From Health and Fitness

The Worst That Could Happen? Going Blind, People Say

Personal Health
By JANE E. BRODY

Feeling My Way Into Blindness,” an essay published in The New York Times in November by Edward Hoagland, an 84-year-old nature and travel writer and novelist, expressed common fears about the effects of vision loss on quality of life.

Mr. Hoagland, who became blind about four years ago, projected deep-seated sadness in describing the challenges he faces of pouring coffee, not missing the toilet, locating a phone number, finding the food on his plate, and knowing to whom he is speaking, not to mention shopping and traveling, when he often must depend on the kindness of strangers. And, of course, he sorely misses nature’s inspiring vistas and inhabitants that fueled his writing, though he can still hear birds chatter in the trees, leaves rustle in the wind and waves crash on the shore.

Mr. Hoagland is hardly alone in his distress. According to Action for Blind People, a British support organization, those who have lost some or all sight “struggle with a range of emotions — from shock, anger, sadness and frustration to depression and grief.”

When eyesight fails, some people become socially disengaged, leading to isolation and loneliness. Anxiety about a host of issues — falls, medication errors, loss of employment, social blunders — is common.

A recent study from researchers at the Wilmer Eye Institute at Johns Hopkins University School of Medicine found that most Americans regard loss of eyesight as the worst ailment that could happen to them, surpassing such conditions as loss of limb, memory, hearing or speech, or having H.I.V./AIDS. Indeed, low vision ranks behind arthritis and heart disease as the third most common chronic cause of impaired functioning in people over 70, Dr. Eric A. Rosenberg of Weill Cornell Medical College and Laura C. Sperazza, a New York optometrist, wrote in American Family Physician.

Some 23.7 million American adults reported in 2015 that they are unable to see at all or have trouble seeing even with corrective lenses. This number is projected to perhaps double by 2050 based on the aging of the population and increasing prevalence of diseases that can cause vision loss. Yet, the Wilmer Eye Institute’s national study of 2,044 adults found that many Americans are unaware of the diseases and factors that can put their vision at risk and steps they might take to lower their risk.

Perhaps the single most valuable message to emerge from studies of vision loss is the importance of having a thorough eye checkup at least once every two years, if not annually. Many sight-robbing conditions can be effectively treated if detected early enough, in many cases limiting or eliminating the damage to eyesight.

Four eye diseases — age-related macular degeneration, diabetic retinopathy, glaucoma and cataracts — account for most cases of adult blindness and low vision among people in developed countries. Unlike many other ailments associated with aging, they cause no pain and often no early symptoms and thus do not automatically prompt a person to seek medical care. But a thorough checkup by an ophthalmologist can detect them in their earliest stages, followed by treatment that can slow or halt their progression or, in the case of cataracts, restore normal vision.

Macular degeneration, a leading cause of vision loss in Americans 60 and older, involves an irreversible loss of retinal cells that robs people of the central vision needed to read, watch a TV program or identify a face or object in front of them. There are two types, dry and wet. In the dry type, the light-sensitive cells in the macula, a structure near the center of the retina, gradually break down. In the wet type, abnormal blood vessels grow under the macula.

Steps you can take to lower your risk of macular degeneration or slow its progression include not smoking, eating lots of dark leafy green vegetables, wearing sunglasses to block ultraviolet light, and taking one or more supplements formulated to support macular health. There are also treatments specific for wet A.M.D., including laser surgery, photodynamic therapy and drugs that are injected into the eye to slow the growth of abnormal blood vessels.

Diabetic retinopathy, the cause of most blindness in American adults, also affects the light-sensitive retina, damaging the vision of more than half of people with diabetes age 18 or older. The most effective preventive is maintaining a normal level of glucose in the blood through medication and a proper balance of diet and exercise. Blood glucose should be routinely monitored, high blood pressure effectively treated and smoking avoided entirely.

Glaucoma, another leading cause of blindness, involves a rise in fluid pressure inside the eye that damages the optic nerve. It affects more than four million Americans, about half of whom don’t know they have it, and is especially common among African-Americans and Hispanics. It can be detected with a comprehensive eye exam, which should be done annually for African-Americans and those with a family history of the condition.

Although glaucoma is not curable, treatment to lower pressure in the eye with prescription eye drops and, in some cases, pills or surgery can control the condition.

Cataracts are the most common cause of vision loss among people over 40. They involve a gradual clouding of the lens, a normally transparent tissue directly behind the iris and pupil that helps to focus images on the retina. As cataracts progress, it becomes increasingly difficult to see clearly, impairing the ability to read, drive or recognize faces.

Preventing or slowing the development of cataracts involves protecting the eyes from sun damage, not smoking, consuming a diet rich in vegetables and fruits and, if you have diabetes, keeping blood sugar under control.

In years past, doctors often advised patients with cataracts to wait until they were far advanced before removing them surgically. This is no longer the case. Cataract surgery is now done when the condition begins to affect a person’s quality of life or interferes with the ability to perform normal activities.

The surgery is nearly always done under local anesthesia on an outpatient basis. If both eyes have cataracts, as is usually the case, the second eye is typically treated some weeks after the first to avoid the rare risk of a postoperative infection in both eyes. The operation involves removing the clouded lens and, in most cases, replacing it with a clear artificial lens that often gives patients better vision than they had even before developing cataracts.

How to Reduce Wrinkles Without Lasers or Chemicals

By COURTNEY RUBIN

On March 31, 2016, Jamie O’Banion, a former Miss Teen Texas with dewy, perfect skin, was barely 12 minutes into her debut on the Home Shopping Network’s beauty hour when a buzzer sounded and the words “Sold Out” were stamped in bright red on the screen. She was less than halfway through her allotted airtime.

At 35, Ms. O’Banion, a founder of Beauty Bioscience in Dallas, was clearly an effective advertisement for her product: the $199 GloPro, a hand-held device for at-home microneedling — that is, using teeny tiny surgical steel needles to prod the skin into increasing production of collagen and elastin, and as a result improving texture and tone and potentially reducing wrinkles and scars.

In those 12 minutes, Ms. O’Banion sold 22,000 units (some $400,000 worth), according to company figures. In the roughly eight months of 2016 the device was available — at HSN, the shopping network, and also at Neiman Marcus and Bergdorf Goodman later on — about $30 million worth were sold. HSN does not release sales figures, but Alicia Valencia, the network’s senior vice president for beauty, said that GloPro, which looks like a miniature needle-studded paint roller, was the top performing tool. It is also the top-selling beauty tool at Neiman Marcus.

“Beauty’s New Cult Device,” Women’s Wear Daily declared. (GloPro is not the only at-home microneedling device — there are several, and with varying needle lengths — but it is the one attracting the most attention.)

Customers are as exclamatory as, well, an infomercial. Asked about results, Evelyn Savich, of Salem, Ohio, said: “Heavens, yes! Almost immediate tightening of the pores, the lines around my eyes softened, and the lines around my mouth are almost gone.”

Ms. Savich, who said her closets overflow with useless high-end beauty products, added, “After about 45 years of looking, you know when you’ve found something good.”

Tina Craig, a founder of the popular Bagsnob blog empire, reported that during New York Fashion Week people kept asking her what she was doing to her skin. “It looked amazing and glowy,” said Ms. Craig, who had just begun using the GloPro. (Asked to rank the device on a suffering-for-beauty scale, Ms. Craig, who says she is so sensitive that she has to comb out her own hair at the beauty salon, said the pain was “less than waxing but more than threading.”)

Wounding the skin — by chemical peel, dermabrasion or laser, for example — has traditionally been the only way to jump-start collagen production and rejuvenation, and that sort of injury to the epidermis can be inflicted only very occasionally. But microneedling, sometimes called “the poor man’s laser,” has fewer limitations, said Dr. Terry James, a dermatologist, founder of Beauty Bioscience and Ms. O’Banion’s father.

The process creates tiny microwounds that trigger the body to fill them with collagen, but leave the epidermis intact, said Dr. S. Tyler Hollmig, an assistant professor of dermatologic surgery at Stanford. That gives microneedling two advantages: One, it can be repeated often, without producing the red, irritated, unsightly skin of, say, a peel, Dr. James said.

And two, it has a lower risk of causing hyperpigmentation as compared to many lasers, a real advantage for minority skin types, Dr. Hollmig said.

A study funded by Beauty Bioscience and conducted by an independent company found almost-too-good-to-be-true results: a 30 percent reduction in wrinkles among women ages 41 to 64 with just a minute of use, three times a week, for 30 days. (The tool, which has 540 0.3-millimeter needles, is rolled vertically, horizontally and diagonally across the face, as though the user is aerating a lawn.)

Microneedling done in a doctor’s office has shown some compelling evidence in smaller studies that it works, though there haven’t been a lot of large, randomized control trials, which is the gold standard, Dr. Hollmig said.

But home microneedling devices have shorter needles than those used by doctors and spas, which might suggest that results will not be as good. Dr. Hollmig theorized that collagen production, for example, would be minimal with such a conservative treatment. Dr. James, however, pointed to a study published in the journal Plastic and Reconstructive Surgery showing that collagen formation isn’t dependent on needle length and that best results occur with regular microneedling.

His daughter was quicker with the sales patter. “If you think about exercising,” she said, “is it better to go to the gym twice a year and lift a 20-pound weight for two hours, or is it better to be doing something smaller and going often?”

Dr. Mathew Avram, director of the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, suggested the results may be real but fleeting.

“When you roll something on your skin that creates little holes, you may get a little bit of swelling, which would give you a bit of plumping and make you think you look better temporarily,” said Dr. Avram, who was skeptical about the tool’s long-term benefits. “There’s a real need for data to justify the excitement.”

GloPro also promotes the fact that 100 percent of its users, when surveyed, thought the tool stimulated their natural collagen production, though collagen formation is visible only under a microscope.

Beauty Bioscience says it took it four years to find the right number of needles, which were tested in 10-needle increments from 100 to 800, seeking the best effect with the leastpain. (Think of microneedling as a circus act where someone walks across a bed of nails without bleeding: It’s all about the even distribution of weight.) A GloPro head designed for use on the body, with 1,680 needles, was introduced in December; it sold out immediately and was back-ordered until mid-January.

There is a small risk of infection with the device, especially if you roll it through an infected hair follicle or what dermatologists call a “scratched acne lesion.” Alcohol, the suggested means of cleaning the tool, doesn’t do the job for many surgical instruments, as certain bacteria (like those causing outbreaks now and again at nail salons) aren’t eliminated without really vigorous sterilization. (Short of buying a personal autoclave, there isn’t much you can do.)

Another potential problem: GloPro speaks of its ability to make your skin absorb more product, but your chances of having an allergic reaction to said product may be higher, though still relatively rare. In microneedling done in spas, for example, there have been reports of what’s called “delayed hypersensitivity reactions” — that is, nasty skin rashes — caused by the creams applied afterward. Normally, the outer layer of skin would prevent the creams from sinking deeply enough to cause a problem, but microneedling enables them to reach deeper, and set off an immune response.

The flip side is that microneedling may be able to assist a user in getting all sorts of potentially helpful stuff into the skin. “This is pretty exciting, “but is a little too close to the Wild West right now for this dermatologist to be feel completely comfortable,” Dr. Hollmig said.

When Retirement Comes With a Daily Dose of Cannabis

Ruth Brunn finally said yes to marijuana. She is 98.

She pops a green pill filled with cannabis oil into her mouth with a sip of vitamin water. Then Ms. Brunn, who has neuropathy, settles back in her wheelchair and waits for the jabbing pain in her shoulders, arms and hands to ebb.

“I don’t feel high or stoned,” she said. “All I know is I feel better when I take this.”

Ms. Brunn will soon have company. The nursing home in New York City where she lives, the Hebrew Home at Riverdale, is taking the unusual step of helping its residents use medical marijuana under a new program to treat various illnesses with an alternative to prescription drugs. While the staff will not store or administer pot, residents are allowed to buy it from a dispensary, keep it in locked boxes in their rooms and take it on their own.

From retirement communities to nursing homes, older Americans are increasingly turning to marijuana for relief from aches and pains. Many have embraced it as an alternative to powerful drugs like morphine, saying that marijuana is less addictive, with fewer side effects.

For some people, it is a last resort when nothing else helps.

Marijuana, which is banned by federal law, has been approved for medical use in 29 states, including New York, and the District of Columbia. Accumulating scientific evidence has shown its effectiveness in treating certain medical conditions. Among them: neuropathic pain, severe muscle spasms associated with multiple sclerosis, unintentional weight loss, and vomiting and nausea from chemotherapy. There have also been reports that pot has helped people with Alzheimer’s disease and other types of dementia as well as Parkinson’s disease.

Across the nation, the number of marijuana users who are in their later years is still relatively limited, but the increase has been significant, especially among those 65 and older, according to recent studies.

“It’s a bigger issue than we thought,” said Brian Kaskie, a professor of health policy at the University of Iowa who co-wrote a study published in January, “The Increasing Use of Cannabis Among Older Americans: A Public Health Crisis or Viable Policy Alternative?” “This is an elephant we’re just starting to get our hands on.”

A medical marijuana education and support club started by residents of Rossmoor Walnut Creek, a retirement community east of San Francisco, has grown to 530 members — so many that it has changed meeting rooms three times.

“I would be in a lot worse shape if I wasn’t using cannabis, both physically and mentally,” said Anita Mataraso, 72, a grandmother of six who is the program director and takes marijuana daily for arthritis and nerve pain, among other ailments.

In the state of Washington, at least a dozen assisted living facilities have formal medical marijuana policies in response to demands from their residents, said Robin Dale, the executive director of the Washington Health Care Association. The association, an industry group, has posted a sample medical marijuana policy on its website.

In March, an influential group of medical providers, AMDA — The Society for Post-Acute and Long-Term Care Medicine, will tackle the issue at its annual conference. Cari Levy, the group’s vice president, will offer a “Marijuana 101” lesson on the benefits, the risks and the potential pitfalls for providers.

“People are using it, and we need know how to respond,” she said.

But as older people come to represent an emerging frontier in the use of marijuana for medical purposes, questions are being raised about safety and accessibility. Even in states where medical marijuana is legal, older people who stand to benefit often cannot get it. Most nursing homes do not openly sanction its use, and many doctors are reluctant to endorse pot use, saying not enough is known about the risks in the oldest age groups.

“This is a target demographic that may have their access limited, if not cut off altogether, simply because they reside in a facility,” said Paul Armentano, deputy director of NORML, a group that advocates the legalization of marijuana. “It is a problem that may infringe on their quality of life.”

While there is no shortage of research on marijuana, relatively little of it has focused explicitly on older users even as their numbers grow — and not just in the United States. In Israel, for instance, older people have been treated with medical marijuana for years. And Americans for Safe Access, an advocacy group, helped open a research center in the Czech Republic that is evaluating its impact on older people.

“It’s an area that’s very important to look at,” said Dr. Igor Grant, the director of the Center for Medicinal Cannabis Research at the University of California, San Diego, adding that older people are now one of the center’s research priorities.

“Older people can be more sensitive to medicine,” he said. “It’s possible a dose safe for a 40-year-old may not be in an 80-year-old.”

Dr. Thomas Strouse, a psychiatrist and palliative care doctor at the University of California, Los Angeles, said that just as sleeping and pain medications could harm older people, marijuana could possibly make them confused, dizzy or more likely to fall.

“There is no evidence that it is particularly helpful to older people, and some reason that it could be harmful,” he said.

Most nursing homes have also taken a cautious position, often resorting to a “don’t ask, don’t tell” approach.

“If residents are taking it, they are taking it undercover without the staff knowing so it’s not part of their care plan,” said Dr. Cheryl Phillips, senior vice president for public policy and health services for LeadingAge, an industry group representing more than 2,000 nursing homes. “I think that creates a safety problem.”

Fred Miles, a Colorado lawyer who represents nursing home operators, said nursing homes — unlike assisted living facilities — were regulated by the federal government, and were fearful of jeopardizing their Medicare and Medicaid funding. Staff members who administer marijuana could also theoretically face criminal prosecution under federal law, he said, though he has never heard of that happening.

The federal Centers for Medicare and Medicaid Services said no nursing home had specifically lost financing or been penalized for permitting the use of marijuana. In New York State, which started a medical marijuana program in 2016, its use is restricted to people with designated medical conditions, including neuropathy, epilepsy, multiple sclerosis, Parkinson’s, H.I.V., AIDS and cancer.

At the Hebrew Home in the Bronx, the medical marijuana program was years in the making. Daniel Reingold, the president and chief executive of RiverSpring Health, which operates the home, said he saw its powers firsthand when his own father, Jacob, was dying from cancer in 1999. To ease his father’s pain, Mr. Reingold boiled marijuana into a murky brown tea. His father loved it, and was soon laughing and eating again.

“The only relief he got in those last two weeks was the tea,” Mr. Reingold said.

When Mr. Reingold requested approval from the nursing home’s board members, there were no objections or concerns, he said. Instead, they joked that they would have to increase the food budget.

Then Dr. Zachary Palace, the medical director, developed a program that seeks to offer marijuana as an option but also comply with federal regulations: Though the nursing home recommends and monitors its use, residents are responsible for buying, storing and administering it themselves.

Last fall, the first three residents started taking marijuana pills. Their families obtain the pills at a dispensary in Yonkers run by Etain, a company licensed by the state to sell medical marijuana to qualifying patients or their designated caregivers, who must live in New York. Dr. Palace said that as the program expanded this month, as many as 50 residents could be using marijuana.

Marcia Dunetz, 80, a retired art teacher who has Parkinson’s, said she worried at first about what people would think. “It’s got a stigma,” she said. “People don’t really believe you’re not really getting high if you take it.”

But she decided to try it anyway. Now, she no longer wakes up with headaches and feels less dizzy and nauseated. Her legs also do not freeze up as often.

For Ms. Brunn, the marijuana pills have worked so well that she has cut back on her other pain medication, morphine.

Her daughter, Faith Holman, 61, said the pills cost $240 a month, which is not covered by health insurance. Ms. Holman, who lives in New Jersey, also has to ask a family friend to go to the Yonkers dispensary.

“Obstacles had to be overcome,” Ms. Holman said. “But I think she was meant to have it because everything has worked out.”

Inside the Minds of the Ultrawealthy

I asked the psychologist Brad Klontz to tell me more about what it’s like to work with billionaires.

HOW ARE ULTRA-HIGH-NET-WORTH INDIVIDUALS DIFFERENT FROM RUN-OF-THE-MILL AFFLUENT INDIVIDUALS?

They have this feeling that rules don’t apply to them, although that mind-set is often the key to much of their success. If they’re told something can’t be done a certain way, they think that doesn’t apply to them and find a way around it. It can be viewed as elitist or having a sense of entitlement, but it’s also a highly effective strategy for innovative thinking.

WHAT MOTIVATES A BILLIONAIRE TO KEEP WORKING?

Status is a very big part of it. They want to win. That’s part of the motivation. We’re all competitive in our own way. It’s part of our tribal DNA. If you think about tribal societies, the person who has the most power also has the most access to resources, and they can protect and provide for their family. The closer others are to that leader, the safer they feel. It’s the pursuit that brings them happiness — the pursuit of business goals or their passion, that is giving them joy. The money is a side effect, but it’s not what is giving them joy.

THERE ARE MANY EXTREMELY WEALTHY PEOPLE, LIKE BERNIE MADOFF, MARTHA STEWART AND JORDAN BELFORT (THE WOLF IN THE FILM “THE WOLF OF WALL STREET”), WHO COMMIT SERIOUS CRIMES LIKE FRAUD. WHY WOULD A SOMEONE WHO IS ALREADY WEALTHY BEYOND IMAGINING COMMIT A CRIME FOR FINANCIAL GAIN?

One reason is a lack of boundaries. They think the rules don’t apply to them. And you know what? They are right, the rules don’t. They get all this exclusive access to everything, because people are courting them for their money. The rules don’t apply even if the billionaire wants them to apply, and that makes it challenging to have boundaries. Professionals with very strict codes of conduct will loosen their own boundaries to work with these individuals and not get fired by them. It becomes hard for a billionaire to get objective feedback from others because of their status. We’ve been fired by more than one ultrawealthy person because they didn’t hear from us what they wanted to hear, and they have five or six other experts around them that will say what they want to hear.

WHAT IS THE BIGGEST MISCONCEPTION PEOPLE HAVE ABOUT BILLIONAIRES?

We think the very wealthy are nefarious and greedy, and that money corrupts them. We don’t have to look too far to find well-known wealthy people doing some terrible things with their money. But I find that generally, they want to do something constructive with their money, and are looking for ways to help and contribute. In general, billionaires, like everyone else, want to be loved, find purpose and feel safe. And those core values and needs drive all of us, not just the 1 percent of the 1 percent.

WHEN BILLIONAIRES COME TO YOU, WHAT ARE THEY CONCERNED ABOUT?

The ultra-high-net-worth clients of ours, including billionaires, tend to want to be more responsible with their money. Many are worried about the next generation and are wanting to take steps to set them up for success. They don’t want their children to be psychologically messed up around money, and that usually means being financially dependent or financially irresponsible. Financial dependence, whether it is with multigenerational welfare families or multigenerational trust-fund families, is quite debilitating. In our research, we have found that financial dependence is associated with a lack of passion, creativity and drive, and is also associated with feelings of resentment towards whomever controls the purse strings. Money is a powerful reinforcer of behavior, and when it is given freely and is not attached to desired behaviors, it can reinforce a lack of initiative or drive. For the ultrawealthy, it is a lot easier to pass down money to children than it is to pass down values. The latter requires careful consideration.

If the wealthy individual is a first-generation earner, much of their success has come from long work hours and sacrificing time with their family. Many are trying to make up for their lack of availability as their children were growing up and can see the damage that has done. Some financially enabled their children quite accidentally, as they were only trying to give their children a better childhood than they themselves had. Some are prone to use money as instruments of control or give money to others out of a sense of guilt.

In situations where ultra-high-net-worth individuals have inherited their money, and their parents and grandparents were not successful in passing down a desired sense of drive and purpose, we work with them as they struggle to find meaning and purpose, since the drive to make money is not primary.

Billionaires and other ultrawealthy individuals often question their own self-worth outside of their financial resources and success. They struggle with wondering if people actually care about them for who they are or for their money, fame and/or social status.

HOW DO YOU HELP THEM?

What works in the business world, in terms of communication and motivation, does not work with intimate relationships, so we often work with them on improving their listening and communication skills and improving their relationship with a spouse, children and extended family members. Sometimes we work with them individually, sometimes with them and their spouse, sometimes with the entire family and sometimes with key business associates. We will often help them strategize on how to best help, nurture and support their loved ones without financially enabling.

We often use experiential techniques to help create motivation and insight with clients, where instead of just explaining what is happening, we show them. We focus on what we call exquisite listening — the ability to shut out all distractions and maintain a laserlike focus on what the speaker is saying, with a deep curiosity about the feelings, values, goals and internal conflicts the speaker is trying to convey. We also use our assessment tools — for example, money script assessments — which help clients identify their unconscious beliefs about money.

IS YOUR COUNSELING FOR A BILLIONAIRE DIFFERENT FROM WHAT IT WOULD BE FOR A LESS AFFLUENT PERSON?

Not really. In many aspects, the only difference between billionaires and their less affluent counterparts is the number of zeros in their bank accounts.

WHAT CAN THE REST OF US LEARN FROM HOW BILLIONAIRES WORK THROUGH THEIR PROBLEMS?

The ultrawealthy are not afraid to ask for help. They are more likely to have an internal locus of control, where they are quick to take credit for their successes and admit their failures, at least to themselves. In managing their often very complex lives, they have had to rely on a variety of experts to help them along the way. When they run into problems, they are less hesitant than most of us to seek help from someone who is an expert.

Who Will Listen to a Billionaire’s Troubles?

Who doesn’t want to be a billionaire? A millionaire, even? Think of all the troubles that would simply melt away.

Of course, we know deep down that money won’t solve all of life’s problems. And billionaires, it seems, have problems, too. One difference is, no one is likely to feel sorry for them.

“When you have a billion dollars, of course you’re happy about that,” said Brad Klontz, a psychologist and certified financial planner who works with the uber-wealthy.

As a society, he said, we believe the wealthy have no right to complain about their lives. “We have little patience for that,” he said. “But the truth is, the ultrarich suffer from the same existential angst as anyone else.”

The difference between their angst and ours is that a billionaire can’t indulge in the fantasy that money would make everything better. “Billionaires can look behind the curtain and see the wizard doesn’t exist,” Mr. Klontz said. “More money is not going to make them happy.”

In an effort to gain a deeper understanding of the wealthy, Mr. Klontz was the lead investigator in a study of wealthy individuals (conducted with three others, including Paul Sullivan, a financial columnist for The New York Times), published in 2015. The study found the ultrarich to be deeply conflicted.

“Although they know money is not the key to happiness, they can’t stop counting it,” Mr. Klontz said. It’s especially challenging for those who are self-made, as opposed to those who inherit a fortune. For self-made billionaires, he said, “Their entire self-image and all their self-esteem is wrapped up in the pursuit of money.”

Billionaires often feel isolated, Mr. Klontz said, and find it difficult to trust people or have authentic relationships that are not about money. On top of that, they have a hard time finding a sympathetic ear. “There is a sense they can’t really tell anyone what they are dealing with, because no one wants to hear about their struggles,” he said. “As a society, we don’t have the head space to entertain the notion of a billionaire having a bad day.”

But like everyone else, billionaires do have bad days, and some turn to Mr. Klontz for help.

Mr. Klontz’s interest in helping billionaires and others in their income bracket comes from an unlikely place: his own low-income past. “I came from generations of poverty,” said Mr. Klontz, 46.

“I wanted to see how they and their families were able to pass down a way of thinking and behaving associated with financial success,” he said of the very rich. “My goal was to identify how their psychologies differ to help people achieve their financial goals.”

He generally works with clients of Your Mental Wealth, a registered investment advisory firm in which he is a partner and co-founder. Although he is a certified financial planner, Mr. Klontz does not do any investing for his clients, leaving that to his partners in the firm. Instead, he works with them as coach and consultant. (Mr. Klontz is based on the Hawaiian island of Kauai, so much of his work is done by video conference or phone.)

He and his father, Ted Klontz, also a psychologist, train financial advisers and therapists in their five-course online curriculum in financial psychology and behavioral finance at Heider College of Business at Creighton University in Omaha. And the pair are the founders of the Financial Psychology Institute, which certifies financial behavior therapists, and have written several books, including “Mind Over Money.”

The entire field of financial therapy is still in its infancy, said Megan Ford, a marriage and family therapist pursuing a doctorate in financial planning. She is also president of the Financial Therapy Association.

The association was created by financial and mental health professionals who recognized that each group could benefit from the other’s skill set. The association’s members are trying to figure out how to combine those skill sets — financial and mental health — while protecting consumers. “Like any other blossoming discipline, there is a lot of groundwork that needs to be done,” Ms. Ford said.

Becoming a counselor for the ultrarich was a long journey for Mr. Klontz, who grew up outside Detroit. His parents divorced when he was 2, and his mother, a part-time kindergarten teacher pregnant with his sister at the time, was granted full custody. Although she remarried a few years later to a high school teacher, their economic situation barely improved. Mr. Klontz said they went from being under “tremendous financial strain” to straddling the lower- to middle-class line during the rest of his childhood.

Despite earning a doctorate in psychology, he remained financially strapped, graduating with $100,000 in accumulated student loan debt and a lot of anxiety about it.

But it was 1999, and many of his friends were making lots of money trading stocks. “I thought: This is what rich people do, so I’ll do this, too,” he said. Mr. Klontz sold his truck for about $7,000, bought a $450 car and threw everything that was left into tech stocks. “In three months the bubble burst and I lost everything I invested.”

Rather than blame the market, Mr. Klontz decided to figure out what had caused his behavior. “I went home and interviewed several of my family members about their relationship with money,” he said. “I found stories that blew my mind. But the one that is most salient, is that my grandfather lost all the family’s money in the Great Depression and after that, never put a dollar in a bank again, not for the rest of his life. He died in his 90s, living in a trailer park.”

Mr. Klontz became interested in learning more about his family’s enormous anxiety around money. His mother, for example, had so much anxiety around it that she put every cent she saved into low-interest-bearing certificates of deposit, rather than the stock market. “I saw these patterns around money in families that I call dysfunctional pendulum swing: You either do exactly what your parents did or the exact opposite,” he said. “And that’s what I did: I did the riskiest thing you could do.”

After his stock market gamble, it took him three years of living extremely close to the bone to pull himself out of debt. The desire to understand the financial beliefs and behaviors of his own, lower-income family led him to dissect the behaviors and beliefs of high-net-worth individuals. And now he works with some of the wealthiest people in the world, many of whom came to him after reading his books or being referred by other clients.

Mr. Klontz and his father also repaired their relationship.

When Mr. Klontz was 19, his father bought Onsite Workshops, a treatment center in South Dakota, and Mr. Klontz lived with him while getting his master’s degree in counseling; he also worked in his father’s treatment program.

And now, after all these years, what, if anything, does Mr. Klontz think psychologically separates the super rich from everyone else — understanding, of course, that generalizations by nature don’t give a full picture.

“In many ways, I would say they are just like you and I, if we had a billion dollars,” he said. “Different problems, but not a lack of problems.

“They often have a distorted feedback loop. People are drawn to them for their status and perceived power, so they tend to be surrounded by people who endorse their worldview and don’t challenge their way of thinking. Very few people are honest with them.”

Universities Face Pressure to Hold the Line on Title IX

Advocates are launching a campaign to try to persuade colleges to maintain the Obama administration’s tough policies for protecting women on campuses from sexual assault, even if the Trump administration relaxes enforcement.

Many people expect the Trump administration to tilt the balance of federal guidance to make it harder to discipline the thousands of students, almost all of them men, who are accused of sexual violence against women each year.

Women’s groups are leading the push, along with an organization that represents the campus administrators responsible for enforcing federal sexual assault policy — a group whose numbers have grown into the thousands in just a few years.

The main goal of those involved in the effort is to convince college presidents that the Obama-era policies have positively transformed the lives of women on college campuses.

“This is a chance to be doing what we should be doing rather than what we must be doing,” said Brett Sokolow, executive director of the Association of Title IX Administrators, which takes its name from the federal sex discrimination law.

On one side of the issue are those who believe the Trump administration could usher in a new era of stigmatizing young women who speak up when they have been sexually assaulted by fellow students. On the other are critics, including many conservative activists and lawyers, who say that young men are being demonized and having their rights trampled in campus disciplinary proceedings.

Mr. Sokolow’s group has drafted a document, “The ATIXA Playbook: Best Practices for the Post-Regulatory Era,” which he said would be distributed to 33,000 people at schools, colleges and universities whose job involves enforcing Title IX.

The paper’s introduction notes that many critics have said colleges should not be in the business of policing sexual violence, and that this is a “politically opportune moment to offer a spirited defense” of why they should be.

End Rape on Campus, a “survivor advocacy organization,” created the hashtag #DearBetsy, a reference Betsy DeVos, the new federal education secretary, and has urged the posting of messages on Twitter in support for “sexual assault survivors” and others protected from discrimination by Title IX policies, including lesbian, gay and transgender students.

“I want us to take a stance proactively,” said Sofie Karasek, director of education for the advocacy organization. “I don’t want us to just react to things that happen. I want to get ahead of whatever is going to come down the pipeline.”

On Wednesday, the National Women’s Law Center and other women’s and student groups held a “call-in” to the Education Department, demanding that Ms. DeVos commit to the current federal sexual assault guidance.

“That was our first big action collectively,” said Neena Chaudhry, the law center’s senior counsel and education director. “We’re looking at a Twitter storm sometime soon.”

Colleges and universities are in a delicate position, reluctant to dismantle the current system for addressing sexual assault, while viewing the new administration as potentially making it less fraught for them.

“Schools must and will continue to support survivors and to be fair to both parties, we are required to do that, but federal guidance can be a straitjacket that forces schools to act in a way that may not further those goals,” said Terry Hartle, senior vice president of the American Council on Education, a higher education trade group.

Mr. Hartle acknowledged that colleges and universities chafe at the public scrutiny that comes with being put on a list of institutions under investigation, even before findings have been made. That list now numbers 309 cases at 227 colleges and universities, including Cornell, Harvard, M.I.T., Johns Hopkins, and Stanford.

He said the criteria for such federal investigations were “vague” and “ambiguous,” and that colleges would like clarification.

“How do we avoid getting sued by the government?” he said.

He said that many college presidents believe disciplinary proceedings could be carried out more equitably through mediation, which could better account for complexities like memories dimmed by alcohol and stories that conflict and lack witnesses, rather than through the current system, in which there are clear winners and losers. But mediation is not now allowed.

But Mr. Hartle said that trying to reshape sexual assault policy could be politically risky.

“I think the challenge for the new administration will be to ask themselves, can this be changed in a way that does not get us killed?”

Ms. DeVos said during her confirmation hearing that it would be premature for her to take a position on Title IX, and a spokesman for her office declined to comment Friday. Sexual assault policy is carried out by the department’s Office for Civil Rights, and whoever takes over that office would have a strong influence on any change in direction.

Gail Heriot, a leading critic of Obama-era policies, and a University of San Diego law professor, has been put forward as a candidate by more than 240 largely conservative activists and college faculty members, in a letter sent to the Trump administration and reported by The Chronicle of Higher Education. Among those signing were Harvey Silverglate, a co-founder of the Foundation for Individual Rights in Education, a free-speech group, and Heather Mac Donald, a fellow at the Manhattan Institute.

Ms. Heriot said in an email Friday that she had not heard from Ms. DeVos or anyone acting on her behalf. “I have no evidence that I am actually being considered for the job,” she said.

Advocates credit the threat of federal investigations with fostering a better understanding of campus rape as a serious problem deserving of clear consequences, up to suspension and expulsion.

Critics, including prominent law school professors, say the federal guidance has trampled on the due process rights of the accused — almost always young men — by setting a low standard of evidence and by not requiring the involvement of the police and other law enforcement agencies.

“There are poorly trained administrators, faculty and students investigating alleged criminal conduct, sitting in judgment and doling out punishment,” said Charles Wayne, a lawyer in Washington, D.C., who has represented more than a dozen men accused in campus proceedings.

Mr. Sokolow said his group’s tracking indicated that 10,000 to 12,000 cases reach the disciplinary phase every year — many more when sexual harassment, stalking and relationship violence are counted too. Others said the number was hard to come by, but perhaps in the low thousands.

Some of the activists have been buoyed by the success of the women’s marches the day after President Trump’s inauguration, which, according to estimates, drew more than 1 million people in cities across the United States and more around the world.

“I have called the Department of Education quite a few times and called my senator quite a few times,” said Jessica Davidson, a 2016 graduate of the University of Denver and an activist with End Rape on Campus who said a fellow student had been found guilty of raping her through the campus disciplinary process.

Mr. Sokolow said that Title IX officers are prepared for whatever may come. “I’m playing a long game and looking at this as a cyclical retraction,” he said. “Title IX is 45 years old. It’s waxed and waned. It isn’t going anywhere. We just have to figure out how to navigate it.”

China Fights Spread of Deadly Avian Virus

BEIJING — The Chinese authorities are battling a surge in H7N9 “bird flu” infections, and have shuttered live poultry markets across the country after dozens of people in recent weeks were killed by the disease.

As of Friday, health officials confirmed eight deaths and 77 diagnosed cases just in February, according to Xinhua, the state news agency.

Last month, 192 people in China learned they had the virus, and 79 of them died, according to official numbers released on Tuesday. The strain, H7N9, is an avian influenza virus that can infect people who come in close contact with infected live or newly killed birds.

The latest deaths include a woman in her twenties and her young daughter, who both had contact with live poultry. In rural and small-town China, many residents prefer to buy live chickens, ducks and geese that are slaughtered on the spot or at home. China’s National Health and Family Planning Commission has banned sales of live poultry in some areas across eastern, southern and southwestern China. The eastern province of Zhejiang ordered all live-poultry markets closed.

Nearly all of the confirmed infections have come from direct contact with birds. But experts worry that the virus could eventually mutate into one that passes easily between people.

The first confirmed outbreak of H7N9 in humans was in 2013 in China. Each subsequent winter and spring has seen a spike in new cases. This year’s resurgence is the deadliest in four years. In January 2016, Chinese health authorities recorded 28 human infections, including five deaths. Since November, there have been at least 355 confirmed H7N9 cases in mainland China, according to the Hong Kong Center for Health Protection.

An outbreak of SARS, or severe acute respiratory syndrome, which spread across China in 2003, deeply damaged public trust in the government after senior officials tried to conceal its spread. At least 336 people died in China from the outbreak, and hundreds more died abroad. Since then, the Chinese government has improved its monitoring of communicable diseases.

In Chongqing, a sprawling municipality in southwest China, three people were detained by the police for spreading rumors that bird flu had been found there, the police said on Friday. The police in Hubei Province in central China also detained a woman accused of spreading false rumors about the virus.

Eco-friendly, Nontoxic and Vegan: It’s a Condom

By DAVID GELLES

A dozen employees at Ricky’s, a beauty shop in downtown New York, huddled below a display of lustrous wigs. Around them, hair irons, press-on nails and makeup kits were stacked to the ceiling. But on this morning, the clerks had gathered to learn about an unusual new item on the shelves: nontoxic, eco-friendly vegan condoms.

Meika Hollender, the co-founder and co-chief executive of Sustain Natural, addressed the crowd and showed off her wares. The latex in Sustain condoms comes from a Fair Trade rubber plantation in Southern India, she explained. The factory is solar powered. And the condoms are free from nitrosamines, possible carcinogens found in many popular brands.

“Everyone is thinking about the ingredients in their food and their makeup,” she said. “But no one is thinking about the ingredients that go in the products they put in the most intimate parts of our body.”

With Sustain, Ms. Hollender is trying to do for the contraceptive industry what brands like Honest Company, Mrs. Meyer’s and Seventh Generation have done for cleaning products — introduce all-natural alternatives to household staples such as diapers, hand soaps and paper towels.

That’s no coincidence. Jeffrey Hollender, one of the founders of Seventh Generation, is Meika’s father and runs Sustain with her.

“Growing up, my dream was to start a condom company with my dad,” Ms. Hollender, 29, quipped to the staff at Ricky’s.

Seventh Generation was an instant success, hitting $8 million in sales within three years of its founding in 1988. But the market for condoms is much smaller than the market for diapers and soaps. And three years after founding Sustain, the Hollenders are working to overcome some early missteps — and a fickle consumer base — as they try to make their eco-condoms mainstream.

Mr. Hollender, 62, decided he wanted to start Sustain while he was on a surfing trip. After founding Seventh Generation and building revenues into the hundreds of millions, he lost control and was forced out by his partners in 2010.

On the beach, contemplating the meaning of life and what he should do next, he zeroed in on condoms. Condoms, he figured, were a product that hadn’t yet gotten the full environmental treatment. And he knew that they were an inherently sustainable product — latex is made from the sap of the rubber tree, an endlessly renewable resource.

Mr. Hollender initially wanted to call the company Rainforest Rubbers. Meika, who was working in the consumer products industry, persuaded him to go with a name suggested by an investor: Sustain.

To give the new condoms additional ecological bona fides, the Hollenders focused on eliminating nitrosamines. Common chemicals that are present in everything from processed meat to balloons, nitrosamines have been found to be carcinogenic in large doses. And while only minuscule amounts are found in most products, including condoms, the World Health Organization recommended that condom makers minimize nitrosamines in their products.

The Food and Drug Administration monitors the presence of nitrosamines in various products, but has not banned them outright. As a result, they are found in small doses across a wide array of products.

The Hollenders hired a former employee at Durex, another condom brand, who had figured out how to make nitrosamine-free latex. And they found the rubber plantation. Finally, for the small number of stringent vegans who try to avoid using any animal products at all, Sustain removed casein, a milk protein commonly found in traditional latex condoms.

“We’re like the Seventh Generation for your vagina,” Ms. Hollender said at Ricky’s.

But vegan condoms are shaping up to be a more difficult sell than recycled paper towels. The Hollenders approached more than 25 venture capital firms looking for backing. All of them said no. Instead, the Hollenders have used their own money and funds from friends and family. Three years after founding the company, sales have topped $1 million annually, and big stores like CVS and Target are carrying their products, but the brand has yet to really crack the mainstream.

Coyote Amrich, the director of purchasing and product development at Good Vibrations, a chain of sex shops, said more customers were asking for Sustain and other environmentally friendly brands.

“There’s a growing environmental awareness,” she said. “But does that mean everyone wants to know if their condom is vegan? No.”

Sustain is not the first condom of its kind. Glyde, a rival brand, also makes vegan condoms that are certified as Fair Trade, a designation used by manufacturers to connote sustainable farming practices. And certain varieties of the major condom brands, including Trojan, Durex and Lifestyles, also are nitrosamine free.

What’s more, the Hollenders have come under fire for what critics describe as dangerous alarmism. Shortly after founding Sustain in 2014, the Hollenders funded a report by two nonprofit groups, the Reproductive Health Technologies Project and the Center for Environmental Health, that evaluated nitrosamine levels in condoms. Then Sustain started a petition encouraging the F.D.A. to ban nitrosamines from condoms, and its Twitter account posted a separate video titled “Are Condoms Killing You.”

The backlash was swift, with bloggers attacking the Hollenders and writing articles with headlines including “Cigarettes Cause Cancer; Condoms Don’t.”

“They came into the condom industry hoping to change the market, maybe not understanding that some people had already carved that out,” Ms. Amrich said. “The market is ready for them, but they’ve had some challenges.”

Today Ms. Hollender has tempered her message. “I’m not saying condoms cause cancer,” she said in an interview.

Yet Sustain still touts the fact that its condoms are free of nitrosamines on its packaging. “This is what resonated with consumers,” said Ms. Hollender. “Maybe because it’s a big, scary chemical word.”

Sustain sells more than just condoms. It makes a personal lubricant that uses aloe, instead of petroleum, as its base. That change can help women avoid bacterial vaginosis, an unpleasant infection that can make women more susceptible to sexually transmitted diseases. And the company is also marketing “post play” wipes, made with cotton and organic ingredients.

Hoping to jump-start sales, Sustain this month is changing its packaging. Instead of the previous boxes depicting stones, rivers and bamboo, the new logos feature an illustration of two people kissing.

The update suggests that Sustain is learning, Ms. Amrich said. “You don’t market condoms the same way you market paper towels,” she said.

At Ricky’s, the clerks were receptive to Ms. Hollender’s message, and Sustain condoms were displayed prominently next to the cash registers.

“A couple of the managers are vegan,” said one employee at the store. “So that helped.”

Yoga at Steakhouses, and Boot Camps in Dining Rooms

By SHIVANI VORA

Michael Chernow, an exercise buff and the owner of the NoLIta seafood restaurant Seamore’s, started a weekly workout class available to his 40-odd employees soon after the restaurant opened in 2015.

Every Wednesday at 9 a.m., about 10 to 15 staff members of Seamore’s Fit Squad meet for either an indoor cycling class or for a four-mile run across the Williamsburg Bridge. Sometimes there are yoga or boot camp classes at the restaurant, where employees push aside tables and chairs to transform the dining room into a gym.

“I care deeply about the people who work for me, and this club is my way to offer them an avenue to health,” Mr. Chernow said.

The cost of organizing the group averages $200 a week, but the benefits to staff members, they say, is immeasurable.

The bartender Bobby Brower said that the squad got him back into exercise after more than a year away. Given his 12-hour shifts, usually followed by a 3 a.m. bedtime, Mr. Brower was apprehensive about the early-morning meetings, but he adjusted. “There’s such an energy to the group, and I look forward to waking up and getting a positive start to my day,” he said. Since joining the club, he’s dropped 10 pounds.

Taylor Nobel, a server, said, “I noticed right away that I was able to power through my shift, and I think of the workouts as an opportunity to stay healthy in a career that has a reputation for being the opposite.”

Seamore’s is one of several New York City restaurants encouraging employee bonding and wellness through fitness.

Claus Meyer, the owner of Great Northern Food Hall and Agern, two Nordic restaurants in Grand Central Terminal, leads a monthly running club, which is open to his 350 employees as well as the general public. Attendees meet in Central Park and run three to six miles. Afterward, they head to Grand Central, where they relax and chat over free coffee and cinnamon buns.

“I try to counteract my constant eating by being active daily, and I wanted to give that same chance to my employees and the larger community,” Mr. Meyer said.

The West Village steakhouse Quality Eats offers yoga classes twice a month at the restaurant. One server, Hali Tsotetsi, leads around 10 co-workers through an hourlong session of vinyasa moves, along with some meditation. “The yoga began as a team building initiative and has now become a part of the restaurant’s culture,” Ms. Tsotetsi said.

For some, the exercise doesn’t have to be extreme to make a difference. The chef Michael White of the Altamarea Group regularly holds walking meetings around the city with staff members from several of his restaurants, including Marea and Vaucluse. “Whether we’re discussing business or menus, doing it while we’re walking, getting fresh air and increasing our heart rates makes the meetings more productive,” Mr. White said.

Mr. White has lost 137 pounds since starting the walking meetings, he said. “There’s no question that walking has changed my life,” he said, “and hopefully, has also had a positive impact on the employees who walk with me.”

Viewpoints: GOP Health Plan Runs Contrary To Robin Hood’s Rules By Redirecting Funding From Poor To Rich; The Town Hall Duck And Run

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

The Washington Post: Trump’s Toxicity Has Republicans Running Away From Their Constituents
As recent town-hall meetings of GOP Reps. Tom McClintock of Elk Grove, Jason Chaffetz of Utah, Gus Bilirakis of Florida, Diane Black of Tennessee and others turn into well-publicized tongue-lashings, their colleagues are ducking and running. … The scene is reminiscent of the tea party summer of 2009, but the energy is on the other side this time. Now, as then, the victims say the perpetrators are outsiders – Chaffetz said those who protested him included “paid” people from out of state, an echo of Nancy Pelosi’s claim of “astroturfing” – but now, as then, the anger is real. (Dana Milbank, 2/15)

Los Angeles Times: Trump Tries To Save Obamacare Exchanges While Undermining Them
With the drive to “repeal and replace” Obamacare losing steam, the Trump administration quietly moved to shore up a key feature of the healthcare law this week: the state exchanges where people shop for non-group coverage. And to its credit, Trump’s Department of Health and Human Services zeroed in on some of the factors that have led a handful of major insurers to leave the exchanges. (Jon Healey, 2/16)

Bloomberg: A Sign That Obamacare Exchanges Are Failing
Yet more bad news for Obamacare this week: Molina Healthcare lost $110 million on the exchanges last year, and the CEO told investors, “There are simply too many unknowns with the marketplace program to commit to our participation beyond 2017.” At first glance, it’s hard to see why this piece of news is worth worrying about. UnitedHealth recently projected several times those losses, and it’s a bigger player on the exchanges. Why spend so much time looking at one modest-size insurer? Because Molina is one of the companies that has been repeatedly pointed to, by virtually every health-care-policy wonk in the business, as one of the “bright spots” on the exchanges. (Megan McArdle, 2/16)

The New England Journal Of Medicine: Adjusting Risk Adjustment — Accounting For Variation In Diagnostic Intensity
In the U.S. health care system, payments and performance measures are often adjusted to account for differences in patients’ baseline health and demographic characteristics. The idea behind such risk adjustments is to create a level playing field, so that providers aren’t penalized for serving sicker or harder-to-treat patients and insurers aren’t penalized for covering them. For example, the private insurance companies that participate in Medicare Advantage and the Affordable Care Act (ACA) exchanges receive risk-adjusted payments from the U.S. government, with the rationale that insurers should be reimbursed more for enrollees with higher expected costs. (Amy Finkelstein, Matthew Gentzkow, Peter Hull and Heidi Williams, 2/16)

RealClear Health: A Small HSA Fix Could Produce Big Results
As Congress and the Trump administration begin laying the foundation for their replacement plan for the Affordable Care Act (ACA), their starting point should be ensuring all Americans have a ready path for enrollment in health insurance that, at a minimum, provides protection against major medical expenses. They should also promote broadened enrollment in Health Savings Accounts (HSAs) as an important means for paying for care before insurance coverage kicks in. (James C. Capretta, 2/17)

Louisville Courier-Journal: Demand For Medicaid Waivers Exceeds Funds
The “most vulnerable of our society” is a phrase that gets thrown around a lot. Politicians employ it in speeches and press releases to describe constituents who cannot take care of themselves. People with intellectual and developmental disabilities fall under this banner of protection. (Amanda Beam, 2/16)

Sacramento Bee: California Provides Model To Replace The Affordable Care Act
The new administration and Congress are under intense pressure to craft a market-based alternative to the Affordable Care Act. It won’t be easy. To achieve the financial stability required to make the market work, reformers should heed some important lessons from California. Health plans and risk-taking medical groups essentially made a “deal” with Congress to participate in the ACA. They agreed to cover applicants with pre-existing conditions without charging higher premiums in return for: an expanded individual market driven by a federal mandate that everyone buy insurance; premium and cost-sharing subsidies financed by insurers and the government; and three federal risk-mitigation programs to help stabilize the new marketplaces. (Leonard D. Schaeffer and Dana Goldman, 2/14)

Orange County Register: California Job Losses From Obamacare Repeal? Fear Not!
Obamacare was a cash cow for providers, which now argue it was a program for jobs and economic growth. They now say that repealing Obamacare will kill California jobs. That grabs any politician’s attention, but it is not true. According to a study by the UC Berkeley Labor Center, which is promoted by the California Hospital Association, “The majority (135,000) of these lost jobs would be in the health care industry, including at hospitals, doctor offices, labs, outpatient and ambulatory care centers, nursing homes, dentist offices, other health care settings and insurers. (John R. Graham, 2/16)

Cleveland Plain Dealer: Boost Funding To An Ohio Foster Care System Increasingly Burdened By The Opioid Crisis
Ohio Gov. John Kasich has been in the thick of the battle against deadly opioids, signing a bill this year to tighten restrictions on prescription opioids, speaking at conferences about heroin and even sending an Ohio Highway Patrol superintendent in April to Trumbull County after beleaguered officials there begged for help in quelling a rising tide of opioid overdoses and deaths. (2/17)

The Des Moines Register: A Second Chance To Pass Aid-In-Dying Bills
In a Gallup Poll conducted May 4-8, 2016, respondents were asked: “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his or her family request it?” Sixty-nine percent of respondents answered yes. (John S. Westefeld, 2/16)

Lexington Herald Leader: Whooping Cough Making A Comeback
In the past few weeks, there have been several confirmed cases of whooping cough, also known as pertussis, in Fayette County schools and other surrounding counties. Many parents are concerned about exposure and have questions about preventing pertussis infection or recognizing symptoms. (Jessica Murray, 2/16)

The New England Journal Of Medicine: Addressing The Fentanyl Threat To Public Health
Fentanyl, a powerful synthetic opioid, poses an increasing public health threat. Low production costs encourage suppliers to “cut” heroin with the drug, particularly white powder heroin sold in the eastern United States. Fentanyl also appears as a prevalent active ingredient in counterfeit OxyContin (oxycodone) tablets. The result is that fentanyl plays a major role in rising mortality due to heroin or opioid overdose. It poses a serious overdose risk because it can rapidly suppress respiration and cause death more quickly than do other opioids. (Richard G. Frank and Harold A. Pollack, 2/16)

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: Medicaid Block Grants; Job Loss And The ACA; Growing HIV Coverage

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

Urban Institute: What TANF Can Teach Us About Block Granting Social Services
White House officials and congressional leaders have talked about seizing the opportunity to pass sweeping changes to federal antipoverty programs. One potential change is to give block grants of federal funds to states and allow states greater flexibility …. House Speaker Paul Ryan has long contended that expanding the block grant model to other facets of the safety net — such as Medicaid and food stamps — would afford states the flexibility to drive innovation in combating poverty. But examining the results of welfare reform after two decades presents a more cautionary tale …. Simply put, all states ended up with far fewer funds and a diminished ability to meet their residents’ needs. (Hahn and Coffey, 2/7)

The Kaiser Family Foundation: Current Flexibility In Medicaid: An Overview Of Federal Standards And State Options
This brief provides an overview of current federal standards and state options in Medicaid to help inform upcoming debates about increasing state flexibility in the program as part of efforts to restructure Medicaid financing. Today, states operate their Medicaid programs within federal standards and a wide range of state options in exchange for federal matching funds that are provided with no limit. Each state Medicaid program is unique, reflecting states’ use of existing flexibility and waiver authority to design their programs to meet their specific needs and priorities. As proposals to restructure Medicaid financing develop, it will be important to examine what additional flexibilities they would provide to states and what standards, accountability and enrollee protections would remain for states to access federal funds. (Artiga et al., 1/31)

Urban Institute/Robert Wood Johnson Foundation: Recent Evidence On The ACA And Employment: Has The ACA Been A Job Killer? 2016 Update
We find no evidence to support claims that the ACA has been a job killer. Through 2016, the ACA had little to no adverse effect on employment and usual hours worked per week. For both measures, levels in 2014, 2015, and 2016 are statistically identical to our projections based on patterns existing before 2014, the year the major provisions of the ACA went into effect. Our conclusion applies to the full sample of nonelderly persons and to subgroups of nonelderly persons based on gender and educational attainment. Levels of part-time work (29 or fewer hours per week) have fallen since 2014, but remain at somewhat higher levels than would be expected given recent declines in the unemployment rate and overall economic improvement. (Garrett, Kaestner and Gangopadhyaya, 2/16)

The Kaiser Family Foundation: Insurance Coverage Changes For People With HIV Under The ACA
This brief provides the first national estimates of changes in insurance coverage among people with HIV since the implementation of the ACA. It is based on analysis of data from the Centers for Disease Control and Prevention (CDC). We find that coverage increased significantly for people with HIV due to the ACA’s Medicaid expansion; indeed, increased Medicaid coverage in expansion states drove a nationwide increase in coverage for people with HIV. In addition, the share relying on the Ryan White HIV/AIDS Program also increased. (Kates and Dawson, 2/14)

Brookings/USC Schaeffer Center for Health Policy & Economics: Re-Balancing Medical And Social Spending To Promote Health: Increasing State Flexibility To Improve Health Through Housing
The health impacts of interventions that improve economic conditions such as household income are still the subject of considerable debate. Some economists find little support to show that public transfer payments improve health outcomes, while others argue that federal assistance frees family income to spend on better access to health care, and thereby improves population health. Some researchers have identified evidence that stressful work environments and educational disparities are social mechanisms with a deleterious impact on health, but the evidence that increased public spending targeting these mechanisms will improve health outcomes is nascent. In contrast, the research showing that expenditures that improve access to safe, affordable housing improve population health is relatively strong. (Butler, Matthew and Cabello, 2/15)

Here is a selection of news coverage of other recent research:

MedPage Today: Study: Beware The Snippy, Snarky Surgeon?
The more complaints lodged at surgeons, the more likely it was for their patients to suffer complications after going under the knife, a study found, helping explain why operators with the least favorable reviews get sued the most. Surgeons who had a history of unsolicited patient reviews — often regarding rudeness and intimidation directed at patients and other healthcare professionals alike — were tied to greater risks of: Complications for patients …. Surgical complications …. Patient readmissions. (Lou, 2/15)

Reuters: Salt Reduction Policies Cost-Effective Even Without Healthcare Savings
Government policies designed to reduce how much salt people eat may be cost-effective even without considering the potential healthcare savings, a recent study suggests. That’s because efforts to curb salt use through policies like public education and industry agreements would not cost that much relative to their potential to reduce mortality and disability, researchers estimate. (Rapaport, 2/10)

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

State Highlights: Ga. Senate Panel Amends But OKs Surprise Medical Bill Measure; Conn. Non-Profit Hospitals Fight Bid To Make Them Pay Local Property Taxas

Outlets report on news from Georgia, Connecticut, Minnesota, Kansas, Texas, Massachusetts, Florida, Washington, Arizona, Wisconsin, Ohio and Louisiana.

Georgia Health News: After Tweak In Payment Formula, Senate Committee OKs Remedy For ‘Surprise’ Billing
A Georgia Senate panel Thursday passed legislation to halt ‘’surprise’’ medical billing – but not without a last-minute amendment that changed the contentious payment formula. The Health and Human Services Committee approved Senate Bill 8, which will address those situations in which patients get unexpected bills from providers who are not in their network, even though the hospital is a network facility. (Miller, 2/16)

The CT Mirror: CT Hospitals Launch TV Ad To Protest New Tax Proposal
Connecticut’s hospital industry launched a new television ad Thursday to protest Gov. Dannel P. Malloy’s proposal to end nonprofit hospitals’ exemption from local property taxation. The Connecticut Hospital Association announced the commercial will air starting today on network and cable television stations, and also can be seen at http://nomorehospitaltax.org. The commercial opens by listing a variety of occupations and one common thread among the people in all of them: they all pay a price when taxes rise on Connecticut hospitals. (Phaneuf, 2/16)

The CT Mirror: Budget Cuts Cost CT Medical Examiner’s Office Full Accreditation 
The Connecticut Office of the Chief Medical Examiner (OCME) has lost its full accreditation and was downgraded to provisional status because of staffing and facility shortcomings driven largely by budget cuts. The National Association of Medical Examiners (NAME), which ordered the downgrade, will reassess Connecticut’s status in September, the state office announced this week. (Phaneuf, 2/16)

The Star Tribune: Report On Minnesota Hospital Errors Sees Problems With Lost Tissue Samples 
The misplacing of irreplaceable biological specimens has proved to be a vexing problem for Minnesota hospitals, which reported 31 instances in the 12 months that ended last Oct. 6. The state’s 13th annual report on hospital “adverse events,” released Thursday, included 336 reportable mistakes, including operations on the wrong body parts and disabling medication errors. But few were as common as lost tissue samples, which also can have serious consequences. (Olson, 2/17)

KCUR: House Committee OKs Involuntary Hold Plan For Kansans In Mental Health Crisis 
A bill that would allow treatment centers to detain Kansans in mental health crisis for up to three days moved forward Thursday after months of work to develop a compromise. A similar bill proposed last year raised concerns that it would deprive Kansans with mental illnesses of their due process rights. A committee of law enforcement officers, treatment providers, mental health advocates and others met six times between legislative sessions to come up with a compromise bill that still fulfilled the original goal of providing short-term mental health care. (Wingerter, 2/17)

Stat: Texas Board Recommends Sanctions Against Stanislaw Burzynski
Along-running battle between the Texas Medical Board and controversial Houston doctor Stanislaw Burzynski could be coming to a head. The board said this week that it had proposed $380,000 in fines and a stiff set of sanctions for Burzynski’s failure to adhere to proper medical procedures in treating cancer patients. The decision is preliminary, and will be submitted and formally reviewed on March 3. (Tedeshci, 2/16)

Boston Globe: For This Hospital Chaplain, Work Is A Matter Of Life And Death 
As [Alyssa] Adreani, 41, likes to point out, [she] isn’t hanging out in the Newton hospital’s chapel and doesn’t wear a collar or a cross. She makes the rounds of the neonatal intensive care unit, oncology, ICU, orthopedics, and medical/surgical units, following her personal Golden Rule of chaplaincy: “Wear comfortable shoes.” The Globe spoke with Adreani about how hospital chaplains are considered part of the treatment team, sometimes even improving health outcomes. (Atoji Keene, 2/16)

Seattle Times: State Regulators Investigating Swedish’s Cherry Hill Hospital, Top Surgeon 
State health regulators have launched an investigation into the practices of Swedish Health Services’ Cherry Hill hospital, days after a Seattle Times report uncovered wide-ranging concerns about patient care at the facility. David Johnson, a spokesman with the state Department of Health, said Thursday a case-management team authorized the new investigation after reviewing The Seattle Times’ findings. Johnson added that the state Medical Commission, which handles issues involving specific doctors, was in the process of investigating complaints filed against Dr. Johnny Delashaw. (Baker, 2/16)

Arizona Republic: New Flu-Tracking App Uses Maricopa County As Beta Site
A California-based health diagnostics company has chosen Maricopa County as the pilot testing site for Communidy, a free web app that allows users to see the age and county of people who currently have the flu. The app, which displays real-time data from doctors’ offices, hospitals, clinics and labs, may encourage people to get vaccinated early, said Machrina Leach, nurse program manager at the Maricopa County Department of Public Health. (Bosch and Jha, 2/16)

Milwaukee Journal Sentinel: United Community Center Opens Third Residential Treatment Facility
This month, the United Community Center, commonly known as UCC, opened its third residential treatment facility for people working to overcome alcoholism and drug addictions. The $1.1 million residence, named Latinas Unidas II, will enable 16 more women to participate in UCC’s residential treatment program at any given time. The new residence, UCC’s second for women, also will treat women who are pregnant or who have infant children, and the program will include prenatal and post-partum care, child care coordination and parenting classes. (Boulton, 2/16)

Cleveland Plain Dealer: Summa Health Gift Establishes Traumatic Stress Chair 
Longtime philanthropists Jim and Vanita Oelschlager have donated more than $4 million to Summa Heath over the last three decades. This week, couple’s foundation provided another donation to Summa Health to establish a Chair in Traumatic Stress. Dr. Patrick Palmieri, director of the Traumatic Stress Center, will serve as the first Oelschlager Chair. As director of the Summa Health Traumatic Stress Center, Palmieri is responsible for the center’s clinical, training and research activities for patients experiencing post-traumatic stress disorder, anxiety and depression. (Becka, 2/16)

Health News Florida: Students Discover Lead In Tap Water May Be Common In Older Homes 
Last semester, the students in Laura Manke’s community cares class embarked on a project, collecting samples of tap water from their homes.  And testing provided by University of South Florida researchers revealed that all of the 46 samples contained lead.Fortunately, the amount of lead in the water in their homes fell below levels that would trigger action under Environmental Protection Agency standards. But experts, including the EPA, say any amount of lead is not good for the body, especially in children under six. Damage can be permanent. (Ochoa, 2/16)

Pioneer Press: Forest Lake Nurse Avoids Jail Time For Stealing Patient’s Medication
A Forest Lake nurse who pretended to check on a patient so he could steal the man’s medication evaded jail time for the offense. Gregory Thomas Welcher, 30, was sentenced in Ramsey County District Court Thursday to five years probation on one count of felony-level theft. He also was ordered to spend one day in jail, but was given credit for the day he already logged at the Ramsey County Correctional Facility. Welcher pleaded guilty to the charge this past December. (Horner, 2/16)

Shreveport Times: Workshop Lets Caregivers Take Care Of Themselves
Social workers seeking a moment of rest from careers steeped in others’ suffering participated in a free “Compassion Fatigue” workshop on Thursday. The workshop, presented by the Noel Memorial United Methodist Church’s arts program, aimed at offering those who take care of others a chance to center and to take care of themselves. (Talamo, 2/16)

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U.S. Urged China To Crack Down On Synthetic Opioids Killing Hundreds Here

China is believed to be a major source for bootleg opioids, including the potent carfentanil, that are brought into the U.S. and contribute to the painkiller epidemic. In related news on the crisis, Georgia lawmakers consider regulations for opioid treatment centers.

The Wall Street Journal: U.S. Authorities Pressed China For Action On Deadly Opioid
China’s crackdown on an extremely potent synthetic narcotic came amid pressure from U.S. authorities and evidence linking it to hundreds of U.S. overdose deaths since it first emerged in Ohio in July. The drug, carfentanil, has been connected to at least 700 fatalities in states including Ohio, Michigan and Florida, according to data compiled by The Wall Street Journal from county medical examiners and NMS Labs, a private laboratory outside Philadelphia that performs toxicology testing for counties around the U.S. (Kamp and Campo-Flores, 2/17)

WABE: Ga. Lawmakers Look To Tighten Regulations On Opioid Clinics 
Georgia lawmakers are considering a bill that would further regulate opioid treatment centers in the state. The bill, sponsored by state Sen. Jeff Mullis, R-Chickamauga, would put into place new requirements for those wanting to open up centers in Georgia. The centers offer medical-assisted treatment and counseling to help treat patients with addictions to heroin and other opioids. (Yu, 2/16)

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Fla. Law Barring Docs From Discussing Guns With Patients Violates Free Speech, Court Rules

The 11th U.S. Circuit Court of Appeals, in a 10-1 ruling, said, “Florida does not have carte blanche to restrict the speech of doctors and medical professionals on a certain subject.”

The New York Times: Florida Doctors May Discuss Guns With Patients, Court Rules
A federal appeals court cleared the way on Thursday for Florida doctors to talk to their patients about gun safety, overturning a 2011 law that pitted medical providers against the state’s powerful gun lobby. In its 10-to-1 ruling, the full panel of the United States Circuit Court of Appeals for the 11th Circuit concluded that doctors could not be threatened with losing their license for asking patients if they owned guns and for discussing gun safety because to do so would violate their free speech. (Alvarez, 2/16)

Atlanta Journal-Constitution: Federal Appeals Court: Doctors Can Ask About Guns In The Home
A federal appeals court, in a case that has pitted the First Amendment against the Second Amendment, sided Thursday with free speech. The 11th U.S. Circuit Court of Appeals ruled Thursday that Florida’s so-called “Docs and Glocks” law, which prohibited doctors from asking patients about guns in the home, violated a physician’s free speech rights. (Cook, 2/16)

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Mediocre Protection Rates Have Many Asking When We’ll Get A Better Flu Vaccine

Though it was no worse than previous ones, the fact that this year’s shot only cut the chance of infection in half highlights the need for a more effective vaccination.

Stat: Flu Vaccine Is Only Moderately Protective This Year, CDC Says
This year’s flu vaccine is offering moderate protection against the main family of viruses causing illness, data released Thursday by the Centers for Disease Control and Prevention show. The data come as what has been a pretty active flu season is near its apex in many parts of the country. “We won’t know when the peak has occurred until we’ve passed it and have a couple of weeks to look back,” said Lynnette Brammer, head of domestic influenza surveillance at the CDC. “We hopefully are approaching the peak but we may not be there yet.” (Branswell, 2/16)

Bloomberg: This Year’s Flu Shot Only Cut Infection Risk By Less Than Half 
Americans who rolled up their sleeves for a flu shot this year cut their chances of coming down with the aches and fever of influenza by almost half, a level of protection that is disappointing for a vaccine but still better than in some recent years. As the virus continues to sweep across the U.S. at epidemic levels, vaccine effectiveness level was 48 percent against acute respiratory illness from the end of November through Feb. 4, according to an analysis of 3,144 people enrolled in the U.S. Influenza Vaccine Effectiveness Network. (Cortez, 2/16)

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Exclusive CRISPR Licenses ‘Bottleneck’ Innovation, Legal Experts Argue

Licensing deals cut by UC-Berkeley and Massachusetts’ Broad Institute may be limiting the potentially lie-saving applications of this gene-editing technology, according to assertions made by intellectual property experts in Friday’s issue of the journal Science.

Stat: Exclusive CRISPR Licenses Slow Development Of Therapies, Legal Experts Argue
The exclusive licenses granted to three for-profit companies on key discoveries about the revolutionary genome-editing technology CRISPR-Cas9 threaten to “bottleneck” its use “to discover and develop useful human therapeutics,” patent experts argued in a paper published on Thursday. What the exclusive licenses have done “is give an entire industry to … companies that will never be able to fully exploit it,” Jorge Contreras of the University of Utah, a co-author of the paper in Science, said in an interview. “And that may hold back the development of therapies.” (Begley, 2/16)

San Jose Mercury News: UC-Berkeley CRISPR License Could Hinder Innovation
A smart biotech company could have a great idea for how to use gene editing to develop a new lifesaving therapy — but because of the way licensing deals have been cut by UC-Berkeley and Massachusetts’ Broad Institute, it would never get a chance to try it. That’s the assertion of intellectual property experts in Friday’s issue of the journal Science, who criticize the licensing landscape around the taxpayer-funded and powerful new tool called CRISPR-Cas9, warning it could limit its promise. (Krieger, 2/16)

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Kansas Committee Expected To Take First Vote On Medicaid Expansion Today

The issue has been swatted down repeatedly since the health law went into effect, but after moderates ousted several conservatives in last fall’s elections, a legislative panel is scheduled to vote on a measure today. The committee’s chairman, Rep. Dan Hawkins, a Wichita Republican, says it will be close. News outlets also report on Medicaid developments in Ohio, Alabama and California.

KCUR (Kansas City, Mo., Public Radio): Close Vote Expected On KanCare Expansion Bill 
Kansas lawmakers are getting ready to do something they have never done before: vote on a Medicaid expansion bill. For the past three years, conservative Republicans who controlled the Legislature refused to allow a vote on the issue. Things are different this session due to the ouster of several conservative incumbents by moderate Republican and Democratic challengers. (McLean, 2/16)

Toledo Blade: After Expansion, Medicaid Attracts More Older Men
Those enrolled in Ohio’s expanded Medicaid program in partnership with the federal Affordable Care Act turned out to be older than expected. Barbara Sears, Gov. John Kasich’s Medicaid director and former state representative from Monclova Township, said Thursday she was a little surprised to see how the population skewed older. “But when we knew we weren’t getting the younger folks into the [federal Obamacare private insurance] marketplace, we knew they probably weren’t getting into [the Medicaid expansion],” she said after speaking to the legislative Joint Medicaid Oversight Committee. (Provance, 2/16)

Modern Healthcare: Alabama Could Lose Medicaid Funding For Allegedly Rejecting Eligible Enrollees
The CMS may cut Alabama’s Medicaid funding after learning state officials reject people eligible for Medicaid coverage if they are found to have engaged in fraud or abuse but were never convicted of any criminal act. The CMS said Alabama officials also had a practice of recouping funds from these individuals. Alabama has said it is simply trying to take action against those who lie on their applications about having been previously accused of criminal activity. (Dickson, 2/16)

California Healthline: Some Immigrants, Fearful Of Political Climate, Shy Away From Medi-Cal
Some foreign-born Californians are canceling their Medi-Cal coverage or declining to enroll in the first place, citing fears of a Trump administration crackdown on immigrants. Among those dropping coverage are people in the country legally but concerned about jeopardizing family members who lack permanent legal status, according to government officials, immigration attorneys and health care advocates. (Bazar, 2/16)

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Lawsuit Alleges United Healthcare Overcharged Medicare For Advantage Plan Customers

The lawsuit, which was unsealed Thursday after a five-year investigation by the Department of Justice, suggests the company may have improperly collected “hundreds of millions” of dollars by claiming patients were sicker than they actually were.

Modern Healthcare: DOJ Joins Medicare Advantage Fraud Lawsuit Against UnitedHealth
The U.S. Justice Department has joined a whistleblower lawsuit claiming that UnitedHealth Group and affiliated health plans have been gaming the Medicare program and fraudulently collecting millions of dollars by claiming patients were sicker than they really were. The lawsuit, initially brought in 2011 and unsealed Thursday after a five year-long investigation by the Justice Department, alleges that Minnetonka, Minn.-based UnitedHealth has inflated its plan members’ risk scores since at least 2006 in order to boost payments under Medicare Advantage’s risk adjustment program. (Livingston, 2/16)

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Lawmakers Move To Ease Obama-Era E-Cigarette Regulations

A proposal by Republican Reps. Tom Cole of Oklahoma and Sanford Bishop of Georgia would get rid of a “grandfather” clause that requires companies selling cigars, pipe tobacco, and vapor products such as e-cigarettes after Feb. 15, 2007 to disclose their ingredients and prove that their products meet the applicable public health standards set by the law.

Stat: E-Cigarettes Would Be Excluded From Some Regulations Under New Proposal
Congressional supporters of the tobacco industry have wasted no time in proposing legislation to help e-cigarette companies escape rules adopted under President Barack Obama. In what Republican Reps. Tom Cole (Okla.) and Sanford Bishop (Ga.) described as a “clarification,” the two introduced a bill Thursday that would revise Food and Drug Administration rules governing the sale and advertising of e-cigarettes and cigars. (Kaplan, 2/16)

In other news from Capitol Hill —

CQ Roll Call: Senate Appropriators Signal Interest In Mental Health Funding
Senate appropriators signaled an interest in supporting mental health funding at a hearing Wednesday, appearing particularly interested in finding a way to address provider shortages in underserved areas. Witnesses at the hearing of the Appropriations Subcommittee on Labor-HHS-Education told lawmakers that attracting professionals to the field is the most pressing need. Some urged Republicans to consider the importance of the Medicaid expansion under the 2010 health care law (PL 111-148, PL 111-152) in expanding coverage of mental health services. (Siddons, 2/15)

Kaiser Health News: Right-To-Die Fight Hits National Stage
Melissa Bailey reports: “Opponents of aid-in-dying laws are claiming a small victory. They won the attention of Congress this week in their battle to stop a growing movement that allows terminally ill patients to get doctors’ prescriptions to end their lives. The Republican-led effort on Capitol Hill to overturn the District of Columbia’s aid-in-dying law could fail by Friday. But advocates worry the campaign will catalyze a broader effort to fully ban the practice, which is legal in six states and being considered in 22 more.” (Bailey, 2/16)

Kaiser Health News: Congressman’s Ties To Foreign Biotech Draw Criticism
When a small Australian biotechnology company, Innate Immunotherapeutics, needed a clinical trial for an experimental drug it hoped to turn into a huge moneymaker, the company landed a U.S. partner where it had high-level connections: Roswell Park Cancer Institute in Buffalo, N.Y. The company is partly owned by Rep. Chris Collins, a wealthy Republican entrepreneur from Buffalo, whose enthusiasm for Innate helped persuade others to invest. (Bluth and Kopp, 2/17)

The Baltimore Sun: Cummings Contradicts Trump Over Meeting On Drug Prices
President Donald Trump blamed Rep. Elijah E. Cummings on Thursday for failing to schedule a meeting about the cost of prescription drugs, suggesting the Baltimore Democrat didn’t want to come to the White House because it was “bad politics.” Cummings, the top Democrat on the House Oversight and Government Reform Committee, disputed that characterization, saying the president had made it up. The congressman said he has been waiting to schedule a meeting until he has crafted a prescription drug bill for the president to consider. (Fritze, 2/16)

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‘Tsunami’ Of Alzheimer’s Cases Among Latinos Raises Concerns Over Costs, Caregiving

SACRAMENTO, Calif. — Florence Marquez liked to describe herself as a cannery worker, even though she was best known in her heavily Latino East San Jose neighborhood as a community activist.

She strode alongside Cesar Chavez in the farmworker movement during the 1960s and 70s. She helped build affordable housing for poor families near her local church.

But eight years ago, Florence, now 86, couldn’t find her way to the house she had lived in for 50 years. “That’s when we knew she needed 24-hour care,” said her oldest daughter, Barbara Marquez, 61.

Florence was diagnosed with Alzheimer’s disease, which robbed her of her memory and her fierce independence. Across the United States, stories like hers are becoming more common, particularly among Latinos — the fastest growing minority in the country.

With no cure in sight, the number of U.S. Latinos with Alzheimer’s is expected rise by more than eight times by 2060, to 3.5 million, according to a report by the USC Edward R. Roybal Institute on Aging and the Latinos Against Alzheimer’s network.

Advanced age is the leading risk factor for Alzheimer’s disease and the likelihood of developing Alzheimer’s doubles about every five years after age 65. As a group, Latinos are at least 50 percent more likely than whites to have Alzheimer’s, in part because they tend to live longer, the report notes.

Barbara Marquez visits her mother Florence Marquez at her nursing home on Friday, December 16, 2016. Barbara was her mother’s primary caregiver until the family decided to put their mother in a 24-hour care facility. (Heidi de Marco/KHN)

Barbara Marquez visits her mother Florence Marquez at her nursing home, Sagebrook Senior Living, in Carmichael, Calif., in December 2016. Barbara was her mother’s primary caregiver until the family decided to put their mother in a 24-hour care facility. (Heidi de Marco/KHN)

“This is an incoming tsunami,” said Dr. William Vega, one of the report’s authors and the Roybal Institute’s executive director. “If we don’t find breakthrough medication, we are going to be facing a terrible financial crisis.”

That tidal wave of Alzheimer’s cases is prompting some tough conversations in Latino families, who often pride themselves on caring for elders at home, rather than placing them in nursing homes.

Those talks come with a lot of guilt, Barbara said. Until recently, Barbara was her mother’s primary caregiver. Her sister and brother helped out.

“But it was more than I could have anticipated,” Barbara said, recalling sleepless nights as she tried to make sure Florence didn’t get up and wander off. “It impacts your health, it impacts your marriage. So we looked for help.”

About 1.8 million Latino families nationwide care for someone with Alzheimer’s and other types of dementia. And while the Roybal report shows that Latino families are less likely than whites to use formal care services, such as nursing home care, institutionalized care is becoming more common among these families.

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Between 1999 and 2008, the number of elderly Latinos living in U.S. nursing homes grew by about 55 percent, a rate that outpaced the growth of the overall Latino population during that time, according to research published in July 2011 in Health Affairs.

That can be costly. Nationwide, the average cost for basic services in an assisted living facility is $43,200 per year, according to the Alzheimer’s Association. Yearly nursing home care now averages more than twice that, at slightly more than $92,000.

For many Latino families, getting outside help isn’t an option. It’s often too expensive for seniors who aren’t eligible for Medi-Cal, California’s version of the Medicaid program for low-income people, which generally pays for nursing home care. Immigrants who are in the country unlawfully do not qualify for it, nor do people whose incomes are too high.

Florence’s children decided to take their mother out of her house in San Jose, and they brought her to live with her daughter Barbara in Fair Oaks, just outside Sacramento. They sold the San Jose house, thinking it would help pay for institutionalized care should their mom need it down the road.

She did not qualify for Medi-Cal, so she lived with Barbara for about three years. But after trying out a senior day care program outside of the house at a cost of about $78 a day, Barbara and her family placed Florence in a senior home in the Sacramento suburb of Carmichael, where she has been living for the past year.

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Dwindling Resources

The decision to institutionalize Florence Marquez left her children feeling both guilty and overwhelmed by the steep expense. Her care now costs $3,000 to $4,000 per month, they said. They pay extra for specialized services.

They had the proceeds from the sale of Florence’s house, “but those resources are dwindling,” Barbara said. “What do we do when that money is gone?”

Marquez, 85, was diagnosed with Alzheimer’s disease eight years ago. She lived in the same house for 50 years, but one day she couldn’t find her way back home. (Heidi de Marco/KHN)

Florence Marquez, 85, was diagnosed with Alzheimer’s disease eight years ago. She lived in the same house for 50 years, but one day she couldn’t find her way back home. (Heidi de Marco/KHN)

The Roybal study estimates that the cumulative economic impact of Alzheimer’s among Latinos will hit $2.35 trillion by 2060. That figure includes the costs of medical and long-term care, as well as the lost earnings of family members who provide unpaid in-home care, and of the Alzheimer’s victims themselves, according to the study.

Gustavo Lopez of Chicago cares for his mother, Agustina Lopez, 76, who was diagnosed with Alzheimer’s disease seven years ago.

Gustavo, 48, and his four siblings looked into assisted living but couldn’t afford it. Agustina, after moving between her children’s homes, eventually landed with Gustavo, her youngest.

When Gustavo first took on the role of primary caregiver, his mother still did most things on her own, he said. But she now relies on him to help her eat, bathe, dress and take her medication.

So Gustavo needs a job with flexible hours. He’s worked mostly as a waiter. Other employment opportunities have come his way, some with better pay, but caring for his mother comes first, he said.

Asking For Help

Gustavo does get some help from family friends who check in on his mom while he is at work. He also found Casa Cultural in Chicago, a social service agency that offers a day program for seniors. He can drop his mom off at the center for a few hours, giving him a respite.

Free or low-cost programs like these are available in many communities, but families need to do research and ask for help, said Constantina Mizis, president of the Chicago-based Latino Alzheimer’s and Memory Disorders Alliance.

The alliance, formed in 2009, focuses on family members who are primary caregivers. Mizis said she has met many caregivers who are near their breaking point. The nonprofit offers training for them, helps find resources to boost their own well-being and puts on community events for families.

When seeking support, the best place to start is at a local community group or center — a church, a nonprofit, a United Way office, or the local Alzheimer’s Association chapter, for example, Mizis said. These groups will most likely refer caregivers to a county’s Agency on Aging or a state’s Department of Aging.

There, families are assigned a social worker who can discuss what benefits are available. If an Alzheimer’s patient qualifies for Medicaid, these benefits could include caregiver training and payment through programs such as California’s In-Home Supportive Services. But benefits and eligibility vary by state.

In 2010, the Social Security Administration recognized early-onset Alzheimer’s as a medical condition eligible for disability income. That could help people whose Alzheimer’s disease is diagnosed before the age of 65, but many Latino families aren’t aware the program exists, Mizis said.

A Push For Awareness

Because Latinos are more likely to use informal and more affordable care options, the Roybal report calls for improving training and resources for families in both English and Spanish.

Among the caregivers who opt to keep a parent with Alzheimer’s at home is Julia Garcia, of Houston, Texas. She rotates with her three daughters to watch her mother, Marcela Barberena, 85, who was diagnosed with the disease last year.

Julia, who had been unfamiliar with Alzheimer’s, initially thought her mother’s forgetfulness and childlike behavior was due to age.

“Too often people will see Alzheimer’s as a result of old age, but this brain-deteriorating disease is not natural,” said Vega, co-author of the report.

Julia Garcia said she realized it was something more serious when her mother took a shuttle bus from Houston’s international airport without knowing her destination.

“We had agreed I’d pick her up, but she left on her own,” Julia said. “She ended up downtown. It was the scariest moment of my life.”

As a new caregiver, Julia reached out to her local Alzheimer’s Association chapter for information. While some resources are available in Spanish in the Houston chapter, Julia noticed very few Latinos attending the informational workshops or classes.

Barbara Marquez takes her mother, Florence Marquez, on a walk on Friday, December 16, 2016. (Heidi de Marco/KHN)

Barbara Marquez takes her mother, Florence Marquez, on a walk. (Heidi de Marco/KHN)

Spanish-language media provided little information about the disease. “You rarely hear anything about it on TV or the radio,” she said.

In addition, many Latinos, including the Marquez, Lopez and Garcia families, are often unaware of clinical trials through which families can gain access to experimental therapies and medications at little or no cost.

Latinos are underrepresented in clinical trials sponsored by the National Institutes of Health: They account for 17 percent of the U.S. population but only 7.5 percent of participants at the 32 NIH-funded Alzheimer’s research centers across the country, according to the Roybal study.

Latino volunteers for these trials are important in helping researchers develop Alzheimer’s treatments that work for all ethnic groups, the report says.

“This is why it is so important to invest in the education of these communities,” Mizis said.

Her group helps train promotoras, or community health educators, in regions with large Latino communities — including San Francisco, Los Angeles, Baltimore and New York. Going door-to-door, promotoras educate families about the disease.

“I see firsthand everyday how much help our communities need,” Mizis said. “And this need keeps growing.”

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

Categories: Aging, California Healthline, Mental Health, Public Health, Syndicate

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El “tsunami” de casos de Alzheimer entre latinos plantea inquietudes sobre el cuidado y los costos

SACRAMENTO, Calif. — A Florence Márquez le gustaba describirse a ella misma como una trabajadora de fábrica de conservas, a pesar que era conocida en su latinísimo vecindario del este de San José como una activista comunitaria.

Ella caminó junto a César Chávez en el movimiento de trabajadores agrícolas durante los años 60 y 70. Ayudó a construir viviendas asequibles para familias pobres cerca de su iglesia local.

Pero hace ocho años, Florence, ahora de 86, no pudo encontrar su camino a la casa en la que había vivido durante 50 años. “Fue cuando supimos que necesitaba atención las 24 horas”, dijo su hija mayor, Barbara Márquez, de 61 años.

Florence fue diagnosticada con la enfermedad de Alzheimer, que le robó su memoria y su feroz independencia. A lo largo de los Estados Unidos, historias como Florence Márquez se están convirtiendo en más comunes, particularmente entre los latinos, la minoría de más rápido crecimiento en el país.

Sin una cura a la vista, se espera que el número de latinos con Alzheimer aumente más de ocho veces para 2060, a 3.5 millones, según un informe del Edward R. Roybal Institute on Aging de la Universidad del Sur de California (USC) y de la red Latinos Against Alzheimer.

La edad avanzada es el principal factor de riesgo para la enfermedad de Alzheimer y la posibilidad de desarrollar el mal se duplica cada cinco años después de los 65. Los latinos son al menos 50% más propensos que los blancos no hispanos a tener Alzheimer, en parte porque viven vidas más largas, destaca el informe.

Barbara Marquez visits her mother Florence Marquez at her nursing home on Friday, December 16, 2016. Barbara was her mother’s primary caregiver until the family decided to put their mother in a 24-hour care facility. (Heidi de Marco/KHN)

Barbara Marquez, de 61 años, visita a su madre, Florence Marquez, de 85, en el hogar Sagebrook Senior Living, en Carmichael, Calif., el viernes 16 de diciembre de 2016. (Heidi de Marco/KHN)

“Este es un tsunami en marcha”, dijo el doctor William Vega, uno de los autores del informe y director ejecutivo del Roybal Institute. “Si no encontramos medicamentos innovadores, vamos a enfrentar una terrible crisis financiera”.

Esa marea de casos de Alzheimer está provocando algunas conversaciones difíciles en las familias latinas, que a menudo se enorgullecen de cuidar a sus ancianos en casa, en lugar de ponerlos en hogares para adultos mayores.

Esas charlas se presentan con mucha culpa, dijo Barbara Márquez. Hasta hace poco, Barbara era la principal cuidadora de su madre. Su hermana y su hermano ayudaban.

“Pero fue más de lo que yo podría haber previsto”, dijo Barbara, recordando las noches sin dormir mientras intentaba asegurarse de que Florence no se levantara y escapara. “Afecta tu salud, tu matrimonio. Así que buscamos ayuda”.

Alrededor de 1,8 millones de familias latinas en todo el país cuidan a alguien con Alzheimer y otros tipos de demencia, y mientras que el informe de la USC muestra que las familias latinas tienen menos probabilidades que los blancos no hispanos de usar servicios de atención formales, como un hogar, el cuidado institucionalizado se está convirtiendo en una opción más popular entre estas familias.

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Entre 1999 y 2008, el número de latinos seniors que vivían en hogares aumentó un 55%, una tasa que superó el crecimiento de la población latina en general durante ese período de tiempo, según una investigación publicada en julio de 2011 en Health Affairs.

A nivel nacional, el costo promedio de los servicios básicos en un centro de asistencia es de $43,200 al año, según la Asociación de Alzheimer. Los cuidados anuales en hogares de ancianos son, en promedio, unos $92,000, más del doble.

Para muchas familias latinas, obtener ayuda externa no es ni siquiera una opción. A menudo es demasiado costoso para las personas mayores que no son elegibles para el Medi-Cal, la versión de California del Medicaid para personas de bajos ingresos, que generalmente paga por el cuidado de enfermería en hogares de ancianos. Los inmigrantes que están en el país ilegalmente no califican, ni tampoco las personas cuyos ingresos son demasiado altos.

Después de probar un programa de cuidado de ancianos fuera de la casa a unos $78 al día, Barbara y su familia pusieron a Florence en una residencia para ancianos de la zona de Sacramento, donde ha estado viviendo durante el último año.

 Recursos en baja

La decisión de institucionalizar a Florence Márquez dejó a sus hijos no sólo sintiéndose culpables, sino también con una economía tambaleante por los elevados gastos. El cuidado de su mamá ahora cuesta de $3,000 a $4,000 por mes, dijeron. Pagan extra por servicios especializados.

Florence actualmente no califica para el Medi-Cal, por lo que la familia Márquez vendió la casa de su madre en San José para pagar por su atención. “Pero esos recursos están disminuyendo”, dijo Barbara. “¿Qué vamos a hacer cuando se acabe el dinero?”.

El informe de la USC estima que el impacto económico acumulado de la enfermedad de Alzheimer entre los latinos llegará a $ 2,35 mil billones en 2060. Esta cifra incluye los costos de atención médica y de largo plazo, así como la pérdida de ingresos de los miembros de la familia, y de las propias víctimas del Alzheimer, según el estudio.

Gustavo López, de Chicago, se preocupa por su madre, Agustina López, de 76 años, diagnosticada con la enfermedad de Alzheimer hace siete años.

Gustavo, de 48 años, y sus cuatro hermanos buscaron un centro de asistencia, pero no pudieron solventarlo. Agustina, después de vivir en las casas de todos sus hijos, eventualmente se quedó con Gustavo, el más joven.

Marquez, 85, was diagnosed with Alzheimer’s disease eight years ago. She lived in the same house for 50 years, but one day she couldn’t find her way back home. (Heidi de Marco/KHN)

Florence Marquez, de 85, fue diagnosticada con Alzheimer hace 8 años. Marquez vivió en la misma casa por 50 años, pero un día no pudo encontrar el camino a su hogar. (Heidi de Marco/KHN)

Cuando Gustavo asumió por primera vez el papel de cuidador principal, su madre todavía hacía la mayoría de las cosas por su cuenta, dijo. Pero ahora depende de él para comer, bañarse, vestirse y tomar su medicación.

Así que Gustavo necesita un empleo con horario flexible. Ha estado trabajando principalmente como camarero. Han aparecido otras oportunidades de empleo, algunos con mejor salario, pero el cuidado de su madre está primero, dijo.

 Pidiendo ayuda

Gustavo recibe ayuda de amigos de la familia que vigilan a su madre mientras está en el trabajo. También encontró Casa Cultural en Chicago, una agencia de servicios sociales que ofrece un programa de día para personas mayores. Puede dejar a su mamá en el centro por unas horas, lo que le da un respiro.

Programas gratuitos o de bajo costo como éstos están disponibles en muchas comunidades, pero las familias necesitan investigar y pedir ayuda, dijo Constantina Mizis, presidenta de la Latino Alzheimer’s and Memory Disorders Alliance, con sede en Chicago.

La alianza, formada en 2009, se centra en los miembros de la familia que son los principales cuidadores. Mizis dijo que ha conocido a muchos cuidadores que están al borde de quebrarse. La organización sin fines de lucro les ofrece capacitación, ayuda para encontrar recursos para impulsar su propio bienestar, y participación en eventos comunitarios para las familias.

Al buscar apoyo, el mejor lugar para comenzar es en un grupo o centro comunitario local: una iglesia, una organización sin fines de lucro, una oficina de United Way o el capítulo local de la Asociación de Alzheimer, por ejemplo, dijo Mizis. Es probable que estos grupos refieran a los cuidadores a la Agencia de Envejecimiento del condado o al Departamento de Envejecimiento del estado.

Allí, se les asigna a las familias un trabajador social que puede discutir qué beneficios están disponibles. Si un paciente de Alzheimer califica para Medicaid [Medi-Cal en California], estos beneficios podrían incluir capacitación para cuidadores y pago a través de programas de “efectivo y consejería”. Los Servicios de Apoyo en el Hogar de California es uno de esos programas. Sin embargo, los beneficios y la elegibilidad varían según el estado.

En 2010, la Administración del Seguro Social reconoció al Alzheimer de inicio temprano como una condición médica elegible para los ingresos por discapacidad. Eso podría ayudar a las personas cuya enfermedad de Alzheimer se diagnostica antes de los 65 años, pero muchas familias latinas no son conscientes de esto, dijo Mizis.

Un impulso para la concientización

Debido a que los latinos son más propensos a usar opciones de atención informales y más asequibles, el informe de la USC pide mejorar la capacitación y los recursos para las familias, tanto en inglés como en español.

Entre los cuidadores que optan por mantener a un padre con Alzheimer en casa está Julia García, de Houston, Texas. Ella se rota con sus tres hijas adolescentes y adultas para cuidar a su madre, Marcela Barberena, de 85 años, quien fue diagnosticada con la enfermedad el año pasado.

Julia, que no estaba familiarizada con el Alzheimer, pensó que el olvido y el comportamiento infantil de su madre se debían a la edad.

“Demasiado a menudo la gente ve al Alzheimer como resultado de la vejez, pero la enfermedad que deteriora el cerebro no es natural”, dijo Vega, coautor del informe de la USC.

Barbara visits her mother almost every weekend. Her mother's care now costs $3,000 to $4,000 per month, says Barbara. (Heidi de Marco/KHN)

Barbara Marquez saca a pasear a su madre, Florence Marquez, el viernes 16 de diciembre de 2016. (Heidi de Marco/KHN)

Julia García dijo que se dio cuenta de que era algo más serio cuando su madre tomó un micro desde el aeropuerto internacional de Houston sin saber su destino.

“Habíamos acordado que la recogería, pero ella se fue por su cuenta”, dijo Julia. “Terminó en el centro de la ciudad. Fue el momento más espantoso de mi vida”.

Como nueva cuidadora, Julia se acercó a la sede local de la Asociación de Alzheimer para obtener información. Aunque algunos recursos están disponibles en español en el capítulo de Houston, Julia notó que muy pocos latinos asistían a los talleres informativos o a las clases.

Lo mismo ocurre con los medios en español, que proporcionan poca información sobre la enfermedad. “Rara vez se oye nada en la televisión o en la radio”, dijo.

Muchos latinos, incluyendo las familias de Márquez, López y García, no saben sobre los ensayos clínicos y cómo pueden ayudar a sus seres queridos.

Los latinos están subrepresentados en los ensayos clínicos patrocinados por los Institutos Nacionales de Salud: representan el 17 por ciento de la población de los Estados Unidos, pero sólo el 7,5 por ciento de los participantes en los 32 centros de investigación de Alzheimer financiados por los INS en todo el país, según el informe de Roybal.

Los voluntarios latinos son importantes para ayudar a los investigadores a desarrollar tratamientos para el Alzheimer que funcionen para todos los grupos étnicos, según el informe de USC.

“Por eso es tan importante invertir en la educación de estas comunidades”, dijo Mizis.

Su grupo ayuda a entrenar promotoras o educadores comunitarios de salud en regiones con grandes comunidades latinas, incluyendo San Francisco, Los Ángeles, Baltimore y Nueva York. Al ir de puerta en puerta, las promotoras educan a las familias sobre la enfermedad.

“Veo de primera mano cuánto necesitan ayuda nuestras comunidades”, dijo Mizis. “Y esta necesidad sigue creciendo”.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorial independiente de la California Health Care Foundation.

Categories: Aging, Mental Health, Noticias En Español, Public Health, Syndicate

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First Edition: February 17, 2017

Feb 17 2017

NOTE TO READERS: KHN’s First Edition will not be published Feb. 20. Look for it again in your inbox Feb. 21. Here’s today’s early morning highlights from the major news organizations.

Kaiser Health News: Congressman’s Ties To Foreign Biotech Draw Criticism
Rachel Bluth and Emily Kopp report: “When a small Australian biotechnology company, Innate Immunotherapeutics, needed a clinical trial for an experimental drug it hoped to turn into a huge moneymaker, the company landed a U.S. partner where it had high-level connections: Roswell Park Cancer Institute in Buffalo, N.Y. The company is partly owned by Rep. Chris Collins, a wealthy Republican entrepreneur from Buffalo, whose enthusiasm for Innate helped persuade others to invest.” (Bluth and Kopp, 2/17)

Kaiser Health News: Treatment Gaps Persist Between Low- And High-Income Workers, Even With Insurance
Michelle Andrews writes: “Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn’t result in hospitalization, a new study found. At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.” (Andrews, 2/17)

California Healthline: Some Immigrants, Fearful Of Political Climate, Shy Away From Medi-Cal
Emily Bazar reports: “Some foreign-born Californians are canceling their Medi-Cal coverage or declining to enroll in the first place, citing fears of a Trump administration crackdown on immigrants. Among those dropping coverage are people in the country legally but concerned about jeopardizing family members who lack permanent legal status, according to government officials, immigration attorneys and health care advocates.” (Bazar, 2/16)

Kaiser Health News: Right-To-Die Fight Hits National Stage
Melissa Bailey reports: “Opponents of aid-in-dying laws are claiming a small victory. They won the attention of Congress this week in their battle to stop a growing movement that allows terminally ill patients to get doctors’ prescriptions to end their lives. The Republican-led effort on Capitol Hill to overturn the District of Columbia’s aid-in-dying law could fail by Friday. But advocates worry the campaign will catalyze a broader effort to fully ban the practice, which is legal in six states and being considered in 22 more.” (Bailey, 2/16)

The Associated Press: GOP Leaders Unveil New Health Law Outline, Divisions Remain
At a closed-door meeting in the Capitol basement, House Speaker Paul Ryan, R-Wis., and other party leaders described a broad vision for voiding much of President Barack Obama’s 2010 statute and replacing it with conservative policies. It features a revamped Medicaid program for the poor, tax breaks to help people pay doctors’ bills and federally subsidized state pools to assist those with costly medical conditions in buying insurance. Lawmakers called the ideas options, and many were controversial. One being pushed by Ryan and other leaders would replace the tax increases in Obama’s law with new levies on the value of some employer-provided health plans — a political no-fly zone for Republicans averse to tax boosts. (2/16)

NPR: GOP Health Care Would Cut Coverage For Low-Income Families
The outline plan is likely to take away some of the financial help low-income families get through Obamacare subsidies, and also result in fewer people being covered under the Medicaid health care program for the poor. “In general this is going to result in fewer people covered nationwide,” says Caroline Pearson, a senior vice president at Avalere, a health care consulting group. (Kodjak, 2/16)

The Washington Post: House GOP Discusses Obamacare Replacement Ideas — But Doesn’t Call Them A Plan
According to numerous lawmakers and aides in the room, as well as a policy memo distributed afterward, the House leaders laid out elements of a repeal-and-replace plan — including long-standing Republican concepts like health savings accounts, tax credits and state high-risk pools for the chronically sick. But they did not detail how those elements would fit together or get passed into law. “It’s sort of a smorgasbord right now,” said Rep. Daniel Webster (R-Fla.). (DeBonis and Snell, 2/16)

The Wall Street Journal: House Republicans Lay Out Health-Care Plan
The proposal seeks in addition to revamp the individual insurance market where millions of Americans who don’t get employer coverage buy insurance. It would replace the health-law subsidies with tax credits Americans could use to help pay for private insurance, and it would allow for skimpier health plans not permitted under the ACA, which some say would help bring down costs. (Hackman, Peterson and Armour, 2/16)

The Wall Street Journal: GOP May Trim Tax Break For Employer-Backed Insurance
House Republicans, looking for ways to pay for their plan to repeal and replace the Affordable Care Act, are considering changing the special tax treatment for employer-provided health benefits. Capping how much of employees’ health benefits can be shielded from income and payroll taxes is one of the ways GOP lawmakers might offset the cost of their emerging health plan. (Peterson and Rubin, 2/17)

Reuters: Trump, Republicans Set Timeframe For Introducing Obamacare Replacement
Ryan told reporters on Capitol Hill that House Republicans would introduce legislation to repeal and replace Obama’s program after a 10-day recess that begins on Friday. “After the House returns following the Presidents Day break, we intend to introduce legislation to repeal and replace Obamacare,” Ryan said at a press conference. Presidents Day is on Monday and the House returns on Feb. 27. (Cowan and Morgan, 2/16)

Politico: House Republicans Still Apart On Obamacare Repeal-Replace
Newly confirmed Health and Human Services Secretary Tom Price told lawmakers at Thursday’s meeting that President Donald Trump “is all in on” repealing and replacing Obamacare at the same time. Earlier this week, the conservative House Freedom Caucus called on Republicans to repeal the law first and work on a replacement later. “Let’s not miss this opportunity,” Price said, according to a source in the room. “Let’s go shoulder to shoulder, arm to arm.” (Haberkorn, Cheney and Pradhan, 2/16)

The Washington Post: Medicaid Exposes Rifts Within The GOP Over The Program’s Future After The ACA
As congressional Republicans move from talking points to details of how to abolish the Affordable Care Act, behind-the-scenes jockeying over the future of Medicaid demonstrates the delicate trade-offs the GOP faces in trying to steer health policy in a more conservative direction. For years, many Republicans have railed against the ACA’s expansion of Medicaid, which has extended coverage to about 11 million people. But now that they have the political power to reverse those gains, internal disagreements have emerged. Some lawmakers want to preserve the federal money their states are getting under the expansion. Others argue that part of that money should be shifted to states that did not broaden their programs — or used for other purposes. (Eilperin, Goldstein and Snell, 2/16)

The New York Times: Trump Health Pick Says Medicaid Needs A Major Overhaul
President Donald Trump’s pick to run the government’s major health insurance programs said Thursday that Medicaid needs a full overhaul but she doesn’t support turning Medicare into a “voucher” plan. Indiana health care consultant Seema Verma testified before the Senate Finance Committee on her nomination to lead the Centers for Medicare and Medicaid Services, or CMS. The $1 trillion agency oversees programs that cover about 1 out of 3 Americans. (2/16)

Reuters: Trump’s Pick To Lead Health Agency Calls EpiPen Issue ‘Disturbing’
U.S. President Donald Trump’s choice to lead an important health agency said on Thursday that the way pharmaceutical companies classify products as generic or branded needs to be reviewed in order to help hold down government spending, as she cited Mylan NV’s EpiPen emergency allergy treatment. Seema Verma, Trump’s nominee to lead the Centers for Medicare and Medicaid Services (CMS), did not answer questions about whether the U.S. government should negotiate with pharmaceutical companies over drug prices. (Cornwell, 2/16)

USA Today: Seema Verma, Trump’s Pick To Head Medicare And Medicaid, Avoids Giving Policy Views
Sen. Orrin Hatch, the Utah Republican who chairs the Senate Finance Committee, which is vetting her nomination, told Verma she acquitted herself well and would be a strong and skilled leader at CMS. She is expected to be confirmed by the GOP-controlled Senate. Still, Oregon Sen. Ron Wyden, the panel’s top Democrat, said Verma needs to be more specific in the follow-up questions he will submit in writing.“It’s important to get more of a sense of how she would approach it,” Wyden told reporters after. “This is an agency that has a lot of discretion.” (Groppe, 2/16)

NPR: Is It Time To Test Presidents For Dementia?
At 70, Trump is the oldest American president to ever take office. Couple his age with a family history of dementia — his father Fred developed Alzheimer’s disease in his 80s — and one could argue that the question of baseline cognitive testing for the U.S. head of state has taken on new relevance. An assortment of fairly simple tests exist that can establish a reference point for cognitive capacity and detect early symptoms of mental decline. (Stetka, 2/16)

The Wall Street Journal: House Votes To Let States Strip Money From Planned Parenthood
House Republicans took the first step Thursday to strip federal funding from Planned Parenthood and other abortion providers, starting what will become a broader battle over funding for the women’s health-services agency. The House voted 230-188 to rescind a regulation that bans states from denying certain funds to health-care providers that perform abortions, in essence freeing states to refuse to give the funds to Planned Parenthood Federation of America Inc. and similar organizations. (Andrews and Hackman, 2/16)

The Wall Street Journal: Court Issues Temporary Order Keeping Cigna From Terminating Merger With Anthem
A Delaware judge on Wednesday issued a temporary restraining order that blocks Cigna Corp. from immediately terminating its troubled $48 billion merger with rival health insurer Anthem Inc. The development is the latest in what could be a long and bitter legal battle between the two companies in the wake of a federal judge’s ruling earlier this month that the proposed merger violates U.S. antitrust law. (Kendall, 2/16)

The Wall Street Journal: U.S. Authorities Pressed China For Action On Deadly Opioid
China’s crackdown on an extremely potent synthetic narcotic came amid pressure from U.S. authorities and evidence linking it to hundreds of U.S. overdose deaths since it first emerged in Ohio in July. The drug, carfentanil, has been connected to at least 700 fatalities in states including Ohio, Michigan and Florida, according to data compiled by The Wall Street Journal from county medical examiners and NMS Labs, a private laboratory outside Philadelphia that performs toxicology testing for counties around the U.S. (Kamp and Campo-Flores, 2/17)

The New York Times: Florida Doctors May Discuss Guns With Patients, Court Rules
A federal appeals court cleared the way on Thursday for Florida doctors to talk to their patients about gun safety, overturning a 2011 law that pitted medical providers against the state’s powerful gun lobby. In its 10-to-1 ruling, the full panel of the United States Circuit Court of Appeals for the 11th Circuit concluded that doctors could not be threatened with losing their license for asking patients if they owned guns and for discussing gun safety because to do so would violate their free speech. (Alvarez, 2/16)

NPR: Brown Recluse Spider Bites Are Often Misdiagnosed
The best way to diagnose a strange skin bump is often to decide what it’s not. So say the researchers who have devised a mnemonic device useful for determining that the lesion or lump isn’t a bite from a brown recluse spider — a diagnosis that can be very common and very false, they say. (Boddy, 2/16)

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

Trespassing in Christina’s World

By CHRISTINA BAKER KLINE

At the steering wheel my father consults his large paper map, turning it this way and that, squinting at the small blue lines that squiggle through tiny Maine coastal towns. He’s heard that the author E.B. White’s house is somewhere around here, and he’s determined to find it.

My mother, next to him in the passenger seat of our rusty gold station wagon with my baby sister on her lap, raises her eyebrows at my other two sisters and me, free-ranging in the second row. It’s the early 70s, and seatbelts haven’t caught on yet. We gaze back at her, knowing that once Dad gets an idea into his head, it’s almost impossible to stop him. We range in age from 1 to 10 (I’m the oldest), and all of us are literally and figuratively along for the ride. Besides, we’re excited at the prospect of meeting this author we already feel we know. We’ve been lulled to sleep every night by the soft cadence of my dad’s Southern accent as he reads us stories about a wise spider and a hapless pig, a resourceful mouse and a mute swan.

Dad pulls off the road into the dusty parking lot of a country store with a lone gas pump, and gets out of the car. We hear him chatting with the attendant through the open window. “Sure is nice around here.”

The guy shrugs.

My sisters and I glance at each other. Rural Mainers tend to be stranger-wary and small-talk averse. But as usual, Dad doesn’t seem to notice. “You lived here long?”

“Ayuh.” Amazingly, before long, and with only a little coaxing, the attendant is telling Dad about his grandkids and his lobster boat and pointing off into the distance, giving him the intel he’s come for. “Mr. White lives right over that hill there. Privet hedge in front. Can’t miss it.”

Back on the road, my sister Cynthia ventures, “Isn’t it rude to show up on someone’s doorstep without asking?”

Dad grins and winks at us in the rearview mirror. “He’ll be flattered.”

We pull up to the farmhouse to find a courtly white-haired man trimming the hedge with a set of clippers. “It’s him!” Dad whispers. He rolls down his window and leans out. “Hello, good sir!” The man seems a little nonplused. “I have a car full of young readers here who’d give anything to meet their favorite author. A word from you, and they’ll remember this moment for the rest of their lives.” What choice does the poor man have? Within a few minutes, the famously reclusive E.B. White is demonstrating to a cluster of little girls in bathing suits that when you crush pine needles between your fingers and hold it to your nose, the smell is as strong as patchouli. And Dad is right — we never will forget it.

My childhood was rife with moments like this. Dad was always going out on a limb, befriending people who didn’t necessarily seem to want new friends, trespassing on private property, pushing the boundaries of acceptable behavior in quest of adventure. His philosophy was that you don’t need money or plans, only a willingness to be present in the moment and to go where inspiration takes you. If you don’t, you’ll miss the entire point of being alive.

Raised dirt poor in rural Georgia by a millworker mother and a father who often went to the bar rather than home after work, Dad learned early on that his quickest route up the social ladder was through charm and smarts. He got himself to college — the first in his family — on a football scholarship, then used seminary to springboard to a doctorate in a foreign land.

As a young academic in the ‘60s, he grew to reject traditional values and had scant respect for the social codes of privilege. At parties, he could often be found talking to the bartender or a 95-year-old Irish grandmother in the kitchen rather than the hosts. A Southerner through and through, even after moving to Maine, he was constitutionally incapable of walking down a street in New York without stopping to chat with doormen, bodega owners and homeless people. He never met a taxi driver whose story he didn’t want to know.

Dad’s unorthodox and sometimes embarrassing friendliness got him, and us, into trouble now and then. Some people didn’t take kindly to probing questions. Others found his puppy-dog openness suspect or unsophisticated. But his innate, bottomless curiosity about the world also taught his four daughters to be open to new experiences and comfortable with improvisation. Even now, in his late 70s, he lives each day with a kind of purposeful recklessness, asking provocative questions and seeking new experiences in the belief that he can break through to something better, more meaningful, more satisfying.

Though my parents had little money, they took us on adventures all over the world. Driving through Scotland in a rainstorm, we pulled over to the side of the road and rode the wild ponies grazing by the fence. We coaxed a stray lamb over to our rented R.V. to feed it. One year my father switched houses, cars, teaching jobs, committees and pets with a professor in Melbourne, Australia, sight unseen. Another year our family of six flew to Crete without a plan; at the airport Dad bought a map and started asking random strangers, with the help of a woefully inadequate Greek phrase book: “What should we do?” “Where should we stay?”

This spontaneity meant that we missed flights, lost luggage, drove on perilous roads late at night, stayed in some cold-water hovels, and sometimes went hungry. But it also yielded beautiful surprises: an undiscovered beach, a fisherman’s hut with a breathtaking view, a hillside breakfast of goats’ milk yogurt and fresh honey that I still remember 35 years later. It led to his daughters’ sense of the world not as a huge frightening place but as a wonderland ripe for discovery.

The Maine farmhouse in Andrew Wyeth’s iconic painting “Christina’s World” was not yet a museum or even open to the public when my father got it into his head — soon after our ambush of E.B. White — to take a family field trip there. Following his usual routine, he pulled into the small village of Cushing and asked a local how to find the Olson house. When we arrived (no doubt trespassing), we picnicked in the field where the woman in the pink dress in the painting had lain. Looking up at that weathered gray house on the hill, and hearing the story of the woman with my name who spent her lifetime there, I was entranced. Years later, I drew on that experience to tell my own story of the painting in my new book.

There’s no doubt that my dad’s endless curiosity has shaped who I am. I often find myself — to my own kids’ embarrassment — chatting with strangers in lines, accepting spontaneous invitations, and seeking out-of-the-way adventures.

I think the most important thing I learned from my dad is that when you go out on a limb there’s a risk it will break, but you’ll get a whole new perspective on the world. And if you’re really lucky, it can feel like flying.

Veteran Teaches Therapists How To Talk About Gun Safety When Suicide’s A Risk

Jay Zimmerman got his first BB gun when he was 7, and his first shotgun when he was 10.

“Growing up in Appalachia, you look forward to getting your first firearm,” he said, “probably more so than your first car.”

His grandfather taught him to hunt squirrels and quail. Zimmerman, who lives in Elizabethton, Tenn., said pretty much everyone he knows has a gun. It’s just part of the culture.

“When I went into the military, that culture was reinforced,” he said. “Your weapon is almost another appendage. It’s part of who you are.”

Zimmerman served as a medic in the Army in the late 1990s and early 2000s, with stints in Bosnia, Africa and the Middle East. Since he came home, he’s struggled with PTSD and depression. It reached a crisis point a few years ago, when his best friend — the guy who had saved his life in a combat zone — killed himself. Zimmerman decided his time was up, too.

“I decided that I would have one more birthday with my daughter, one more Christmas with my daughter,” he said. “I had devised my own exit strategy for 16 February 2013.”

But then he bumped into a woman who used to ride the same school bus when they were kids. His exit date came and went. They’re married now.

Zimmerman still gets depressed, but now he’s a peer counselor at the Mountain Home VA Medical Center in Johnson City, Tenn. He also travels to conferences all over the country, sharing his story with therapists and with other vets, encouraging them to ask for help when they need it.

Even today, he explains at these conferences, if he’s not doing well, he disassembles his guns and stores them separately from ammunition, so he can’t make any rash decisions. And if things get really bad, Zimmerman has a special arrangement with a few friends.

“I call them and say, ‘Look, I’m feeling like it’s not safe for me to have firearms in my home. Can you store them for me for a couple days till I feel like I’m OK to have them back?’ ”

Suicide is often an impulsive act. Nearly half the people who survive an attempt say the time between their first thought of suicide and the attempt itself was less than 10 minutes. But the method can mean the difference between life and death: People who take pills have time to change their minds, or may still be alive when discovered. That’s not the case with guns.

Almost 70 percent of veterans who commit suicide do so with a gun, which prompted President Barack Obama to order the VA to talk to vets about gun safety and storage options like the ones Zimmerman uses.

But here’s the trouble: Most therapists aren’t gun people. They don’t know how to talk about guns and so they don’t.

“One obvious reason for that is that no one has taught them how,” explained Megan McCarthy, a psychologist and National Deputy Director in the Office for Suicide Prevention in the U.S. Department of Veterans Affairs.

McCarthy was invited to speak recently at a suicide prevention conference in San Francisco, aimed at therapists who work with vets.

“How many of you would say you feel really comfortable having a conversation with any of the people you work with about limiting access to all lethal means?” she asked the roomful of therapists.

Hardly anyone raised their hand.

“OK, so that’s why we’re here today,” she said.

Researchers recommend starting with a field trip to a shooting range. There, therapists can learn about different kinds of firearms, as well as gun locks, and get an introduction to gun culture.

When counseling vets, therapists have to ask more questions and be less directive, McCarthy said.

“We often conceive of ourselves as experts — as people who impart information to clients,” she said. But with vets, “it may take time to build trust. Telling them what to do the first time you’ve met them is probably not going to be a very effective approach.”

McCarthy presented a case study at the conference: A 28-year old, unmarried Army veteran who fought in Iraq told his VA psychiatrist that he had an argument with his girlfriend last week. He drove to an empty parking lot and sat with his loaded handgun in his lap, intending to kill himself.

He didn’t do it. A week later, the man told his psychiatrist things were still tense with his girlfriend. But he didn’t want to talk about suicide or storing his gun.

McCarthy asked the clinicians in the audience what they would do next, if they were this man’s psychiatrist.

“Why did he not do it? That would be my question,” one therapist said.

“I would want to see this individual again, within the same week,” said another. “I believe in strong intervention.”

Jay Zimmerman, the former army medic and peer counselor, stood up and explained his different perspective.

“Chances are the reason he’s not talking to you is because he’s afraid he’s going to lose his gun that he carries pretty much all the time,” Zimmerman said. “My buddies are the same way. We all carry — all the time.”

A lot of veterans would sometimes rather confide in a fellow vet than someone in a white coat, Zimmerman said. And that was an unusual takeaway for the professional counselors: Sometimes their role is not to intervene at all, but to be a facilitator. To make sure vets have someone to talk to outside the therapy office.

This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

Categories: Mental Health, Public Health, Public Radio Partnership, Syndicate

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