From Health and Fitness

When Being Tied Down To Kidney Dialysis Is Unappealing, An Alternative Option Few Are Told About Can Help Older Patients

More than 200,000 patients age 65 and older receive dialysis and are often told they’d die without it, yet few are informed about a conservative option that helps manage the disease. Public health news also looks at spanking; gay Catholic priests; CBD oil; a CRISPR patent; unsafe radiation exposure; presidents’ public speech patterns; new Ebola treatments and more.

Resistance And Mistrust Around Vaccinations Aren’t Anything New–They’ve Always Existed Together

Although the antivaccination movement has grown in the past few years, thanks in part to social media, there has always been a fierce outcry against compulsory shots for as long as vaccines have been used. Experts are hoping to leverage the recent outbreak in the Pacific Northwest to change minds. And some recent trends suggest that it might be the case.

Following Investigation Into IHS Doctor, Lawmaker Calls For Broad Assessment Of The Indian Health Service

An investigation this month has revealed that the Indian Health Service mishandled allegations against a doctor who was allowed to continue practicing for years following the accusations. Now Sen. Mike Rounds wants a broader assessment of the problems at the department. “Come hell or high water, we’re going to get to the bottom of what the problems are,” he said.

VA Paid Thousands For Adviser Involved In Privatization Push To Commute From California To D.C. Over Three Month Period

Darin Selnick, a senior Veterans Affairs adviser, flew to Washington, D.C. from California for two weeks out of every month, at taxpayers’ expense. Reports show that the costs for the six trips during the time period between Oct. 21, 2018, and Jan. 19, 2019 included: $3,885.60 for six round-trip flights in coach, $5,595.46 for 23 nights in hotels and $1,976 for meals. In other news, an army veteran is suing over defective earplugs.

For 2020 Dem Hopefuls, ‘Medicare-For-All’ Is A Defining Issue, However They Define It

Democrats with 2020 presidential aspirations are courting the party’s increasingly influential progressive wing and staking out ambitious policy platforms.

Front and center are three words: Medicare. For. All.

That simple phrase is loaded with political baggage, and often accompanied by vague promises and complex jargon. Different candidates use it to target different voter blocs, leading to sometimes divergent, even contradictory ideas.

“People are talking about this as a goal, as a commitment, as a value as much as a specific program,” said Celinda Lake, a Democratic pollster.

In championing “Medicare-for-all,” politicians often put forth a general idea: universal health care, or some system in which everyone can afford medical care. But their visions for achieving that vary wildly.

Sometimes Medicare-for-all is meant to promise a single-payer health care system —meaning everyone is covered by one, often government-run health plan. In other cases, politicians who say they support “for all” actually mean “for more.”

Every proposal brings its own trade-offs.

“There’s not just one easy answer to what a single-payer system would do to the United States,” said Jodi Liu, an economist at the nonprofit Rand Corp. who studies single-payer proposals. “What happens depends on how that change is being designed, and how it’s being implemented.”

Here’s a primer on the Medicare-for-all debate. Keep it in your back pocket: This argument won’t be disappearing anytime soon.

Isn’t Medicare-for-all what it sounds like? Medicare for everybody?

Not quite. But also, kind of.

Politicians talking about Medicare-for-all typically mean one of two things. It’s either a specific proposal in which every American is covered by the same, single health plan, or the general idea that anyone has the option to get health care through Medicare.

The first understanding is outlined in a bill from Sen. Bernie Sanders (I-Vt.). Co-sponsors include Senate Democrats like Elizabeth Warren of Massachusetts, Kamala Harris of California, Cory Booker of New Jersey, Kirsten Gillibrand of New York and Jeff Merkley of Oregon. All have either announced a run for president or indicated they are strongly considering one.

And they are talking about this on the campaign trail.

Sanders’ bill would outlaw private insurance where it competes with the public plan and change Medicare substantially by eliminating copays and other cost sharing, while expanding the program to cover long-term care, prescription drugs, dental care and vision. (As the bill is written, it’s hard to see what would be left for private plans to cover.)

The program would phase in over four years and cover every American. And it’s worth noting that, though many countries run a single-payer system, none offers all of those “expanded” benefits because the expense could be enormous. Also, many single-payer programs do require a degree of cost sharing, involving small copayments or deductibles.

In other cases, the “Medicare-for-all” phrase has been repurposed.

The midterms saw a wave of Democrats campaigning on it. But beyond the buzzwords, what they were actually talking about was lowering Medicare’s eligibility age or giving people the option to buy in or join the program. This would leave the private insurance industry intact. It would also preserve Medicare Advantage, in which the government pays private companies to run Medicare plans.

For many voters, it’s less about granular details and more about the principle, Lake suggested: “The highest level of support is when you talk about [Medicare-for-all] generally.”

So are Democrats saying we should get rid of private insurance?

Democrats who have signed on to Sanders’ bill have endorsed legislation that would outlaw virtually all private health insurance. That’s controversial.

Private insurance covers the largest share — 56 percent in 2017 — of Americans. And voters are often afraid of losing what they have if it’s uncertain they’ll get something better in exchange. Just ask then-President Barack Obama, whose Affordable Care Act-related promise that “if you like your plan, you can keep it” sparked sharp backlash after proving untrue.

This gets at a key question: Can Medicare-for-all advocates convince voters they’ll replace their health plans with something better?

After all, most Americans say they support Medicare-for-all. But some of the same polls indicate that most people with employer-sponsored insurance think their coverage would be unaffected by the switch. That’s false.

Critics also say eliminating private insurance could gut a major sector of the health economy. As of December 2018, private health coverage was directly responsible for almost 540,000 jobs, according to the Bureau of Labor Statistics. Economists note, though, that predicting how many jobs would go away — versus how many could be absorbed by the new system — is difficult, as is projecting any macroeconomic impact.

The magnitude of such a change underscores why some Democrats are trying to tread lightly for fear of land mines.

When probed on Medicare-for-all, Harris said she supported eliminating private insurance — while also saying she would, in the interim, back other bills that expand access to health care. Warren, in a televised interview, sidestepped specifics altogether. And Booker told reporters he would not outlaw private health care, noting that many other countries have achieved universal coverage without taking this step.

For example, Germany has universal health care but leaves private insurance intact, while heavily regulating the industry and requiring plans be not-for-profit.

So what other options are Democrats talking about?

Voters should get familiar with two other ideas: lowering Medicare’s eligibility age, and the “public option,” either through a Medicare or Medicaid buy-in.

These concepts are decidedly not Medicare-for-all — think “Medicare for more“ or “Medicaid for more.”

Lowering the eligibility age loops more people into the current system and is seen by advocates as a potential step toward single-payer, said Alex Lawson, head of the left-leaning Social Security Works, who has been involved in drafting Medicare-for-all legislation.

The public option lets people purchase coverage through Medicare or Medicaid. It has attracted criticism from Democrats aligned with the Sanders wing, who argue it’s settling for less.

Senate Democrats have introduced bills advancing such ideas — including Merkley, who pushed a Medicare-based public option to let individuals and employers buy Medicare coverage, while also attaching himself to Sanders’ measure. A proposal from Sens. Tim Kaine (D-Va.) and Michael Bennet (D-Colo.) would extend that option only to individuals. (Bennet is also purportedly weighing a 2020 bid.)

Said Liu, the health economist: “The devil is in the details.”

Shouldn’t we consider who would pay? Would this make things better?

Any health system comes with trade-offs, winners and losers. Would Medicare-for-all mean higher taxes? Probably. Opponents would definitely say it does, an argument that, polling shows, weakens support.

Would the average person pay more? That’s hard to know.

People would not pay what they currently do for health insurance, an outlay that’s only getting more expensive. They would also likely get more generous health coverage. And lawmakers are pitching various other bills — see Warren’s wealth tax, Sanders’ estate tax or the 70 percent marginal tax on the wealthy touted by Rep. Alexandria Ocasio-Cortez (D-N.Y.) — that backers argue would generate revenue to pay for something like Medicare-for-all.

Perhaps more significant, at least politically, are the implications for health care stakeholders like hospitals, insurers and drugmakers. All stand to lose under single-payer, especially if it’s used to bring down health care costs. They’re already working to make their opposition felt. (That said, opposition from the health industry is not universal.)

When Democrats say they want Medicare-for-all, then do they really mean single-payer?

There has been a lot of brouhaha on this.

Take the backlash when Harris, after backing single-payer, said she also supported “Medicare-“ and “Medicaid for more”-type policies. Her spokesman compared that to “wanting a burrito” while being willing to accept tacos in the meantime.

Of course, Harris isn’t the only one to straddle those plans. Merkley, Gillibrand, Booker and Warren have put their names to multiple health reform bills. So, in fact, has Sanders, who voted to support, among other bills, the Affordable Care Act — decidedly not single-payer.

So are Democrats wavering? Is saying “Medicare-for-all,” or even single-payer, a hook to win votes, or a bargaining strategy to end up with a public option instead?

It just isn’t that simple.

“None of us can see into the hearts of anybody. And it’s not a low-bar thing to sponsor a bill,” said Lawson of Social Security Works. In a presidential campaign, though, “people will want to hedge.”

But, he added, Medicare-for-all’s popularity — even as a concept — shows something significant.

“There is a consensus that the current system needs to fundamentally transform,” he said. “There’s a commitment to do that. Then we have to argue out the details.”

The High Cost Of Sex: Insurers Often Don’t Pay For Drugs To Treat Problems

For some older people, the joy of sex may be tempered by financial concerns: Can they afford the medications they need to improve their experience between the sheets?

Medicare and many private insurers don’t cover drugs that are prescribed to treat problems people have engaging in sex. Recent developments, including the approval of generic versions of popular drugs Viagra and Cialis, help consumers afford the treatments. Still, for many people, paying for pricey medications may be their only option.

At 68, like many postmenopausal women, Kris Wieland, of Plano, Texas, experiences vaginal dryness that can make intercourse painful. Her symptoms are amplified by Sjogren’s syndrome, an immune system disorder that typically causes dry eyes and mouth, and can affect other tissues.

Kris Wieland, left, of Plano, Texas, pictured with daughter Anne, was denied coverage by her Medicare Part D plan for a drug that replenishes vaginal estrogen, prescribed by her doctor.(Courtesy of Kris Wieland)

Before Wieland became eligible for Medicare, her gynecologist prescribed Vagifem, a suppository that replenishes vaginal estrogen, a hormone that declines during menopause. That enabled her to have sex without pain. Her husband’s employer plan covered the medication, and her copayment was about $100 every other month.

However, after she enrolled in Medicare, her Part D plan denied coverage for the drug.

“I find it very discriminatory that they will not pay for any medication that will enable you to have sexual activity,” Wieland said. She plans to appeal.

Under the law, drugs used to treat erectile or sexual dysfunction are excluded from Part D coverage unless they are used as part of a treatment approved by the Food and Drug Administration for a different condition. Private insurers often take a similar approach, reasoning that drugs to treat sexual dysfunction are lifestyle-related rather than medically necessary, according to Brian Marcotte, CEO of the National Business Group on Health, which represents large employers.

So, for example, Medicare may pay if someone is prescribed sildenafil, the generic name for Viagra and another branded drug called Revatio, to treat pulmonary arterial hypertension, a type of high blood pressure in the lungs. But it typically won’t cover the same drug if prescribed for erectile dysfunction.

Women like Kris Wieland may encounter a similar problem. A variety of creams, suppositories and hormonal rings increase vaginal estrogen after menopause so that women can have intercourse without pain. But drugs that are prescribed to address that problem haven’t generally been covered by Medicare.

Sexual-medicine experts say such exclusions are unreasonable.

“Sexual dysfunction is not just a lifestyle issue,” said Sheryl Kingsberg, a clinical psychologist who is the chief of behavioral medicine at University Hospitals MacDonald Women’s Hospital in Cleveland. She is the immediate past president of the North American Menopause Society, an organization for professionals who treat women with these problems. “For women, this is about postmenopausal symptoms.”

Relief may be in sight for some women. Last spring, the federal Centers for Medicare & Medicaid Services sent guidance to Part D plans that they could cover drugs to treat moderate to severe “dyspareunia,” or painful intercourse, caused by menopause. Plans aren’t required to offer this coverage, but they may do so, according to CMS officials.

The North American Menopause Society applauded the change.

“Dyspareunia is a medical symptom associated with the loss of estrogen,” said Kingsberg. “They had associated it with sexual dysfunction, but it’s a menopause-related issue.”

For men who suffer from erectile dysfunction, treatment can confer both physical and emotional benefits, according to experts in sexual health.

“In my clinical work, I see a lot of older couples,” said Sandra Lindholm, a clinical psychologist and sex therapist who is also a nurse practitioner in Walnut Creek, Calif. “They are very interested in sex, and they feel like they’re able to embrace their erotic lives. But there may be medical issues that need to be addressed.”

Roughly 40 percent of men over age 40 have difficulty getting or maintaining an erection, studies show, and the problem increases with age. A similar percentage of postmenopausal women experience genitourinary syndrome of menopause, a term used to describe a host of symptoms related to declining levels of estrogen, including vaginal dryness, itching, soreness and pain during intercourse, as well as increased risk of urinary tract infections.

Low sexual desire is another common complaint among women and men. A drug called Addyi was approved in 2015 to treat low sexual desire disorder in premenopausal women. But many insurers don’t cover it.

Unfortunately, medications that treat these conditions may cost people hundreds of dollars a month if their insurance doesn’t pick up any of the tab. A 10-tablet prescription for Viagra in a typical 50-milligram dose may cost more than $600, for example, while the price of eight Vagifem tablets may exceed $200, according to GoodRx, a website that publishes current drug prices and discounts.

In recent years, much more affordable generic versions of some of these medications have gone on the market.

Generic versions of Viagra and Cialis, another popular erectile dysfunction drug, may be available for just a few dollars a pill.

“I never write a prescription for Viagra anymore,” said Dr. Elizabeth Kavaler, a urogynecologist at Lenox Hill Hospital in New York City. “These generics are inexpensive solutions for men.”

There are generic versions of some women’s products as well, including yuvafem vaginal inserts and estradiol vaginal cream.

But even those generic options are often relatively pricey. Some patients can’t afford $100 for a tube of generic estradiol vaginal cream, said Dr. Mary Jane Minkin, a clinical professor of obstetrics, gynecology and reproductive medicine at Yale University School of Medicine.

“I’ve asked, ‘Did you try any of the creams?’ And they say they used up the sample I gave them. But they didn’t buy the prescription because it was too expensive.”

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Did you guys get as big a kick out of the #healthpolicyvalentines hashtag as I did? (I feel I’m talking to the right crowd here.) They’re quite delightful, including this timely one from KHN’s own Rachel Bluth: “Not even a PBM could get in the middle of our love.”

On to the news from the week.

Thursday was a somber day for many as the country marked the anniversary of the Parkland, Fla., mass shooting at Marjory Stoneman Douglas High School that left 17 dead.

On the eve of the anniversary, the House Judiciary Committee approved two bills that would expand federal background checks for gun purchases. Although the legislation faces certain demise in the Senate, it is the first congressional action in favor of tightening gun laws in years. In the votes you see echoes of a recent trend: Lawmakers are no longer treating gun control as “the third rail in politics.” The difference is stark if you look at just over 10 years ago when then-candidate Barack Obama was sending out mailers assuring voters he supported the Second Amendment.

Politico: House Democrats Make First Major Move to Tighten Gun Laws

The Associated Press: Parkland Anniversary Highlights Democratic Shift on Guns

There were too many heartbreaking anniversary stories to highlight just one, but a project worth checking out is one from The Trace, a nonprofit news organization that reports on gun violence. In the year since Parkland, nearly 1,200 more children have lost their lives to guns. The Trace brought together more than 200 teen reporters from across the country to remember those killed not as statistics, but as human beings with rich histories.

14 Children Died in The Parkland Shooting. Nearly 1,200 Have Died From Guns Since.

A handy reference: The good people at The Tampa Bay Times and the AP put together a useful list of all the gun laws that have been enacted in the country since the shooting.

Tampa Bay Times and Associated Press: Here Is Every New Gun Law in the U.S. Since the Parkland Shooting

There are some lawmakers on the Hill who are almost giddy to hold hearings on “Medicare-for-all” — and they’re not Democrats. Republicans have been struggling to find a winning stance on health care, ever since Dems’ midterm victories, which were attributed in part to their stance on the issue.

For the previously floundering GOP lawmakers, MFA is practically a gift-wrapped present that fell right into their laps. They’re confident they can frame the idea as reckless, radical and expensive, and pick off moderate voters who want to keep their insurance the way it is. Democratic leadership blasted the GOP’s calls for hearings as “disingenuous,” but MFA supporters were raring to duke it out — verbally, of course. “They think it’s going to be a ‘gotcha’ moment,” said Rep. Pramila Jayapal (D-Wash.) in Politico’s coverage. “But they have been wrong on this and continue to be wrong on it.”

Politico: Republicans Can’t Wait to Debate ‘Medicare For All’

Meanwhile, Democrats introduced legislation this week that would allow people over 50 to buy in to Medicare. The measure is much more politically palatable than MFA, and its sponsors are selling it is a realistic and incremental step in the direction toward universal coverage.

Politico: Push for Medicare Buy-In Picks Up With ’50 and Over’ Bill

Here’s something you don’t hear every day: Republicans and Democrats maybe (just maybe!) have found some common ground on the health law. As part of a package of bills to shore up the Affordable Care Act, Democrats are proposing slapping some consumer warnings on short-term plans. The hint of bipartisanship in the air, though, was limited to the advisories — Republicans were not fans of the rest of the changes proposed.

Modern Healthcare: Short-Term Health Insurance Plans May Get Consumer Warnings

Advocates deem Utah’s move to limit voter-approved Medicaid expansion as a “dark day for Democracy.” The governor and lawmakers who rushed through the restrictions to the expansion, however, say the work requirements and caps are necessary to make it sustainable for the state.

The Associated Press: Utah Reduces Voter-Backed Medicaid Expansion in Rare Move

As 2020 comes into focus, the abortion debate is definitely on the front burner for President Donald Trump, who has seized on recent controversies over so-called late-term abortions. This week, Trump and White House officials met with advocates, including Susan B. Anthony List President Marjorie Dannenfelser. While the discussions weren’t open to journalists, Dannenfelser confirmed that Trump was keenly interested in the issue. “The national conversation about late-term abortion … has the power to start to peel away Democrats, especially in battle grounds,” Dannenfelser said in The Hill’s coverage.

The Hill: Trump Offers Preview of Abortion Message Ahead of 2020

There was some movement in the agencies this week that should be on your radar:

— The Food and Drug Administration has announced it’s cracking down on the $40 billion supplement industry, especially targeting diseases that really should require medical care. Right now, that landscape is pretty much the Wild Wild West, where anything goes. And consumers don’t realize that.

The New York Times: F.D.A. Warns Supplement Makers to Stop Touting Cures for Diseases Like Alzheimer’s

— The Environmental Protection Agency has released its plan to address long-lasting toxins in drinking water. Activists were not impressed, saying the “action plan” was quite short on action.

Reuters: U.S. Unveils Plan to Control Some Toxins in Drinking Water, Sets No Limits

— The Centers for Medicare & Medicaid Services released two major proposed regulations that are meant to help ease patients’ access to their health care records. Right now, many health care providers and hospitals offer patient portals, but they often lack material such as doctor notes, imaging scans and genetic-testing data. Sometimes they’ll even charge for the data. The rules would address restrictions such as those.

The Wall Street Journal: New Rules Could Ease Patients’ Access to Their Own Health Records

In a sign of the growing awareness about the United States’ maternal mortality problem, the task force that sets the standards insurers are required to follow is expanding its guidance when it comes to depression during and after pregnancy. The U.S. Preventive Services Task Force already recommends that doctors screen pregnant women and new mothers, but the old guidelines focused on patients who were experiencing symptoms. The new advice is more proactive about addressing women who may be at risk.

The Wall Street Journal: New Mothers at Risk of Depression to Get Counseling Services, Covered By Insurance, Under New Guidelines

It’s a well-established fact that doctors have an unconscious bias when it comes to race and pain — one that leaves many minority patients undertreated and undermedicated. What’s interesting is to see how that disparity has shaped the opioid epidemic in the country — the ones that wreaked havoc on white communities.

Los Angeles Times: Why Opioids Hit White Areas Harder: Doctors There Prescribe More Readily, Study Finds

While all eyes are on the massive consolidated opioid lawsuit in Ohio that’s being compared to the Big Tobacco reckoning of the ’90s, this little case in Oklahoma might steal its thunder.

Stateline: Pay Attention to This Little-Noticed Opioid Lawsuit in Oklahoma

In the miscellaneous file for the week:

• A powerful investigation from The Wall Street Journal and Frontline uncovers the history behind an Indian Health Service doctor who was accused of molesting Native Americans yet allowed to continue practicing for decades. Where did it go wrong?

The Wall Street Journal: HHS to Review Indian Health Service After Revelations on Pedophile Doctor

• Rural hospitals are collapsing everywhere, leaving vulnerable residents stranded in health deserts. It can be devastating for towns to watch their hospitals die. Ducktown, Tenn., offers a snapshot of what’s playing out in states all across the country.

Nashville Tennessean: Tennessee Rural Hospitals Are Dying. Welcome to Life in Ducktown

• Employer-sponsored health care is often held up as the gold standard. But is it really that great?

CNN: Employer Health Plans Cover Less Than You Think, Study Finds

• I vividly remember the global fear surrounding the bird flu back in the aughts. People were panicking and countries were stockpiling medical supplies, as everyone braced for an epidemic reminiscent of the catastrophic 1918 Spanish flu. But then nothing happened. So … where’d it go?

Stat: What Happened to Bird Flu? How a Threat to Human Health Faded From View

Early numbers show that the flu vaccine is doing a pretty good job this year, so remember it’s not too late to get your shot! And have a great weekend!

Ambivalence Over Motherhood Could Reshape Practices Around Family Planning

New data from a CDC survey finds that in up to 19 percent of pregnancies, women are unsure if they want to be pregnant, a state of mind doctors need to be in tune with when counseling them, researchers say. Public health news looks at AIDS death rates in the South; depression’s harmful role in aging brains; looking for treatments in moss piglets and a reason to get off the couch this weekend, as well.

Childhood Disease Like Measles Help ‘Keep You Healthy And Fight Cancer,’ Says Wife Of White House Official

The antivaccination claims–that childhood illnesses help boost immunity–touted by Darla Shine, the wife of White House communications director Bill Shine, have been debunked by health experts. Meanwhile, Facebook says it is looking for options to remove the antivaccine information that flourishes on its site.