

Roll Call: A GOP Guide To Running For Cover On Health Care
Most of the news coverage highlighted the CBO’s estimate that 23 million fewer Americans would have health coverage in 2026 under the bill. But in 2026, most current House Republicans will be lobbyists and strategic consultants — and some future Congress would get the blame. In political terms, the scariest CBO number was that 14 million fewer Americans would be without health insurance next year. And many of these suddenly uninsured people just might remember whom to blame when they cast their 2018 ballots. (Walter Shapiro, 5/26)

Los Angeles Times: Die Hard: Republican Healthcare Bill Has No Problem Throwing You Off A Building
Glendale resident David Cannizzaro has had asthma since he was 7. Prior to Obamacare, his healthcare strategy was to see the doctor as little as possible so his insurer wouldn’t notice his preexisting condition and decide to raise his rates or drop his coverage. Now that Republican lawmakers are advancing a bill that would repeal the Affordable Care Act and potentially allow insurers to jack up premiums for people with preexisting conditions, Cannizzaro, 49, said he’s once again living in fear. “It’s very, very scary,” he told me. (David Lazarus, 5/26)

The Washington Post: Senate Republicans Who Are Gunning For Obamacare Are Caught In A Trap
Republican senators who are being asked today about the brutal Congressional Budget Office score of the health-care plan that passed the House have a ready answer: That doesn’t have anything to do with us. Numerous senators released statements saying that the CBO score just shows that the American Health Care Act (AHCA) is a radioactive fungus, which is why they’re starting over on their own bill. (Paul Waldman, 5/25)

The Washington Post: Don’t Blame The CBO For Problems In The House Health-Care Bill
The new Congressional Budget Office score of the American Health Care Act is devastating. In 2026, 23 million fewer Americans would be insured with it than without it. The response of the secretary of health and human services and other defenders of the Republican bill? Attack the Congressional Budget Office. I had the honor of running the CBO a decade ago and will be the first to admit it’s not perfect. But it’s also far better than the alternatives, and most of the critiques are off base. (Peter Orszag, 5/25)

Los Angeles Times: If You Plan On Having A Baby Under Trumpcare, You Better Start Saving Now
Seventeenth century playwright William Congreve famously wrote that hell has no fury like a woman scorned. House Republicans may feel some of that heat once their constituents find out the healthcare bill they passed could make maternity coverage vastly more expensive and harder to obtain. It’s widely known that the House GOP’s proposed American Health Care Act would bar federal funding for Planned Parenthood, which provides many reproductive and maternal health services to lower-income women across the country. Less well understood is that an amendment to the AHCA would also allow states to lift the mandate that insurers include maternity coverage in all the policies they sell to people in the individual and small-group markets (i.e., everyone not covered by a large company health plan). (Jon Healey, 5/25)

Tribune News Service: Obamacare Replacement Would Give Women Better Options, Lower Costs
Women make the majority of decisions about care and insurance for our families, and we generally consume more healthcare than men. As a result, women have a lot at stake when it comes to the laws that govern American healthcare and insurance. In 2010, the Affordable Care Act — Obamacare — made it illegal for insurers to charge women more than men and mandated that insurance plans cover women’s preventive care, including birth control, with no copay. Therefore, some now suggest repealing the Affordable Care Act would be detrimental for women’s health. But the opposite is true: Repeal will afford women greater choice and lower costs when it comes to insurance plans, doctors and care. (Hadley Heath Manning, 5/25)

Detroit Free Press: Who Will Play Fred Upton In Senate Sequel To House Health Care Farce?
Fred Upton is a 16-term congressman who may or may not be interested in becoming Michigan’s next U.S. senator. But there are almost certainly some Republican U.S. senators interested in becoming the next Fred Upton. A grandson of Whirlpool Corp. co-founder Frederick Upton, Rep. Upton is among the wealthiest members of Congress. Until 2016, he served as chair of the House Committee on Energy and Commerce. (Brian Dickerson, 5/25)

Sacramento Bee: California Democrats Did Far More Than Flip Off Trump 
California Democrats now number more than 8 million for the first time, hold every constitutional office, and command a supermajority in the Legislature because we reflect the values of the citizens of our state.But we are not resting on our laurels, far from it. While President Donald Trump and Republicans in Congress are talking about slashing health care for 23 million Americans, California Democrats re-emphasized their belief that health care is a right, not a privilege, as we pursue Medicare for all with Senate Bill 562. (Eric Bauman, 5/25)

Des Moines Register: Privatized Medicaid Was Supposed To Save Money?
Iowa is now 14 months into its experiment with privatized Medicaid management. … Privatization is a slow-motion train wreck, with providers across the state closing up shop or taking out loans to make payroll because the checks from Medicaid are slow to arrive and patient services are being paid at a lower rate. At the same time, the managed care organizations that Iowa hired to administer Medicaid say they are losing millions, and need an enormous increase in funding in order to make ends meet. This was not only predictable, it was predicted. (5/25)

St. Louis Post-Dispatch: Western Missouri Becomes A Canary In Obamacare Coal Mine
In what could be a disturbing portent, Blue Cross Blue Shield of Kansas City on Wednesday announced it was pulling out of the Obamacare health exchanges in 2018. The decision will leave 67,000 people in 25 Missouri counties and two Kansas counties with no option for private insurance, subsidized or not, under the Affordable Care Act. Blue Cross Blue Shield announced it had lost nearly $100 million on Obamacare policies since 2014; only last year did it take in more premium money than it paid out, and overhead costs pushed the Blues into the red. (5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Research Roundup: Early Hospital Discharges; Missed Vaccinations; Growth In Spending

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Surgery: Costs And Consequences Of Early Hospital Discharge After Major Inpatient Surgery In Older Adults
Do fast-track discharge protocols and shorter postoperative length of stay after major inpatient surgery reduce overall surgical episode payments, or are there unintended increased costs because of postdischarge care? … In a cross-sectional cohort study of 639 943 risk and postoperative complication–matched Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting, or total hip replacement, hospitals with shortest routine postoperative length of stay achieved lowest overall surgical episode payments and did not offset shorter hospital stays with greater postdischarge care spending. (Regenbogen et al., 5/17)

Annals of Internal Medicine: Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations
40 810 adult travelers were included [in an observational study in U.S. pretravel clinics]; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). (Hyle et al., 5/16)

Urban Institute/Robert Wood Johnson Foundation: The Evidence On Recent Health Care Spending Growth And The Impact Of The Affordable Care Act
Conventional wisdom holds that health care cost growth is high and the Affordable Care Act (ACA) has done little to address the problem. However, overall increases in national health expenditures (NHE) since the law passed have been lower than anticipated, premiums and premium growth in the ACA’s health insurance marketplaces are high in some states but quite low in others, and growth in Medicare and Medicaid spending per enrollee has been very modest. NHE are still high, now at 18.3 percent of gross domestic product …. In this brief, we attempt to address several misconceptions about recent spending increases; these misconceptions are centered in three areas: the recent and projected growth in NHE the levels and recent growth of ACA marketplace premiums the recent and projected spending growth in the Medicaid program. (Holahan et al., 5/25)

Urban Institute: Medicaid/CHIP Participation Rates Rose Among Both Children And Parents In 2015
Using the 2013-2015 American Community Survey, this brief finds improvements for both parents and children in uninsurance, Medicaid/CHIP participation, and the number who are eligible for Medicaid/CHIP but not enrolled. Uninsurance fell nationally and in nearly every state, and the number of eligible but uninsured children fell to 2.1 million – declining by over half since 2008. Children’s participation reached 93.1 percent in 2015 (exceeding 90 percent in 36 states), while participation among parents rose to 80.2 percent, with larger gains between 2013 and 2015 in expansion states than nonexpansion states. Participation grew among every subgroup of children and parents examined. (Kenney et al., 5/17)

The Kaiser Family Foundation: Financing Family Planning Services For Low-Income Women: The Role Of Public Programs
Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) are the leading sources of federal funding for the over 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. The Trump administration and the Republican leadership of the 115th Congress have proposed to block federal Medicaid funds from going to Planned Parenthood …. Changes to these programs and funding to the clinics that provide family planning services could limit the availability of contraceptive services, STI screenings and treatment, and preventive cancer screenings, along with other primary care services to low-income women. … One in three low-income women reported that they obtained birth control from a family planning clinic such as Planned Parenthood or another health center or public health clinic. (Ranji et al., 5/11)

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State Highlights: Calif. Legislature Steps Into Tense Fight Over Tobacco Tax; Mass. Agency Finds Avoidable ER Visits Are Driving Up Costs

Media outlets report on news from California, Massachusetts, Connecticut, Ohio, Kansas, Minnesota, Louisiana, Texas, Georgia, Maryland, Arizona, Florida.

Los Angeles Times: California Senate, Assembly Advance Their Own Plans On How To Spend Tobacco Tax Revenue
Perhaps the biggest budget skirmish that remains unsolved this year is how California should spend revenue from the tobacco tax voters approved last fall. Gov. Jerry Brown wants to put that money to expand overall spending on Medi-Cal, which provides subsidized healthcare for the poor. But the some of initiative’s backers, namely doctor and dental groups, have cried foul, arguing that money is meant to go to increasing payments for providers. (Mason, 5/25)

WBUR: Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER 
Forty-two percent of emergency room visits in Massachusetts in 2015 were for problems that could have been treated by a primary care doctor, according to the state’s Health Policy Commission. This state agency, which is charged with driving down costs, says a 5 percent cut in avoidable emergency room trips would save $12 million a year; 10 percent fewer such visits would save $24 million. (Bebinger, 5/25)

The CT Mirror: Advocates: Disabled Children Stranded In CT Hospital ERs 
Insufficient services, a complex funding system and deep state budget cuts have increasingly stranded developmentally disabled children in hospital emergency departments over the past year, often for weeks at a time, two state advocates told legislators Thursday. Sarah Eagan, Connecticut’s child advocate, and Ted Doolittle, the state’s healthcare advocate, said the problem is centered almost exclusively on children with “complex diagnoses,” meaning they face a combination of developmental and intellectual disabilities and mental health conditions. (Phaneuf, 5/25)

Cleveland Plain Dealer: Lawmakers Hear Opposition To Lead Amendment From Doctors, Parents, Elected Officials And Healthy Home Advocates
Doctors, parents, city leaders and healthy home advocates took turns Wednesday telling the Ohio Senate Finance subcommittee on Health and Medicaid why they oppose an amendment to the state budget that would strip municipalities of authority to create local efforts to address childhood lead poisoning… Rep. Derek Merrin, a Republican who represents parts of Lucas and Fulton counties, proposed the amendment last month and has argued that a fractured system of rules that change from city-to-city is not only unfair to landlords but doesn’t give all children in Ohio equal protection from lead exposure. (Dissell and Zeltner, 5/25)

Los Angeles Times: No One Knows How Many Untested Rape Kits There Are In California. This Bill Aims To Fix That
ens of thousands of rape kits are sitting on shelves in police and sheriff’s department evidence rooms nationwide. And no one has tested them to see what crimes they could help solve. A bill by Assemblyman David Chiu (D-San Francisco) would help determine how many of those unanalyzed exam kits exist in California, part of a national backlog that federal officials have grappled with for nearly two decades. (Ulloa, 5/26)

KCUR: Kansas Crisis Centers Say New Law Creates Mental Health Funding Need 
A new law will allow Kansas crisis centers to treat involuntary mental health patients for up to 72 hours, but it isn’t clear if lawmakers will fund it. Gov. Sam Brownback on Wednesday signed House Bill 2053, which allows crisis centers to treat people deemed a danger to themselves or others because of a mental health or substance use disorder. The bill had passed the House unanimously and passed the Senate 27-12 after some amendments. Lawmakers didn’t allocate funding for additional crisis center beds before they left for the Memorial Day weekend, although they have yet to finalize a budget. (Wingerter, 5/25)

California Healthline: For California Hospitals That Don’t Pass Quake Test, Money’s Mostly At Fault
With a state deadline looming, some California hospitals still need to retrofit or rebuild so that their structures can withstand an earthquake — and money remains a challenge. Some hospital officials are turning to voters to raise money, while others are pursuing more innovative financing schemes.About 7 percent of the state’s hospital buildings — 220 — are still designated as having the highest risk of collapse following an earthquake, according to the Office of Statewide Health Planning and Development. That’s a slight drop from 251 buildings a year ago. (Ibarra, 5/26)

The Star Tribune: HCMC Seeks To Ease Patient Bottlenecks With New Mental Health Crisis Center
To ease chronic bottlenecks in countywide mental health services, Hennepin County Medical Center (HCMC) is nearing completion of a new 16-bed home that will help people with mental illnesses transition back into the community after acute hospital stays. The Victorian-style home, located at 3633 Chicago Av. in south Minneapolis, will provide short-term housing and treatment for adults who are stable enough to be discharged from a hospital psychiatric unit but who may need more therapy and social support before returning to their regular homes and jobs. (Serres, 5/25)

New Orleans Times-Picayune: She Saved $3,786 By Shopping Her MRI; Here’s How You Can Save, Too 
It was only after her doctor recommended she get an abdominal MRI that a New Orleans woman learned just how costly it can be to have a medical procedure without first shopping around. The woman, who asked to remain anonymous in order to discuss her health, said her doctor suggested the MRI to help her understand a hereditary condition that might affect her years from now. A month later, the day before the test, she got a call from Tulane Medical Center asking how she planned to pay for it, she said. (Lipinski and Zurik, 5/25)

Texas Tribune: Behind Closed Doors, Texas Lawmakers Strip Funding For Sex Trafficking Victims
In recent private negotiations between the Texas House and Senate about which public programs to fund and how to fund them, state lawmakers opted to kill a $3 million initiative to rehabilitate victims of sex trafficking. That ended hopes from child welfare advocates that 2017 would be the first year in recent memory in which state lawmakers might set aside funds specifically intended to help victims who were sold for sex. (Waltersn, 5/25)

Cleveland Plain Dealer: AxessPointe Offers Healthcare Clinic For North Hill Refugees, Immigrants 
To serve the refugee community in Akron’s North Hill, AxessPointe Community Health Centers will provide a weekly healthcare clinic at the Exchange House. The Exchange House, created by the Better Block Foundation, serves as a community center for the large refugee population, predominantly Bhutanese, which travels mostly on foot and has a large number of children and senior citizens. (Conn, 5/25)

Georgia Health News: Not Just A School Clinic, But A Clinic That’s At A School
Five days a week, a team of nurses and a rotating cadre of pediatricians, nutritionists and dentists at the Gilbert Community Clinic see not just schoolchildren but Walker County residents of all ages… Although the idea of a general medical clinic on the grounds of a public school sounds novel, it’s not a new idea in Georgia. (Park, 5/25)

Georgia Health News: Meals On Wheels: Volunteers Deliver Food As They Fret About Funding
Last year, Meals on Wheels programs brought nearly 4 million meals to 28,000 seniors living in Georgia. But federal support for this program could shrink under President Trump’s proposed budget. If the federal portion of funding for the program is cut, the effects will reverberate in tiny towns like Chickamauga, where Betty Richardson delivers lunches every week. (Male, 5/25)

The Baltimore Sun: Emerging Hopkins Center Harmonizing Music And Medicine 
[Alex] Pantelyat, 34, a Johns Hopkins University neurologist (and, not so incidentally, an accomplished violinist) is a co-founder and co-director of the Center for Music & Medicine, an emerging collaboration between the Johns Hopkins medical community and the Peabody Institute. The mission, he said, is to combine the expertise of faculty members in both camps toward a pair of ends: integrating music and rhythm into medical care and improving the health of musicians worldwide. More than 80 Johns Hopkins faculty members across dozens of disciplines have affiliated themselves with the center, the first of its kind in the eastern United States. (Pitts, 5/26)

Arizona Republic: What To Know As Arizona’s Mandatory Paid Sick-Leave Law Takes Effect
Arizona’s new law mandating paid sick leave starts July 1, and employers had better be prepared for it. Businesses and non-profit groups could face penalties for failing to keep adequate records or post sufficient notice, and they could incur damages for failing to provide paid sick time. Employers who retaliate against workers exercising their rights could face fines of at least $150 per day, say attorneys at Gallagher & Kennedy, a Phoenix law firm that held a workshop to alert employers of the requirements. (Wiles, 5/25)

Miami Herald: Valley Children’s Hospital Has Volunteer Baby Cuddling Program 
Lynne Meccariello, unit support supervisor of the neonatal intensive care unit and a liaison for the hospital’s volunteer services department, describes the cuddling program as providing “developmental care and comfort to babies when their parents can’t be there.” Meccariello says holding a sick baby reduces pain and provides warmth, and the cuddler encourages “self-soothing” – children’s ability to comfort themselves when they aren’t being held. (George, 5/25)

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Many Adults Don’t Know That Secondhand E-Cigarette Vapor Poses Health Risk To Kids

In a survey, nearly one-third say they don’t know if such aerosol causes harm to children. In other public health news, groups worried about superbugs press In-N-Out Burger to make good on its pledge to phase out beef raised with antibiotics. And researchers investigate the impact of Facebook on mental health.

NPR: Many Adults Don’t Think Exposure To Vaping Is Bad For Kids
Despite the toxic ingredients commonly found in e-cigarettes and other vaping products, many adults don’t think secondhand e-cigarette aerosol poses a risk to children, according to a report published Thursday by the Centers for Disease Control and Prevention. About one-third of adults surveyed didn’t know if secondhand aerosol caused harm to children, and 40 percent of the adults said this kind of exposure caused “little” or “some” harm to children. (Columbus, 5/25)

Reuters: Activists Call On In-N-Out Burger To Join The Superbug Fight
Nearly three dozen consumer, environmental and public health groups on Thursday pressed privately held In-N-Out Burger to make good on its vow to set time lines for phasing out the use of beef raised with antibiotics vital to human health. Some 70 percent of antibiotics needed to fight infections in humans are sold for use in meat and dairy production. Medical researchers say overuse of the drugs may diminish their effectiveness in fighting disease in humans by contributing to the rise of dangerous, antibiotic-resistant bacteria often referred to as “superbugs.” (Baertlein, 5/25)

The Wall Street Journal: Does Facebook Make Us Unhappy And Unhealthy?
If you’re one of the almost two billion active users of Facebook , the site’s blend of gossip, news, animal videos and bragging opportunities can be irresistible. But is it good for you? A rigorous study recently published in the American Journal of Epidemiology suggests that it isn’t. Researchers found that the more people use Facebook, the less healthy they are and the less satisfied with their lives. To put it baldly: The more times you click “like,” the worse you feel. (Pinker, 5/25)

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Mapping Zika’s Family Tree With Genome Sequencing Shows The Origins Of An Epidemic

Using the technique could help researchers predict how the next pandemic will move across the globe.

Los Angeles Times: What The DNA Of The Zika Virus Tells Scientists About Its Rapid Spread
A family tree can reveal a lot, especially if it belongs to a microscopic troublemaker with a knack for genetic shape-shifting. DNA sleuthing can outline the route an emerging pathogen might take once it makes landfall in the Americas and encounters a wholly unprotected population. It’s a modern take on old-fashioned public health surveillance strategies that focused on the exhaustive collection and analysis of samples from the field. Now they’ve been bolstered by rapid genome sequencing — and the result can be a picture of an epidemic rendered in exquisite detail, and in near-real time. (Healy, 5/25)

In other news on Zika —

The Wall Street Journal: New York City Issues Zika Travel Warning
In advance of the summer travel season, New York City health officials on Thursday stepped up warnings to would-be parents about the threat of contracting Zika, a mosquito-borne virus that has been linked to serious birth defects in babies and, in some cases, in utero deaths. (West, 5/25)

The New York Times: A Quarter Of U.S. Babies With Zika-Related Birth Defects Were Born In New York
A quarter of all infants in the United States born with defects related to the Zika virus were born to women in New York City, city health officials announced on Thursday, a stark reminder of the dangers posed by the virus. Looking ahead to summer and the threat of the resurgent virus spreading through the Caribbean, the New York City Department of Health said that 402 pregnant women had been infected with the virus and that 32 infants had been infected with the virus and 16 of them had Zika-related birth defects since last spring. (Santora, 5/25)

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Setting Sights On High Drug Prices, Gottlieb Steers FDA Into Waters Previous Chiefs Dared Not Tread

In previous administrations, the heads of the FDA said the agency’s focus is efficacy and safety. But Dr. Scott Gottlieb is launching a concerted effort, hinged on increasing competition with generic drugs, to address skyrocketing costs.

The Wall Street Journal: FDA Chief Proposes Rules Changes To Fight High Drug Prices
The new commissioner of the Food and Drug Administration plans a multifaceted effort to restrain high prescription-drug prices, centered on speeding cheaper generic medicines onto the U.S. market. Previous FDA commissioners have largely professed inability to act on drug costs, even as prices of drugs for cancer, hepatitis and other illnesses climbed to as much as hundreds of thousands of dollars per year or even therapeutic course. The FDA’s job, they said, is to assess safety and efficacy, and little else. (Burton, 5/25)

The Wall Street Journal: The Latest Drug Pricing Threat: The FDA
Health-care investors have another clear signal that regulatory scrutiny of high drug prices isn’t going away. Dr. Scott Gottlieb, the new commissioner of the Food and Drug Administration, made that clear Thursday morning, unveiling a host of policy plans that would enable the FDA to fight high drug prices in ways that the agency hasn’t done before. These policy changes are less drastic than say, overhauling rules surrounding how Medicare pays for prescription drugs, but they should generally be easier to implement. (Grant, 5/25)

Stat: Trump’s FDA Chief Punts On Defending His Boss’s Budget
Dr. Scott Gottlieb was in an awkward position. He’s been head of the Food and Drug Administration for just two weeks, and his boss, President Trump, is pushing a federal budget that would undo years of congressional work and risk bringing the agency to a grinding halt…Trump’s budget request, unveiled on Monday, calls for upending how the FDA has reviewed drugs and medical devices for 25 years. Under current law, companies pay user fees in exchange for product reviews, funding about two-thirds of the FDA’s budget for vetting drugs and devices. Now, in an effort to curtail federal spending, the White House wants to saddle the industry with the entire cost of product reviews, which would spell a roughly 70 percent increase in user fees. (Garde, 5/25)

CQ Roll Call: Lawmakers Skeptical Of Proposed FDA Budget Shift
House Appropriations subcommittee members at a hearing Thursday were skeptical of the Trump administration’s proposal to decrease the Food and Drug Administration’s taxpayer-funded budget by $1 billion in exchange for an increase of about the same amount in so-called user fees from regulated industries. The hearing marked the first appearance before Congress of new FDA Commissioner Scott Gottlieb since he was sworn in two weeks ago. Members pressed for his views on competition and pricing in the prescription drug market, the regulation of e-cigarettes, and food safety, which would lose funding under the Trump administration’s proposal. (Siddons, 5/25)

Politico Pro: FDA Hiring Freeze Lifted, Gottlieb Writes
The FDA is no longer subject to the hiring freeze the Trump administration imposed in late January, Commissioner Scott Gottlieb wrote this morning in an email to agency staff… He added more details will be forthcoming about a new streamlined and efficient process for filling job openings. The FDA currently has about 1,000 vacancies. (Karlin-Smith, 5/25)

In other pharmaceutical news —

Stat: Nevada Passes Bill To Limit Diabetes Drug Prices
In a setback for the pharmaceutical industry, the Nevada state assembly on Thursday voted in favor of a controversial bill aimed at lowering prices for diabetes medicines. The legislation, which passed the state senate last week, now goes to Governor Brian Sandoval. The bill is designed to lower costs by requiring drug makers to report pricing histories, disclose costs, and notify state officials and insurers in advance of price hikes above inflation. And a recently added amendment would also require drug companies to disclose rebates paid to pharmacy benefit managers, the middlemen that negotiate favorable insurance coverage. (Silverman, 5/25)

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Wis. Committee Approves Gov. Walker’s Plan To Test Some Medicaid Enrollees For Drugs

The plan, if it wins full legislative approval and is endorsed by federal officials, would be the first of its kind in the country.

The Associated Press: Walker’s Medicaid Drug-Testing Wins Approval
Gov. Scott Walker’s proposal making Wisconsin the first state to require drug tests to receive Medicaid health benefits has won approval from the Legislature’s budget-writing committee. The Joint Finance Committee on Thursday voted to give itself oversight and final approval on Walker’s plans to drug-test able-bodied, childless adult Medicaid applicants. There would also be a drug test requirement for food stamp recipients. Democratic opponents argue the drug testing would be unconstitutional. (5/25)

The proposal in Wisconsin is one of a number of conservative proposals to modify Medicaid being considered in states.

The Washington Post: At Trump’s Urging, States Try To Tilt Medicaid In Conservative Directions
Wisconsin is preparing to recast its Medicaid program in ways that no state has ever done, requiring low-income adults to undergo drug screening to qualify for health coverage and setting time limits on assistance unless they work or train for a job. The approach places BadgerCare, as the Wisconsin version of Medicaid is known, at the forefront of a movement by Republican governors and legislatures that is injecting a brand of moralism and individual responsibility into the nation’s largest source of public health insurance. (Goldstein and Eilperin, 5/25)

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House Panel Broadens Investigation Of NIH Safety And Compliance Issues

House Energy and Commerce Committee requests more documents in its probe of contaminated research samples reported at the NIH Clinical Center in Bethesda, Maryland. In other administration news, former Rep. Renee Ellmers (R-N.C.) starts her new job as director for the Department of Health and Human Service’s regional office in Atlanta

Roll Call: NIH Probe By House Panel Expands
The National Institutes of Health is in hot water again with the House Energy and Commerce Committee over a scandal that occurred nearly two years ago at one of the agency’s main research institutions. On Thursday, the panel broadened its probe into safety and compliance issues at the NIH Clinical Center, a research hospital located on the agency’s campus in Bethesda, Maryland. In a letter sent to Director Francis Collins and obtained by Roll Call, the committee requested a larger swath of documents not yet provided by the agency. (Williams, 5/25)

Roll Call: Ellmers Gets HHS Job
Former North Carolina Rep. Renee Ellmers has landed a job in the Trump administration as director for the Department of Health and Human Service’s regional office in Atlanta. Ellmers started her job Wednesday, the News & Observer in Raleigh reported. Ellmers was the first Republican member of Congress endorsed by Trump, but lost her primary race last year to fellow Republican Rep. George Holding after redistricting. (Garcia, 5/25)

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‘Health Care’ = Fighting Words In Montana

There was likely good reason why Greg Gianforte, successful Republican candidate for Congress from Montana, lost his cool on the eve of the election — scuffling with a reporter, breaking the man’s glasses and ending up with a misdemeanor assault charge:

He, like many Republicans these days, walks a perilous line when talking health care.

Ben Jacobs, a reporter for The Guardian, approached the candidate armed with an audio recorder and persistent, pesky questions about a Congressional Budget Office (CBO) report, which found that the GOP’s American Health Care Act would leave 23 million more Americans uninsured over 10 years and would effectively price out from coverage millions with preexisting conditions.

Though the AHCA passed muster in the House of Representatives, disapproval of the Republican plan has been high among voters — by ratios of more than 2-to-1 among men and more than 3-to-1 among women, according to a Quinnipiac University poll. Over 50 percent of Republicans opposed cutting federal funding for Medicaid, a component of the bill.

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Torn between conflicting impulses, the GOP candidate for Montana’s only seat in the House of Representatives had already stepped into the health care muck twice — on opposite sides of the issue. He told reporters he would not have voted for the Obamacare repeal bill passed by the House earlier this month, but a tape surfaced of him saying he was “thankful” for that same bill during a fundraising call with D.C. lobbyists. No wonder he wasn’t eager to respond to Jacobs’ question.

On the other side of the political divide, Democratic challenger Rob Quist tried to seize the moment, making opposition to the AHCA a campaign issue. On the final weekend before Thursday’s vote, Quist made a major buy of political ads that pinned the erosion of preexisting condition protections on his opponent. He confided his own preexisting condition — related to “a botched gall bladder surgery” — and noted that about half of all Montanans have a preexisting condition. Approximately 52 million Americans have a health history that could make them uninsurable in the future, if laws don’t guard against the practice.

According to the CBO report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

Quist’s health narrative also dissolved one of Gianforte’s most potent attacks on him: financial problems that led to bankruptcy. Medical bills caused that bankruptcy, Quist said, and indeed, as a folk singer for most of his life, Quist was someone who had to buy health insurance on the unstable and discriminatory individual market. At 69, he can now rely on Medicare.

Gianforte, at 56, is in the age range of those who can be charged five times more than younger people for insurance under the House-passed bill. But, like President Donald Trump, Gianforte is a wealthy businessman, who likely has not had to focus deeply on the high costs of health coverage.

The altercation may not have affected the election. The seat has been occupied by a Republican for more than two decades, and nearly two-thirds of the expected turnout had already cast a ballot by mail. Montana also has same-day voter registration. Reporters from Montana Public Radio heard from brand-new voters Thursday — some who were appalled and compelled by Gianforte’s behavior and others who thought Jacobs was in the wrong.

It’s hard to say how much health care influenced Gianforte’s 6 percentage point win over Quist. The use of public lands had been the central issue in the election, and both candidates had avoided the topic of health care for much of the race, which replaces the seat vacated by Interior Secretary Ryan Zinke.

But Gianforte’s election eve scuffle may signal how tense and explosive health care will be politically for the 2018 election cycle.

Eric Whitney of Montana Public Radio contributed to this report.

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Influx Of Elderly Patients Forces ER To Practice Comfort Care

A man sobbed in a New York emergency room. His elderly wife, who suffered from advanced dementia, had just had a breathing tube stuck down her throat. He knew she never would have wanted that. Now he had to decide whether to reverse the life-sustaining treatment that medics had begun.

Dr. Kei Ouchi, then a resident at Long Island Jewish Medical Center, had no idea what to say. The husband, who had cared for his wife for the past 10 years, knew her condition had declined so much that she wouldn’t want a heroic rescue. But when Ouchi offered to take out the tube, the man cried more: “She’s breathing. How can we stop that?”

Ouchi had pursued emergency medicine to rescue victims of gunshot wounds and car crashes. He was unprepared, he said, for what he encountered: a stream of older patients with serious illnesses like dementia, cancer and heart disease — patients for whom the lifesaving techniques he was trained to perform often only prolonged the suffering.

As the nation’s elderly population swells, more older Americans are visiting the emergency room, which can be an overcrowded, disorienting and even traumatic place. Adults 65 and older made 20.8 million emergency room visits in 2013, up from 16.2 million in 2000, according to the most recent hospital survey by the Centers for Disease Control and Prevention. The survey found 1 in 6 visits to the ER were made by an older patient, a proportion that’s expected to rise as baby boomers age.

Half of adults in this age group visit the ER in their last month of life, according to a study in the journal Health Affairs. Of those, half die in the hospital, the study found, even though most people say they’d prefer to die at home.

The influx is prompting more clinicians to rethink what happens in the fast-paced emergency room, where the default is to do everything possible to extend life. Hospitals across the country, including in Ohio, Texas, Virginia and New Jersey, are bringing palliative care, which focuses on improving quality of life for patients with advanced illness, into the emergency department.

Interest is growing among doctors: One hundred forty-nine emergency physicians have become certified in palliative care since that option became available just over a decade ago, and others are working closely with palliative care teams. But efforts to transform the ER face significant challenges, including a lack of time, staffing and expertise, not to mention a culture clash.

Researchers who interviewed emergency room staff at two Boston hospitals, for instance, found resistance to palliative care.

ER doctors questioned how they could handle delicate end-of-life conversations for patients they barely knew. Others argued the ER, with its “cold simple rooms” and drunken patients screaming, is not an appropriate place to provide palliative care, which tends to physical, psychological and spiritual needs.

Ouchi saw some of these challenges up close during his residency in New York, when he visited the homes of older patients who were frequent visitors to the emergency room.

He saw how difficult it is for these patients to make it to the doctor. Often, “they can barely see. They can barely get out of the house,” he said. To make it to a doctor’s appointment, he said, they’d often have to call for a ride service, which could take several hours to arrive.

“So what do they do?” Ouchi said. “They call 911.”

When these patients arrive at the emergency room, doctors treat their acute symptoms but not their underlying needs, Ouchi said. In more severe cases, when the patient can’t talk and doesn’t have an advanced directive or a medical decision-maker available, doctors default to the most aggressive care possible to keep them alive — CPR, intravenous fluids, breathing tubes.

“Our default in the ER is pedal to the metal,” said Dr. Corita Grudzen, an emergency physician at NYU Langone Medical Center who studies palliative care in the ER. But when doctors learn after the fact that the patient would not have wanted that, the emergency rescue puts the family in the difficult position of deciding whether to remove life support.

(Heidi de Marco/KHN)

When older adults are very ill — if they need an IV drip to maintain blood pressure, a ventilator to breathe or medication to restart the heart — they are most likely to end up in an intensive care unit, Grudzen said. Rates of transfer from the ER to the ICU have been rising, she noted.

“It’s a terrible place to be if you’re older,” Grudzen said, as older patients are more likely to develop hospital-acquired infections and delirium. Meanwhile, it’s not clear whether these aggressive interventions really extend their lives, she said.

Some have sought to address these problems by creating separate, quieter emergency rooms for older patients. Others say bringing palliative care consultations into regular emergency rooms could reduce hospitalization, drive down costs and even extend life by reducing suffering.

There’s no hard evidence that approach will live up to its promise. The only major randomized controlled trial, which Grudzen led at Mount Sinai Hospital in New York City, found that palliative care consultations in the emergency room improved quality of life for cancer patients. It did not find statistically significant evidence that the consultations improved rates of survival, depression, ICU admission or discharge to hospice.

But frontline doctors say they’re seeing how palliative care in the ER can avert suffering. For instance, Ouchi recalled one patient, a man in his late 60s, who showed up at the emergency room — for the fifth time in six months — seeking relief from fever and back pain. In previous visits, doctors had quelled his symptoms, but they hadn’t addressed the underlying problem: The man was dying of cancer, which was causing persistent pain in his bones.

This time, a nurse and social worker called in a palliative care team, who talked to the patient about his goals.

“All he wanted was to be comfortable at home,” Ouchi said. The man enrolled in hospice, a form of palliative care for terminally ill patients. The hospice sent staff to his home to manage his symptoms and spiritual needs. He died about six months later, at home. His daughter returned to the hospital to thank the staff.

Now Ouchi and others are trying to come up with systematic ways to identify which patients could benefit from palliative care.

One such screening tool, dubbed P-CaRES, developed at Brown University, is a simple list of questions clinicians can answer about each patient in the ER. It asks if the patient has life-limiting conditions such as advanced dementia or sepsis. It asks the patient’s frequency of ER visits, the level of caregiver stress, and whether the doctor would be surprised if the patient died within 12 months.

Doctors are using the tool to screen patients at the University of California-San Francisco Medical Center at Parnassus and to connect them to palliative care doctors, said Dr. Kalie Dove-Maguire, a clinical instructor there. The questions pop up automatically on the hospital electronic medical record for every ER patient who is about to be admitted to the hospital.

Dove-Maguire said UCSF hasn’t published results, but the tool has helped individual patients, including a middle-aged man with widespread cancer who showed up at the ER with low blood pressure. The man “would have been admitted to the ICU with lines and tubes and invasive procedures,” she said, but staff talked to his family, learned his wishes and sent him home on hospice instead.

“Having that conversation in the ER, which is the entry point to the hospital, is vital,” Dove-Maguire said.

But time is scarce in ERs, where revenue depends on how many patients come through. Doctors’ performance is measured in minutes, Grudzen noted, and the longer they stop to make calls to refer one patient to hospice, the more patients line up waiting for a bed.

Finding someone to have conversations about a patient’s goals of care can be difficult, too. Ouchi enlisted ER doctors to use the screening tool for 207 older ER patients at Brigham and Women’s Hospital in Boston, where he now works as an emergency physician. They found a third of the patients would have benefited from a palliative care consultation. But there aren’t nearly enough palliative care doctors to provide that level of care, Ouchi said.

“The workforce for specialty palliative care is tiny, and the need is growing,” said Grudzen. Palliative care is a relatively new specialty, and there’s a national shortfall of as many as 18,000 palliative care doctors, according to one estimate.

“You can screen up the wazoo,” Grudzen said, but if there aren’t any palliative care doctors available to talk to a patient, “what are you going to do?”

“We’ve got to teach cardiologists, intensivists, emergency physicians how to do palliative care,” she said. “We really have to teach ourselves the skills.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Categories: Aging, Health Industry, Public Health

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For Two Runners, Married Life Begins at Mile 6

By TAMMY La GORCE

If the particulars of Alex Salazar’s transformation from couch potato to marathon man are fuzzy — he calls his efforts “pretty casual” — the benefits are clearly defined. In addition to toned pectorals and fierce quadriceps, Mr. Salazar gained a sense of purpose and a bustling social life after he started running and working out in 2012.

He also lost 50 pounds and met Krissa Cetner, who would vow to help keep him heart healthy, in both the physical and emotional senses. Though the courtship of the two fitness devotees hardly took place at a frenetic pace, it culminated in the middle of the Brooklyn half marathon on May 20.

Mr. Salazar, now 39 and a technology consultant, first met Ms. Cetner, 36 and a nurse practitioner at the Hospital for Special Surgery in New York, at a volleyball game in Manhattan in the fall of 2012. Mr. Salazar had signed up to referee, and Ms. Cetner had been playing on the Casual Sets team for years.

“So it’s my first time reffing by myself, and I’m all nervous,” Mr. Salazar recalled. “I’m fumbling around with the net, and it’s like 10 minutes in, and Krissa was the closest player to me. I said: ‘Hey, I’m new here and I don’t know what I’m doing. Can you help me?’”

She could. But there was no immediate tug of attraction; Mr. Salazar had a girlfriend, and Ms. Cetner was too interested in spiking the ball to take much notice of him.

“He seemed like a nice guy,” she said, “but I didn’t think much of it.”

That December, she broke her foot while going to block a shot, knocking her out of volleyball for a while. But by March 2013, she felt healthy enough to run in a chilly half marathon in Manhattan.

In the runners’ corral, she recalled, “I saw this guy who was all bundled up, and he looked familiar, but I couldn’t really see him that well.” Slowed by her still-healing foot, she lost him in the crowd.

During her first game back with the volleyball team, she recognized the bundled figure: “I said, ‘Hey, did you run the half marathon?’”

Mr. Salazar said he had, and invited her to join his running group, whose members capped their Tuesday night runs in Manhattan with tacos and beer. The invitation wasn’t meant to be flirtatious. Mr. Salazar was still in an exclusive relationship.

“But my personality has always been, like, the more the merrier,” said Mr. Salazar, who grew up in Brooklyn in what he called a festive Colombian family. His mother, Mavelly, and father, Dario, now live in Central Islip, N.Y.

Ms. Cetner soon began feeling relaxed around Mr. Salazar. “We could talk about anything,” she said.

One night after the runners had gathered, Mr. Salazar walked her to the subway. She was headed home, to her Upper West Side apartment and her cat, Bruce.

“We were standing there on the platform, and I had had a couple of beers, and I said, ‘You know, you and I would be amazing together,’” she said.

Mr. Salazar’s response was not the one most women, emboldened by a beer buzz and a runner’s high, dream of.

“I said something along the lines of, ‘I appreciate you being open and honest with me, but there’s not much I can do with that information,’” he recalled. “I put it out of my mind.”

Months later, Mr. Salazar was refereeing a volleyball game when Ms. Cetner noticed that something was wrong. “I had been in this relationship a year and a half,” he said, “and it was ending, really badly.”

Ms. Cetner asked if he wanted to go for beers.

“I wasn’t thinking, ‘Oh, great, here’s my chance’ or anything,” she said. “I was just thinking he might need to talk.” He poured his heart out. And then they went their separate ways, both dismissing Ms. Cetner’s drunken-crush admission in favor of a more substantial bond, rooted in friendship.

“We kept the idea of dating at arm’s length out of respect for each other,” Mr. Salazar said. Ms. Cetner, who had ended a long-term relationship a year before meeting Mr. Salazar, kept her attention on Bruce, and on her career. Mr. Salazar started seeing other women.

“But in the back of my mind, I knew there was something special about her,” he said.

It wasn’t just her long, athletic legs or the way she wraps her arms around anyone who merits a hug, he said. It was her character.

Ms. Cetner is as self-possessed as she is goal-oriented. She moved to Manhattan from Saratoga Springs, N.Y., in 2007 without much besides her nursing degree. She credits her parents, John R. Cetner of Ballston Spa, N.Y., and Deb Dittner of Saratoga Springs, who divorced when she was young, for her pioneering spirit. And for her excellent cardiovascular system.

“I did my first race when I was in my mom’s belly,” she said. “My parents were runners, and they would take me to races.”

By the summer of 2013, Mr. Salazar decided he was wasting his time dating other women. By late August, Ms. Cetner was spending most nights in Mr. Salazar’s Brooklyn apartment, and they had come up with nicknames for each other that have stuck: She is Baby Giraffe, a reference to her long limbs, and he is Beast, a nod to a workout video he follows.

Ms. Cetner finally moved in with Mr. Salazar in March 2015. Bruce went upstate to Mr. Cetner’s house, because Mr. Salazar is allergic to cats.

“Our relationship just flows,” Ms. Cetner said. Still, she had no idea that Mr. Salazar was planning to propose when they accepted an invitation to stay at a friend’s time share in Cancún, Mexico, in May 2015.

The right moment arrived at an archaeological site in Tulum.

“We were in ancient Mayan ruins, on a cliff overlooking the water,” Ms. Cetner said. “It had been such a great trip, and I said: ‘You’re my running partner, my darts partner and my life partner. It doesn’t get much better than this.’” Mr. Salazar knew an opportunity when he heard one.

“Speaking of life partner,” he said, producing a ring. Ms. Cetner’s acceptance was swift.

On May 20, Mr. Salazar and Ms. Cetner were married during the Brooklyn Half. By 7:30 a.m., Mr. Salazar was suited up in a running shirt silk-screened with a tuxedo motif. Ms. Cetner pulled on spandex pants and a white sleeveless top. At Mile 6, on a stretch in Prospect Park, 50 friends and family members were waiting.

Mr. Cetner greeted his daughter when she pulled off the race route at 9 a.m., panting but excitedly waving her arms toward the crowd. Mr. Salazar had arrived moments earlier. He waited for the bride, hands on thighs, catching his breath.

Before Mr. Cetner walked his daughter down the grassy aisle, her friend Alexis Schuster handed her a runner’s baton with pink peonies poking out of it. The ponytailed bride tucked a flower behind an ear and joined hands with Mr. Salazar. Hundreds of runners, including many who had noticed the custom “bride” and “groom” running bibs pinned to their backs, shouted and whooped their congratulations while hustling by.

The officiant, Alex Valentine, a friend from Mr. Salazar’s college days at N.Y.U., gave the couple some friendly advice.

“Marriage is a marathon, not a sprint,” she said. “Enjoy the highs and power through the lows.”

After a long kiss, a few smeared tears and a shower of blue-and-white confetti, the bride and groom again hit the trail, side by side.

The couple finished the 13.1-mile race in about 2 hours 45 minutes, a little slow for them. “We usually finish in about two hours,” Ms. Cetner said. “But we didn’t care. We accomplished a lot in those 2 hours and 45 minutes.”

My Deaf Son Fought Speech. Sign Language Let Him Bloom

By ELIZABETH ENGELMAN

I watched my toddler wade into the Gulf and launch a fistful of pebbles in flight. They glistened, tiny sparks of light, before I realized he was up to his chin in cold water. And I realized that if I called his name, if I screamed it, the word would sink like stone.

When Micah turned 2 we had learned that he was profoundly deaf. In the audiologist’s office, an auditory brain response concluded he couldn’t hear a helicopter. “You’re taking this well,” the doctor had said. But later, as I watched Micah step deeper into the Gulf water, I wanted to rage. I was so angry, I could have torn the beach apart.

We celebrated his third birthday, and the audiologist turned his cochlear implants on for the first time.

I said, “Hi Micah, can you hear mommy?” His hazel eyes widened and he screamed in terror, his body trembling. Shock.

In American Sign Language, the sign for cochlear implant is similar to the sign for vampire. Vampire is signed with two fingers like teeth to the throat. Cochlear implant is signed with two fingers like teeth behind the ears. The audiologist told me not to sign at all. She said sign language was a crutch that would hinder his speech. When he heard my voice for the first time, his cry was guttural, a stab wound. He was bitten by sound.

The audiologist adjusted the pitch and tuned the levels to make a simulation of sound. She called this process mapping, but there were no guideposts to show the way. How do you chart loneliness? How do you trace a landscape of silence and sound between mother and son?

At home, I wrapped my legs around my toddler and pinned him to the carpet in what looked like a wrestling hold as I tried to keep the processors for his implants on his head. He was crying, and I was crying, and I wondered if my actions could be considered abuse.

He refused to wear the $18,000 sound processors, and his defiance was feral: head butts to my face, kicks, bites. The back of his head smacked against my jaw, and for a moment everything went black. The implant surgery alone had cost $50,000. Auditory verbal therapy was out of pocket, the doctors were out of network. What choice did I have but to force him?

When Helen Keller wouldn’t cooperate, her teacher Annie Sullivan used brute force. In “The Story of My Life,” Sullivan described how teaching obedience to the deaf and blind girl had to precede teaching language. Sullivan compared her work with Keller to housebreaking a dog. She wrote, “to get her to do the simplest thing, such as combing her hair or washing her hands or buttoning her boots, it was necessary to use force, and of course a distressing scene followed.”

To sign the word force, spread your fingers wide and grip an imaginary face with the palm of your hand. With a quick motion, shove the face into an invisible water bucket and don’t let the head rise for air.

Each week, I dragged him to speech therapy. Let the ritual of F begin: His upper teeth on his lower lip as he tried to blow a scrap of paper off the back of his hand. Next came the puh and guh with its grunts and grimaces.

He didn’t resist. He gagged his hands. He let his fingers slip dumb at his sides. He tucked his hands into his pockets like two clipped birds.

Micah was prelingually deaf, meaning his deafness preceded language. Doctors say there is a critical window from birth to 12 months for language acquisition. By the time he was 4 years old, he had a severe language delay, and I feared that his window for language was closing. When I spoke to him, I observed his stoic expression and panic knotted my stomach.

In public, his meltdowns drew unwanted attention on playgrounds and in grocery stores. How had I become the dejected mother in the fruit aisle, helpless as Micah bucked and cried, dangerously hitting his head on the linoleum floor? I felt the eyes of other shoppers watching our distressing scene with pity, others with harsh disappointment, but no one could have been more disappointed in me than myself. I was failing him.

Then I took one too many of his head butts to the chin and woke up paralyzed on the right side of my face. I couldn’t blink. I couldn’t smile. The doctor said it was trauma to the seventh cranial nerve, causing facial muscles to weaken — as happens with Bell’s palsy. My face drooped like a stroke victim’s and for two months, I used a patch over my unblinking eye.

There is no particular sign for the word desperate. Instead, it is conveyed by a panicked facial expression. But my face was frozen, much like Micah’s voice. Stuck.

I blamed myself. I was no Annie Sullivan. I couldn’t break him, and instead, he was breaking me.

I gave up on spoken English, and enrolled in American Sign Language classes at the local community college. Micah’s first sign was flower. To sign flower, the right hand grasps an imaginary stem and holds it first against the right nostril and then against the left, and like a flower, Micah blossomed one new sign at a time and took his implants off his head for good.

The first time he told me a story, he was 6. We were eating greasy burgers and fries in a diner’s pleather booth, and he told me about a dream from the night before. Our mouths were full, chewing, lips sealed, but his story continued with rapid-fire signs.

Sometimes, when we lie side by side in the dark, he places a small hand on my throat to feel my voice, a gesture as intimate as a lullaby, and I consider the symphony of touch. On my skin, I feel his palm outstretch, feeling for vibration, and I think of my voice as a petal pressed between locked pages.

In the dark, his hand reaches up to speak, and I shine a flashlight on his fingers. They make rapid shadow puppets onto the bedroom wall, and I understand his story like a hieroglyph. I see his voice. I hear his face. His pristine silence fills a room far more than sound.

First Edition: May 26, 2017

May 26 2017

NOTE TO READERS: KHN’s First Edition will not be published May 29. Look for it again in your inbox May 30. Here’s today’s early morning highlights from the major news organizations.

Kaiser Health News: ‘You’ve Got Mail’: Emails And Robocalls Hit Home In Promoting Medicaid Enrollment
Michelle Andrews reports: “Postcards, robocalls and other low-tech outreach tools can be as effective as personalized enrollment assistance at encouraging eligible people to sign up for Medicaid, a new study found. Researchers conducted two randomized, controlled trials in Oregon that evaluated the extent to which people who were potentially eligible for Medicaid signed up for coverage following different types of outreach in 2013.” (Andrews, 5/26)

Kaiser Health News: Strategies To Defend Unpopular GOP Health Bill: Euphemisms, False Statements And Deleted Comments
ProPublica’s Charles Ornstein reports: “Earlier this month, a day after the House of Representatives passed a bill to repeal and replace major parts of the Affordable Care Act, Ashleigh Morley visited her congressman’s Facebook page to voice her dismay. “Your vote yesterday was unthinkably irresponsible and does not begin to account for the thousands of constituents in your district who rely upon many of the services and provisions provided for them by the ACA,” Morley wrote on the page affiliated with the campaign of Rep. Pete King (R-N.Y.). “You never had my vote and this confirms why.” (Ornstein, 5/25)

California Healthline: For California Hospitals That Don’t Pass Quake Test, Money’s Mostly At Fault
Ana B. Ibarra reports: “With a state deadline looming, some California hospitals still need to retrofit or rebuild so that their structures can withstand an earthquake — and money remains a challenge. Some hospital officials are turning to voters to raise money, while others are pursuing more innovative financing schemes.About 7 percent of the state’s hospital buildings — 220 — are still designated as having the highest risk of collapse following an earthquake, according to the Office of Statewide Health Planning and Development. That’s a slight drop from 251 buildings a year ago.” (Ibarra, 5/26)

California Healthline: Caring For A Loved One? Care For Yourself, Too
Emily Bazar reports: “Michael Sloss’ mother was diagnosed with dementia about five years ago, and his father a year after that. Now Sloss and his brother care for both parents, ages 83 and 85, whose personalities have been transformed by the decline in their mental and physical health. The brothers wrestle with their parents’ memory loss, anger and delusions. They nurse them when they’re sick and help them bathe. And they lift their father into and out of bed.” (Bazar, 5/26)

The Wall Street Journal: GOP Senators Will Contemplate Health-Care Overhaul During Weeklong Recess
The Congressional Budget Office’s latest analysis of the health-care overhaul bill passed by House Republicans underscored for their GOP colleagues in the Senate that they need a different version. They just don’t know yet what it will look like. “We’re not going to pass that bill in the Senate,” Sen. Marco Rubio (R., Fla.) said of the legislation passed by the House earlier this month dismantling and replacing much of the Affordable Care Act. But the Senate’s bill, he added, is a “work in progress.” (Peterson and Armour, 5/25)

Politico: GOP Turns Gloomy Over Obamacare Repeal
A feeling of pessimism is settling over Senate Republicans as they head into a weeklong Memorial Day recess with deeply uncertain prospects for their push to repeal Obamacare. Senators reported that they’ve made little progress on the party’s most intractable problems this week, such as how to scale back Obamacare’s Medicaid expansion and overall Medicaid spending. Republicans are near agreement on making tax credits for low-income, elderly Americans more generous, but that might be the simplest matter at hand. (Everett and Haberkorn, 5/25)

The Associated Press: GOP Senators Say Tough Report Complicates Health Care Bill
Republicans senators conceded Thursday that a scathing analysis of the House GOP health care bill had complicated their effort to dismantle President Barack Obama’s health care law. “It makes everything harder and more difficult,” Sen. Dean Heller, R-Nev., said of a Congressional Budget Office analysis projecting that the House bill would cause 23 million Americans to lose coverage by 2026 and create prohibitively expensive costs for many others. (5/25)

Politico: Senate Republicans Start Their Version Of Obamacare Repeal
Senate Republicans have started writing their Obamacare repeal bill — even though few decisions have been made about how to resolve the biggest policy disagreements. Senate Budget Chairman Mike Enzi, whose committee oversees the budget process that the GOP is using to fast-track the repeal effort through the Senate, told POLITICO he’s starting to draft the legislation. (Haberkorn, 5/25)

NPR: Patient And Doctor Groups Say CBO Score Reveals Health Care Bill’s Flaws
Health care groups that represent doctors and patients are warning members of Congress that the House Republicans’ plan to overhaul the Affordable Care Act would hurt people who need insurance most. The groups are responding to the latest assessment by the nonpartisan Congressional Budget Office, which concluded that the proposed American Health Care Act would leave 23 million more people without health insurance than under current law and would cut the deficit by $119 billion over 10 years. (Kodjak, 5/25)

The Washington Post Fact Checker: Explaining The CBO’s Vision Of Health-Care Catastrophe In The GOP Plan
The new Congressional Budget Office report on the American Health Care Act, the House GOP replacement for Obamacare, demonstrates how difficult it is to craft a complex law that affects one-sixth of the U.S. economy. There are many variables — and unforeseen outcomes — that can undermine even the most carefully crafted policy initiative. As a service to readers, we are going to explain one surprising element of the CBO report — that in some states, the law’s efforts to protect people with preexisting medical conditions might end up undermining the individual insurance markets so much that effectively there is no protection at all. (Kessler, 5/26)

The Associated Press: GOP Focus On Lowering Health Premiums May Undermine Benefits
Republicans trying to dismantle former President Barack Obama’s health care overhaul have run into the same problem that bedeviled him. Quality health insurance isn’t cheap, especially if it protects people in poor health, older adults not yet eligible for Medicare, and the poor. Something has to give. (Alonso-Zaldivar, 5/26)

The Associated Press: Insurers Continue To Hike Prices, Abandon ACA Markets
People shopping for insurance through the Affordable Care Act in yet more regions could face higher prices and fewer choices next year as insurance companies lay out their early plans for 2018. Blue Cross and Blue Shield of North Carolina is asking regulators for a 23 percent price hike next year because it doesn’t expect crucial payments from the federal government to continue. That announcement comes a day after Blue Cross and Blue Shield of Kansas City said it will leave the individual insurance market next year, a decision that affects about 67,000 people in a 32-county area in Kansas and Missouri. (Murphy, 5/25)

The Washington Post: At Trump’s Urging, States Try To Tilt Medicaid In Conservative Directions
Wisconsin is preparing to recast its Medicaid program in ways that no state has ever done, requiring low-income adults to undergo drug screening to qualify for health coverage and setting time limits on assistance unless they work or train for a job. The approach places BadgerCare, as the Wisconsin version of Medicaid is known, at the forefront of a movement by Republican governors and legislatures that is injecting a brand of moralism and individual responsibility into the nation’s largest source of public health insurance. (Goldstein and Eilperin, 5/25)

The Associated Press: Gov. Walker Wants Wisconsin To Drug Test Medicaid Applicants
Gov. Scott Walker wants to make Wisconsin the first state in the country to require able-bodied, childless adults applying for Medicaid health benefits to undergo drug screening, a move that could serve as a national model. Walker’s plan, which needs federal approval, comes as he prepares to run for a third term next year. Wisconsin’s Republican-controlled budget committee approved Walker’s proposal on Thursday, a key vote that will clear the way for the full Legislature to pass it later this summer. (Bauer, 5/25)

The Associated Press: Poll: Most Older Americans Want Medicare For Long-Term Care
A growing number of Americans age 40 and older think Medicare should cover the costs of long-term care for older adults, according to a poll conducted by the Associated Press-NORC Center for Public Affairs Research. That option is unlikely to gain much traction as President Donald Trump’s administration and Republicans in Congress look to cut the federal budget and repeal President Barack Obama’s 2010 health care law. Most older Americans mistakenly believe they can rely on Medicare already for such care, the poll shows, while few have done much planning for their own long-term care. (5/26)

The New York Times: Greg Gianforte, Montana Republican, Captures House Seat Despite Assault Charge
Greg Gianforte, a wealthy Montana Republican who was charged with assaulting a reporter on Wednesday, nonetheless won the state’s lone seat in the House of Representatives on Thursday, according to The Associated Press, in a special election held up as a test of the country’s political climate. … Mr. Gianforte’s success underscored the limitations of the Democrats’ strategy of highlighting the House’s health insurance overhaul and relying on liberal anger toward President Trump, at least in red-leaning states. (Martin and Burns, 5/25)

The Associated Press: Was Montana’s Wild House Race A Trump Test? Not So Much
Yet Gianforte’s single-digit win paled to Trump’s 20-point romp in Montana in November, a sign that Republicans will have to work hard to defend some of their most secure seats to maintain control of Congress. The race ultimately turned on the weaknesses of both Gianforte and his opponent, folk singer and Democrat Rob Quist, making it tough to use as a barometer for the nation’s political mood. (5/26)

The Wall Street Journal: Republican Greg Gianforte Wins Montana House Special Election Despite Assault Charge
Mr. Gianforte began the race as a weakened candidate, having lost the governor’s race in 2016 in a campaign that portrayed him as an out-of-state millionaire. Still, the Republican remained ahead of Mr. Quist in most polls, if only by single-digit margins. That lead was jeopardized when the Gallatin County sheriff on Wednesday night charged Mr. Gianforte with misdemeanor assault after he allegedly assaulted a reporter, Ben Jacobs of the Guardian, who had asked him about the GOP health-care bill at his campaign headquarters. (Hook and Epstein, 5/26)

Politico: Montana’s Special Election: 5 Takeaways
After an intense focus on Montana in the run-up to Thursday’s vote, much of the attention is now likely to shift back to Georgia, where Democrat Jon Ossoff is looking to pick off the seat formerly held by now-HHS Secretary Tom Price in a June 20 special election against Republican Karen Handel. (Debenedetti, 5/26)

The Wall Street Journal: FDA Chief Proposes Rules Changes To Fight High Drug Prices
The new commissioner of the Food and Drug Administration plans a multifaceted effort to restrain high prescription-drug prices, centered on speeding cheaper generic medicines onto the U.S. market. Previous FDA commissioners have largely professed inability to act on drug costs, even as prices of drugs for cancer, hepatitis and other illnesses climbed to as much as hundreds of thousands of dollars per year or even therapeutic course. The FDA’s job, they said, is to assess safety and efficacy, and little else. (Burton, 5/25)

The Wall Street Journal: The Latest Drug Pricing Threat: The FDA
Health-care investors have another clear signal that regulatory scrutiny of high drug prices isn’t going away. Dr. Scott Gottlieb, the new commissioner of the Food and Drug Administration, made that clear Thursday morning, unveiling a host of policy plans that would enable the FDA to fight high drug prices in ways that the agency hasn’t done before. These policy changes are less drastic than say, overhauling rules surrounding how Medicare pays for prescription drugs, but they should generally be easier to implement. (Grant, 5/25)

Los Angeles Times: What The DNA Of The Zika Virus Tells Scientists About Its Rapid Spread
A family tree can reveal a lot, especially if it belongs to a microscopic troublemaker with a knack for genetic shape-shifting. DNA sleuthing can outline the route an emerging pathogen might take once it makes landfall in the Americas and encounters a wholly unprotected population. It’s a modern take on old-fashioned public health surveillance strategies that focused on the exhaustive collection and analysis of samples from the field. Now they’ve been bolstered by rapid genome sequencing — and the result can be a picture of an epidemic rendered in exquisite detail, and in near-real time. (Healy, 5/25)

The Wall Street Journal: New York City Issues Zika Travel Warning
In advance of the summer travel season, New York City health officials on Thursday stepped up warnings to would-be parents about the threat of contracting Zika, a mosquito-borne virus that has been linked to serious birth defects in babies and, in some cases, in utero deaths. (West, 5/25)

The New York Times: A Quarter Of U.S. Babies With Zika-Related Birth Defects Were Born In New York
A quarter of all infants in the United States born with defects related to the Zika virus were born to women in New York City, city health officials announced on Thursday, a stark reminder of the dangers posed by the virus. Looking ahead to summer and the threat of the resurgent virus spreading through the Caribbean, the New York City Department of Health said that 402 pregnant women had been infected with the virus and that 32 infants had been infected with the virus and 16 of them had Zika-related birth defects since last spring. (Santora, 5/25)

Los Angeles Times: California Senate, Assembly Advance Their Own Plans On How To Spend Tobacco Tax Revenue
Perhaps the biggest budget skirmish that remains unsolved this year is how California should spend revenue from the tobacco tax voters approved last fall. Gov. Jerry Brown wants to put that money to expand overall spending on Medi-Cal, which provides subsidized healthcare for the poor. But the some of initiative’s backers, namely doctor and dental groups, have cried foul, arguing that money is meant to go to increasing payments for providers. (Mason, 5/25)

Los Angeles Times: No One Knows How Many Untested Rape Kits There Are In California. This Bill Aims To Fix That
ens of thousands of rape kits are sitting on shelves in police and sheriff’s department evidence rooms nationwide. And no one has tested them to see what crimes they could help solve. A bill by Assemblyman David Chiu (D-San Francisco) would help determine how many of those unanalyzed exam kits exist in California, part of a national backlog that federal officials have grappled with for nearly two decades. (Ulloa, 5/26)

The Associated Press: Maryland Has New Law To Help Fight Opioid Addiction
Legislation to battle heroin and opioid overdoses in Maryland with education, prevention, treatment and law enforcement was signed into law Thursday by Gov. Larry Hogan. Matt and Cheryl Godbey, whose 24-year-old daughter Emily died in November from a fentanyl overdose, came from Frederick, Maryland, for the bill-signing ceremony. Matt Godbey applauded a new law that will bring stiffer penalties to drug dealers who knowingly sell fentanyl resulting in a death. Fentanyl is a painkiller that is often combined with heroin, with deadly results. (Witte, 5/25)

Reuters: Activists Call On In-N-Out Burger To Join The Superbug Fight
Nearly three dozen consumer, environmental and public health groups on Thursday pressed privately held In-N-Out Burger to make good on its vow to set time lines for phasing out the use of beef raised with antibiotics vital to human health. Some 70 percent of antibiotics needed to fight infections in humans are sold for use in meat and dairy production. Medical researchers say overuse of the drugs may diminish their effectiveness in fighting disease in humans by contributing to the rise of dangerous, antibiotic-resistant bacteria often referred to as “superbugs.” (Baertlein, 5/25)

NPR: Adults Don’t Think Exposure To Secondhand Vapor From E-Cigarettes Is Bad For Kids
Despite the toxic ingredients commonly found in e-cigarettes and other vaping products, many adults don’t think secondhand e-cigarette aerosol poses a risk to children, according to a report published Thursday by the Centers for Disease Control and Prevention. About one-third of adults surveyed didn’t know if secondhand aerosol caused harm to children, and 40 percent of the adults said this kind of exposure caused “little” or “some” harm to children. (Columbus, 5/25)

The Wall Street Journal: Does Facebook Make Us Unhappy And Unhealthy?
If you’re one of the almost two billion active users of Facebook , the site’s blend of gossip, news, animal videos and bragging opportunities can be irresistible. But is it good for you? A rigorous study recently published in the American Journal of Epidemiology suggests that it isn’t. Researchers found that the more people use Facebook, the less healthy they are and the less satisfied with their lives. To put it baldly: The more times you click “like,” the worse you feel. (Pinker, 5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

‘You’ve Got Mail’: Emails And Robocalls Hit Home In Promoting Medicaid Enrollment

Postcards, robocalls and other low-tech outreach tools can be as effective as personalized enrollment assistance at encouraging eligible people to sign up for Medicaid, a new study found.

Researchers conducted two randomized, controlled trials in Oregon that evaluated the extent to which people who were potentially eligible for Medicaid signed up for coverage following different types of outreach in 2013.

Medicaid is the federal-state health insurance program for low-income people, and Oregon is one of 31 states and the District of Columbia that expanded Medicaid under the Affordable Care Act to cover adults with incomes up to 138 percent of the federal poverty level (about $16,000).

For one study group, researchers targeted people who were likely eligible for Medicaid coverage under the ACA because they were already enrolled in assistance programs with similar income standards, including the Supplemental Nutrition Assistance Program (often referred to as food stamps) or those whose kids were signed up with the state Medicaid program.

Michelle AndrewsInsuring Your Health

For the other study group, researchers identified people who had expressed interest in and won a lottery to enroll in Medicaid coverage under the state’s existing program for low-income nondisabled adults. After winning the lottery, they had 45 days to sign up for coverage.

Members of the lottery trial were randomly assigned to one of three groups. The control group received the state’s basic outreach materials, which included a notification letter and an application packet. In addition to the basic state outreach materials, the second group got other “low-intensity” nudges, including additional postcards and other mail, emails and automated phone calls to encourage them to sign up. The third, “high-intensity” group received all the other materials plus in-person enrollment help from trained assistants as well as personalized phone calls.

Twenty-seven percent of the people in the lottery control group signed up in the roughly six weeks after being notified. Enrollment was significantly higher — 41 percent — among those who received extra outreach efforts. There was no difference in enrollment between the people who received one-on-one help and those who were sent mass-outreach materials.

The low-intensity interventions cost an average $1.75 per person, while the high-intensity interventions cost $28 per person, on average, the study found.

“The extra personalization and individual-level contact that we layered on didn’t add much,” said Katherine Baicker, a professor of health economics in the Department of Health Policy and Management at Harvard University’s school of public health, who co-authored the study published in the May issue of Health Affairs. That’s good news for states, Baicker said, who can get more enrollment bang for the buck.

Since the high-intensity interventions had proven relatively ineffective, researchers tested only the low-intensity interventions against the control group in the second trial of people who were likely eligible under the ACA’s Medicaid expansion and looked at the effect on enrollment in the program over time.

The differences in enrollment were less pronounced in that trial. Thirty-eight percent of the control group were still enrolled a year after the intervention, compared with 41 percent of those who had received additional low-intensity encouragement to sign up.

The less dramatic difference in results for this study group makes sense, said Baicker.

In contrast to the lottery group, who had already expressed an interest in being included in the state’s Medicaid lottery, “this group didn’t proactively express any interest in being insured,” she said. However, once the outreach tools got through to them, people stayed insured. “Those people that we reached, there was a durable response,” Baicker said.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insuring Your Health, Medicaid

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Wanting Monogamy as 1,946 Men Await My Swipe

Modern Love
By LAUREN PETERSEN

Leaving Michael’s apartment one Tuesday morning, I smiled and said, “Have a good class today.” That may not sound like much, but I was trying to leave a hint: I was interested in more than our one-night-a-week thing.

Understandably, he didn’t catch on.

So a little later, I texted, “Could you send me a playlist of your favorite songs?”

He sent one, but I still wasn’t sure he got the picture.

I decided to be a little more obvious: “Do you want to go to the Grand Canyon over spring break?”

“Sounds fun,” he replied, “but I’m busy then.”

This was ridiculous. Finally I wrote, “I like you and I want to be with you.” Then I squeezed my eyes shut and pressed “Send.”

Six weeks earlier, Michael and I had met on Bumble, the dating app where women have to make the first move. Our first date had been in a local cafe. Afterward, I told my eager roommate that the date was “just fine,” but “just fine” was fine with me. I wasn’t looking for a relationship, let alone love.

My female friends, who associate dating apps more with the Grim Reaper than with Cupid, warned me against them, saying, “The guys just want to hook up and disappear.”

Again, fine with me. I was graduating in a few months, and attachment would mean a hard goodbye, which would mean tears, tissues and snot. No thanks.

Michael was also graduating. He was tall, thin, looked as if he loved L.A. and routinely announced, “I love L.A.”

Every Monday night for the next month, I would stuff my contact lens solution into my backpack and walk to Michael’s apartment. He’d lean against my shoulder as we watched movies in his barren living room, which he decided not to decorate because he had signed only a one-year lease. “No point when it’s so temporary,” he said.

Everything about us was temporary. We would talk a little, watch a little and then go to bed. In the morning, I would zip up my coat while he asked, “Heading out?”

I would nod and say, “Thanks for the toast.”

There was a rhythm to it. Monday night, pack my bag. Tuesday morning, walk home.

By asking for more, I knew I was breaking the rules. Dating apps allow you to set obvious parameters: age range, distance radius and so on. But there are also unspoken rules: a deadline for the relationship (in our case, graduation); what feelings shouldn’t be expressed, from affection (“Thinking of you!”) to criticism (“It bothers me when you do x”); and boundaries on what shouldn’t be shared about your personal lives (family details, past loves). And you can regulate how much you want to integrate the person into other spheres of your life (not introducing each other to friends).

For a month, I was totally in control. Then one morning, as I returned to my apartment, my hand paused on the doorknob. Instead of considering the warm shower I was about to take, or even dreading the slog of classes that awaited me, I was still thinking about Michael.

I started daydreaming about how the moonlight trickled in while he played me his jazz records, how he chuckled and buried his face in his hands after I explained my odd internships, and how he held up a picture of his family and described each of his brothers. Our kiss was interrupted when he started smiling and then I started smiling.

I was an idiot. Of course I liked him. It was as if I had been carrying an armful of bricks for the past few weeks but only just admitted, “Wow, this is a little heavy.”

I tried reciting my mantra. Hard goodbye. Tissues. Snot. Then I gave in and dropped those hints, which he didn’t get. So I said it flat out: “I like you.”

Within an hour of texting him my confession, my phone lit up with Michael’s reply: “I like you too.”

For a second, my future brimmed with Michael: his records, his quiet demeanor but abrasive sense of humor, his shamelessness in recounting the time he was struck with food poisoning at a hostel in San Francisco. Then another text appeared: “It’s just that I’m apprehensive about the commitment.”

When I clarified that I didn’t expect a long-term commitment, with our coming graduation, he expressed his real concern: “Monogamy.”

My thumbs hovered dumbly over my phone screen. What?

I had known there were other girls. Once, while lying in bed with my head against his shoulder, he squinted at his phone and I caught a glimpse of the name at the top of a text message: Sophie.

Earlier, I had noticed how he’d become Facebook friends with a Sophie, along with a series of girls from other schools. One had cute glasses and a nose ring, and another looked as if she played guitar better than I did. Michael didn’t share mutual friends with them, so I could only assume he had met them on Bumble or Tinder.

I tried to shrug it off. So I was Mondays, and I guessed these girls were maybe Thursdays, Wednesdays or Saturdays. I figured they, like me, were just players of the dating app game, where Michael undoubtedly pressed the proverbial “play again?” button after each successful connection. I thought I could deal with that.

But then Michael started feeling less like a game to me. When he sat across from me, I stopped seeing his face as a “yes” or “no” to swipe on. With the months we had left, I wanted to get to know him, the actual Michael, not the Michael that appeared before me like a selection in an online catalog. I wanted to leave the game behind and develop something special, if only for a short time.

Yet Michael hesitated.

It struck me that the “fling” was dead. Now we have flings, plural, because that’s what dating apps encourage.

Dating apps are the courtship equivalent of next-day shipping, where you don’t have to twiddle your thumbs and wait for an adequate romantic prospect to drift by. They release a flood of potential suitors, your inbox notifications flashing red with heartbeats of their own.

It’s nice to imagine that Michael liked me the most, but even if that were true, I’m not sure what it counts for in a dating scene of instant gratification with seemingly unlimited choice. After all, dating apps never announce, “Congratulations, you’ve matched with everyone you could possibly like!”

They tempt you to keep swiping, and as you whiz through tens, hundreds or even thousands of profiles, you can only infer the obvious. Out of all these people, there’s got to be someone better than the person I’m seeing right now.

Which means that monogamy requires more sacrifice than ever. If offered free travel, why would anyone settle for one place when it’s possible to tour the entire world?

I finally texted Michael back. “You know,” I said, “maybe it would be best if we called it good.” He said he understood. “Good luck with …” I began, a message I would typically end with “… your paper” or “… your test.” But I realized this was the end, so I wrote, “… everything.”

A mere six weeks after our first date, we were over. I’d broken the rules; my glimmer of expressed affection had led to a fatal imbalance in the game.

Feeling a little dispensable, I opened Bumble to pause my account. It was the first time I’d opened it since Michael and I met, and the app had clearly been waiting for me with its arms crossed. A notification flashed, indicating that I had been right-swiped by a few people: 1,946 people.

As the saying goes, there are plenty of fish in the sea, and it turned out my sea held 1,946 of them. The “play again?” button glowed brighter than ever. And yet, almost comically, I wanted to date only one particular person.

Was Michael the best of my 1,946 choices? I doubt it. We differed in too many ways. I showed up to dates five minutes early, while he sauntered into the movie theater five minutes late. I hate Mexican food, and he worships it. But what is “best” anyway?

It’s impossible to know, but that’s what having nearly 2,000 potential dates will make you think about. All I know is Michael lived five blocks away, and he would lean against me and play me his jazz records, and I couldn’t help but appreciate him for all he was and all he wasn’t.

It’s easy to dismiss dating apps as insincere, objectifying and sketchy. But in the end, they did do one thing for me. They introduced me to Michael, someone I was willing to bend the rules for, someone I was actually able to admit I liked. And maybe there is hope in that.

When Is It O.K. to Date a Friend’s Ex?

Social Q’s
By PHILIP GALANES

An old friend dated a really nice guy for a few months, but it fizzled. I definitely felt a spark when we met, but kept it to myself. Months later, I bumped into him at a yarn shop. He invited me out. I told him I would like to go but wanted to ask my friend for her blessing first. When I did, she said, “Absolutely not” — without further explanation. How bad would it be for me to disregard her answer? (Note: I am pushing 40 and don’t feel sparks every day.)

AMI

Save your breath, Ami. You had me at yarn shop. A mate who knits has long been my fantasy — or a nurturing doctor in certain subspecialties. Sadly, I failed on both counts. So, let’s see if we can grab this brass ring for you.

You characterize McCrafty’s ex as “an old friend.” But this raises questions: Is she a close friend? In the Venn diagram of your social circles, is there considerable overlap? And could you live with her rejecting you for overruling her preference (and badmouthing you to your pals in common)? This is a lot to stake on a mere “spark,” no?

Still, your friend’s knee-jerk refusal to bless the date, after having seen this fellow for just a few months, seems selfish. You can always approach her again, if her adamant reply strikes you as out-of-keeping with her better nature. But I might skip this step and simply weigh your desire to go to dinner with the knitter against your friend’s opprobrium. We can’t have it all. So, which means more to you?

If you decide to see him, let your old friend know as soon as you have an inkling things may work out. It will be better for her to hear it from you. And if you decide to move forward — on which I pass no judgment — a note for next time: Don’t ask permission if you don’t care about receiving it. (Also, email me the second you get to quiet nights knitting cashmere socks and listening to Joni Mitchell, understood?)

Be a Child Tamer

I am the grandmother of a 2½-year-old. I take her to a park in Chicago where she loves to play. Lately, a 4-year-old boy charges at her every time we arrive, throwing his hands in the air and roaring. It frightens her, and she asks to go home. His nanny, who is not a native English speaker, seems indifferent; she just keeps chatting with the other nannies. How should I handle this?

SUSAN

Score one for the playground at Washington Square Park. That boy (and his minder) would be in shackles in 15 minutes. I’m not sure why you have written off the nanny simply because she is speaking another language with her associates. This is her job. Say: “Excuse me. Your boy is scaring my granddaughter. Please have him stop screaming and running at her. She’s just a toddler.”

The nanny may surprise you and handle this brilliantly. If she doesn’t, speak to the boy yourself. While remaining mindful that you are speaking with a child, say: “Stop it! You’re frightening her. And that’s mean.” Or escort the boy to his nanny and work out an agreement. What may seem like blowing off steam to them is playground bullying to you (and me). You’re an adult; shut it down.

It Pays to Talk

My husband and I are in our early 30s. We work hard, in tech and finance, and we’re saving to expand our family someday. Recently, we declined an event invitation from his relative because of its cost. Shortly after, we accepted another invitation from him, assuming it was for drinks, which turned out to be a restaurant dinner for 15. When the bill came, this relative asked my husband to pay one-third. He did! I was annoyed at my husband for not pushing back, and at the relative who probably asked my husband to pay more because he’s “in finance.” How to proceed?

ANONYMOUS

Funny thing about your question: When I read it, the Beatles song “Two of Us” popped into my head — about the pleasure of aimless and (relatively inexpensive) drives in the country. (It was probably the lyric, “Two of us riding nowhere, spending someone’s hard-earned pay.”)

For starters, get on the same page with your husband about your budget. Maybe he’s looser with the reins and you’re a little tighter? But if you’re pooling money, agreement is required. He may want to include some spending that seems crazy to you, like paying more at family events. But I bet you can work out a compromise.

Once you have, it will be simple to deal with invitations. If they fit into your agreed budget and you want to go, accept. If not, decline. (Again, more compromising may be required.) With folks whose parties tend to be pay-to-play, don’t be shy about asking what their soirees will set you back. How else will you decide? (And if you have three spare minutes, listen to Aimee Mann and Michael Penn’s cover of “Two of Us.” It’s lovely.)

Strategies To Defend Unpopular GOP Health Bill: Euphemisms, False Statements And Deleted Comments

Earlier this month, a day after the House of Representatives passed a bill to repeal and replace major parts of the Affordable Care Act, Ashleigh Morley visited her congressman’s Facebook page to voice her dismay.

“Your vote yesterday was unthinkably irresponsible and does not begin to account for the thousands of constituents in your district who rely upon many of the services and provisions provided for them by the ACA,” Morley wrote on the page affiliated with the campaign of Rep. Pete King (R-N.Y.). “You never had my vote and this confirms why.”

The next day, Morley said, her comment was deleted and she was blocked from commenting on or reacting to King’s posts. The same thing has happened to others critical of King’s positions on health care and other matters. King has deleted negative feedback and blocked critics from his Facebook page, say several of his constituents who shared screenshots of comments that are no longer there.

“Having my voice and opinions shut down by the person who represents me — especially when my voice and opinion wasn’t vulgar and obscene — is frustrating, it’s disheartening, and I think it points to perhaps a larger problem with our representatives and maybe their priorities,” Morley said in an interview.

King’s office did not respond to requests for comment.

As Republican members of Congress seek to roll back the Affordable Care Act (ACA), commonly called Obamacare, and replace it with the American Health Care Act (AHCA), they have adopted various strategies to influence and cope with public opinion, which, polls show, mostly opposes their plan. ProPublica, with our partners at Kaiser Health News, Stat and Vox, has been fact-checking members of Congress in this debate and we’ve found misstatements on both sides, though more by Republicans than Democrats. The Washington Post’s Fact Checker has similarly found misstatements by both sides.

Today, we’re back with more examples of how legislators are interacting with constituents about repealing Obamacare, whether online or in traditional correspondence. Their more controversial tactics seem to fall into three main categories: providing incorrect information, using euphemisms for the impact of their actions and deleting comments critical of them. (Share your correspondence with members of Congress with us.)

Incorrect Information

Rep. Vicky Hartzler (R-Mo.) sent a note to constituents this month explaining her vote in favor of the Republican bill. First, she outlined why she believes the ACA is not sustainable — namely, higher premiums and few choices. Then she said it was important to have a smooth transition from one system to another.

“This is why I supported the AHCA to follow through on our promise to have an immediate replacement ready to go should the ACA be repealed,” she wrote. “The AHCA keeps the ACA for the next three years then phases in a new approach to give people, states, and insurance markets plenty of time to make adjustments.”

Except that’s not true.

“There are quite a number of changes in the AHCA that take effect within the next three years,” wrote ACA expert Timothy Jost, an emeritus professor at Washington and Lee University School of Law, in an email to ProPublica.

The current law’s penalties on individuals who do not purchase insurance and on employers who do not offer it would be repealed retroactively to 2016, which could remove the incentive for some employers to offer coverage to their workers. Moreover, beginning in 2018, older people could be charged premiums up to five times more than younger people — up from three times under current law. The way in which premium tax credits would be calculated would change as well, benefiting younger people at the expense of older ones, Jost said.

“It is certainly not correct to say that everything stays the same for the next three years,” he wrote.

In an email, Hartzler spokesman Casey Harper replied, “I can see how this sentence in the letter could be misconstrued. It’s very important to the Congresswoman that we give clear, accurate information to her constituents. Thanks for pointing that out.”

Other lawmakers have similarly shared incorrect information after voting to repeal the ACA. Rep. Diane Black (R-Tenn.) wrote in a May 19 email to a constituent that “in 16 of our counties, there are no plans available at all. This system is crumbling before our eyes and we cannot wait another year to act.”

Black was referring to the possibility that, in 16 Tennessee counties around Knoxville, there might not have been any insurance options in the ACA marketplace next year. However, 10 days earlier, before she sent her email, BlueCross BlueShield of Tennessee announced that it was willing to provide coverage in those counties and would work with the state Department of Commerce and Insurance “to set the right conditions that would allow our return.”

“We stand by our statement of the facts, and Congressman Black is working hard to repeal and replace Obamacare with a system that actually works for Tennessee families and individuals,” her deputy chief of staff Dean Thompson said in an email.

On the Democratic side, The Washington Post Fact Checker has called out representatives for saying the AHCA would consider rape or sexual assault as preexisting conditions. The bill would not do that, although critics counter that any resulting mental health issues or sexually transmitted diseases could be considered existing illnesses.

Euphemisms

A number of lawmakers have posted information taken from talking points put out by the House Republican Conference that try to frame the changes in the Republican bill as kinder and gentler than most experts expect them to be.

An answer to one frequently asked question pushes back against criticism that the Republican bill would gut Medicaid, the federal-state health insurance program for the poor, and appears on the websites of Rep. Garret Graves (R-La.) and others.

“Our plan responsibly unwinds Obamacare’s Medicaid expansion,” the answer says. “We freeze enrollment and allow natural turnover in the Medicaid program as beneficiaries see their life circumstances change. This strategy is both fiscally responsible and fair, ensuring we don’t pull the rug out on anyone while also ending the Obamacare expansion that unfairly prioritizes able-bodied working adults over the most vulnerable.”

That is highly misleading, experts say.

The Affordable Care Act allowed states to expand Medicaid eligibility to anyone who earned less than 138 percent of the federal poverty level, with the federal government picking up almost the entire tab. Thirty-one states and the District of Columbia opted to do so. As a result, the program now covers more than 74 million beneficiaries, nearly 17 million more than it did at the end of 2013.

The GOP health care bill would pare that back. Beginning in 2020, it would reduce the share the federal government pays for new enrollees in the Medicaid expansion to the rate it pays for other enrollees in the state, which is considerably less. Also in 2020, the legislation would cap the spending growth rate per Medicaid beneficiary. As a result, a Congressional Budget Office review released Wednesday estimates that millions of Americans would become uninsured.

Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at George Washington University, said the GOP’s characterization of its Medicaid plan is wrong on many levels. People naturally cycle on and off Medicaid, she said, often because of temporary events not changing life circumstances — seasonal workers, for instance, may see their wages rise in summer months before falling back.

“A terrible blow to millions of poor people is recast as an easing off of benefits that really aren’t all that important, in a humane way,” she said.

Moreover, the GOP bill actually would speed up the “natural turnover” in the Medicaid program, said Diane Rowland, executive vice president of the Kaiser Family Foundation, a health care think tank. (Kaiser Health News is an editorially independent project of KFF.)

Under the ACA, states were permitted only to recheck enrollees’ eligibility for Medicaid once a year because cumbersome paperwork requirements have been shown to cause people to lose their coverage. The American Health Care Act would require these checks every six months — and even give states more money to conduct them.

Rowland also took issue with the GOP talking point that the expansion “unfairly prioritizes able-bodied working adults over the most vulnerable.” At a House Energy and Commerce Committee hearing earlier this year, GOP representatives maintained that the Medicaid expansion may be creating longer waits for home- and community-based programs for sick and disabled Medicaid patients needing long-term care, “putting care for some of the most vulnerable Americans at risk.”

Research from the Kaiser Family Foundation, however, showed that there was no relationship between waiting lists and states that expanded Medicaid. Such waiting lists predated the expansion and they were worse in states that did not expand Medicaid than in states that did.

“This is a complete misrepresentation of the facts,” Rosenbaum said.

Graves’ office said the information on his site came from the House Republican Conference. Emails to the conference’s press office were not returned.

The GOP talking points also play up a new Patient and State Stability Fund included in the AHCA, which is intended to defray the costs of covering people with expensive health conditions. “All told, $130 billion dollars would be made available to states to finance innovative programs to address their unique patient populations,” the information says. “This new stability fund ensures these programs have the necessary funding to protect patients while also giving states the ability to design insurance markets that will lower costs and increase choice.”

The fund was modeled after a program in Maine, called an invisible high-risk pool, which advocates say has kept premiums in check in the state. But Sen. Susan Collins (R-Maine) says the House bill’s stability fund wasn’t allocated enough money to keep premiums stable.

“In order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year and that is not in the House bill,” Collins told Politico. “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Deleting Comments

Morley, 28, a branded content editor who lives in Seaford, N.Y., said she moved into Rep. King’s Long Island district shortly before the 2016 election. She said she did not vote for him and, like many others across the country, said the election results galvanized her into becoming more politically active.

Earlier this year, Morley found an online conversation among King’s constituents who said their critical comments were being deleted from his Facebook page. Because she doesn’t agree with King’s stances, she said she wanted to reserve her comment for an issue she felt strongly about.

A day after the House voted to repeal the ACA, Morley posted her thoughts. “I kind of felt that that was when I wanted to use my one comment, my one strike as it would be,” she said.

By noon the next day, it had been deleted and she had been blocked.

“I even wrote in my comment that you can block me but I’m still going to call your office,” Morley said in an interview.

Some negative comments about King remain on his Facebook page. But King’s critics say his deletions fit a broader pattern. He has declined to hold an in-person town hall meeting this year, saying, “to me all they do is just turn into a screaming session,” according to CNN. He held a telephonic town hall meeting but answered only a small fraction of the questions submitted. And he met with Liuba Grechen Shirley, the founder of a local Democratic group in his district, but only after her group held a protest in front of his office that drew around 400 people.

“He’s not losing his health care,” Grechen Shirley said. “It doesn’t affect him. It’s a death sentence for many, and he doesn’t even care enough to meet with his constituents.”

King’s deleted comments even caught the eye of Andy Slavitt, who until January was the acting administrator of the Centers for Medicare and Medicaid Services. Slavitt has been traveling the country pushing back against attempts to gut the ACA.

Since the election, other activists across the country who oppose the president’s agenda have posted online that they have been blocked from following their elected officials on Twitter or commenting on their Facebook pages because of critical statements they’ve made about the AHCA and other issues.

Have you corresponded with a member of Congress or senator about the Affordable Care Act? Or has your comment on an elected official’s Facebook page been deleted? We’d love to hear about it. Please fill out our short form or email charles.ornstein@propublica.org.

Categories: Repeal And Replace Watch, The Health Law

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A 20-Minute Fat-Burning Kettlebell Workout

If you want to fast-track your muscle-building goals, the classic kettlebell is the tool you need. This weight is super versatile, and you can easily incorporate it into your usual routine while sculpting more muscle

Looking to melt fat as well? Go for a fast-paced circuit workout that uses a kettlebell—like the one in this video. It’s a custom routine that Frank Baptiste, fitness coach and founder of FranklyFitness, created for Health. It consists of two circuits that are repeated twice. Each circuit is only three minutes long, but don’t be fooled, you’re going to break a sweat.

WATCH THE VIDEO: Get Total-Body Toned With This Kettlebell Workout From Emily Skye

When picking a kettlebell for this workout, Frank recommends sticking with one that you can press over your head 10 times while maintaining proper form. That means the weight should be lighter than one you’d choose for, say, a squat workout, since you’ll be using it for a variety of quick movements. 

The workout itself includes both bilateral and unilateral movements, as well as a combo of pushing and pulling motions to strengthen the upper body. There’s balance training here too—in other words, your entire body will be worked to the max. Grab a kettlebell and give this awesome, fat-burning workout a try!

No time to watch? Here’s a rundown of the moves:

Warmup: Dynamic Mobility (5-10 minutes)

-Clap jacks

-Regular jumping jacks

-Inchworm into a push-up

Circuit 1: Power and Strength

-Swing to a thruster (8 reps)

-Bent over row (15 reps)

-Swings (20 reps)

20 second break. Repeat first circuit.

Circuit 2: Balance and Stability

-Windmill (8 reps)

-Romanian deadlift with bent over row (8 reps)

20 second break. Repeat second circuit.