From Health Care

WebMD To Be Sold To California Online Media Company

Internet Brands, a company controlled by global investment firm Kohlberg Kravis Roberts, will take over the popular medical information website.

Los Angeles Times: KKR’s Internet Brands Plans To Buy WebMD In A $2.8-Billion Deal
WebMD has found a remedy for its volatile business: A $2.8-billion sale to El Segundo online media company Internet Brands. The Internet’s leading destination for information about rashes, coughs and other ailments has gone through mergers and sales multiple times since its founding in the late 1990s. But investors made a fresh case for a deal earlier this year, contending that being at the cross-section of healthcare and the Internet should be more valuable than what traders were paying for WebMD shares on the stock market. (Dave, 7/24)

The Washington Post: WebMD Health To Be Sold To A KKR Company For $2.8 Billion
Stockholders of the New York-based health information provider would get $66.50 per each share in cash, a 20 percent premium of the Friday closing price of $55.19, before the deal was announced, and a 30 percent premium over the share price on Feb. 15, the day before the company said it would consider a buyout. The stock closed Monday at $66.10 a share. (Radu, 7/24)

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

Molina Healthcare To Lay Off About 1,400 Employees, Memo Says

The insurer says the upcoming cuts to 10 percent of its workforce is driven by losses to its Obamacare exchange business.

Reuters: Molina Healthcare To Cut About 1,400 Jobs: Memo
Molina Healthcare, a health insurer that specializes in the Obamacare and Medicaid healthcare programs for low-income and poor people, plans to cut about 1,400 jobs in the next few months, according to an internal company memo reviewed by Reuters. (Humer, 7/24)

Modern Healthcare: Molina To Lay Off 10% Of Its Workforce
Medicaid health plan Molina Healthcare intends to lay off 1,400 employees, or 10% of its workforce, over the coming months to try to offset losses from its Obamacare exchange business, the company said in an internal memo to employees Monday. The cuts will be across-the-board, including senior leadership, interim CEO and Chief Financial Officer Joe White said in the memo. (Barkholz, 7/24)

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

In Unexpected Turn, Democrats Block Once-Bipartisan Bill Funding VA Choice Program

Under the rules set for the bill, supporters needed support from two-thirds of members to pass the bill. Lawmakers voting against it cited opposition from a large group of veterans organizations that called on Congress to reject the bill because it pays for the choice program through cuts in the VA.

The New York Times: Future Unclear For Veterans Choice Program After House Bill Falters
Congressional lawmakers struggled on Monday to reach an agreement to prop up a popular multibillion-dollar health care program that allows veterans to see a private doctor at government expense. This was supposed to be a relatively easy task, meant to buy lawmakers time as they debated the future of the program. As recently as last week, Republican leaders were considering using a bill temporarily funding the Veterans Choice Program as a vehicle to raise the debt ceiling, a perennially bitter pill for Republicans. (Fandos, 7/25)

Politico: House Democrats Stun GOP By Sinking Veterans, Intel Bills
Kicking off a busy week in the House, most Democrats and a handful of Republicans joined forces to deny GOP leaders big-enough majorities to pass an annual intelligence policy bill and legislation to restore funding for a key veterans health care program. (O’Brien, 7/24)

CQ Roll Call: Veterans’ Health Care Funding Patch Blocked By House
The legislation would add roughly six months of funding to what’s known as the Veterans Choice Program, which provides a route to private care for certain veterans having difficulty getting medical care at traditional Department of Veterans Affairs facilities. (Mejdrich, 7/24)

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

Democrats Probe Whether HHS Videos Panning Health Law Veered Too Close To Advocacy

Administration officials are defending the posts saying they are pointing out problems with the current health law to the public.

The Wall Street Journal: Democrats Accuse HHS Of Using Improper Tactics In Health-Law Battle
Health and Human Services Secretary Tom Price and his department have been publicly panning the Affordable Care Act. Democrats call the campaign an improper use of federal resources to undermine the health law. The disagreement amounts to a low-profile skirmish on health care unfolding in the shadows of the attention-grabbing battle playing out on Capitol Hill. If Republicans in Congress fail to enact a sweeping health-care overhaul, Dr. Price’s battle with Democrats will take on far greater importance as the primary arena for the partisan back-and-forth on health care. (Armour and Hackman, 7/24)

The CT Mirror: Murphy Demands Answers From Price On Anti-Obamacare Videos
Sen. Chris Murphy and two of his Democratic colleagues in the Senate, are questioning whether Health and Human Services Secretary Tom Price misused taxpayer money through advertising and public relations efforts aimed at undermining the Affordable Care Act. In a letter that was also signed by Sens. Brian Schatz, D-Hawaii, and Cory Booker, D-N.J., Murphy asked Price to detail how much money HHS is spending to produce and distribute dozens of anti-Obamacare videos available on the department’s official social media accounts. (Radelat, 7/24)

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

Scope Maker Olympus Hit With $6.6 Million Verdict In Superbug Outbreak Case

A jury ordered the giant medical scope maker Olympus Corp. to pay a Seattle hospital $6.6 million in damages tied to a deadly superbug outbreak — and told the hospital to pay $1 million to a deceased patient’s family.

But jurors on Monday also handed the Tokyo-based manufacturer a key win, rejecting claims that its flagship duodenoscope was unsafe as designed.

The decision follows an eight-week trial, the first in the U.S. related to gastrointestinal scopes causing outbreaks of drug-resistant infections.

The case was filed by Theresa Bigler, 61, and her four children in connection with the August 2013 death of Richard Bigler, a pancreatic cancer patient who contracted an infection linked to a contaminated Olympus scope. The hospital, Virginia Mason Medical Center, later joined in the suit against Olympus, but the jury found it shared some blame in the case.

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An Olympus official offered condolences to the Bigler family in a statement and praised the jury’s decision.

“We are appreciative that the jury recognized that Olympus’ duodenoscope design was not unsafe and did not contribute to Mr. Bigler’s unfortunate passing in 2013,” said Sam Tarry, an attorney for the company.

But the jury also said Olympus failed to provide adequate warnings about the scope or instructions for its use after it was manufactured. The jury said that failure harmed Virginia Mason Medical Center.

Theresa Bigler’s attorneys cast the decision as a win for patient safety.

Theresa Bigler sued Olympus for the death of her 57-year-old husband, Richard, a pancreatic cancer patient who contracted an infection linked to a contaminated Olympus scope. (Courtesy of the Bigler family)

“Olympus hasn’t been playing by the rules for some time and this verdict holds them accountable,” lawyer David Beninger said in a statement.

He said the case should send a broad signal to Olympus and other device manufacturers.

They “must make patient safety a priority and not just a sales pitch,” Beninger’s statement said. “As Olympus’ own expert admitted at trial, lawsuits can change behavior and big lawsuits can make big changes. Hopefully this verdict will convince Olympus and others to listen.”

Medical and legal experts said they were surprised at how well Olympus fared in this case, which was closely watched by other plaintiffs’ lawyers who are waging similar suits against the company.

“In the jury’s opinion, the hospital shared some of the blame,” said Lawrence Muscarella, a hospital-safety consultant in Montgomeryville, Pa.

Muscarella said each case is different and plaintiffs’ attorneys can learn from the evidence presented at this trial. “It remains to be seen what this portends for other cases on the docket,” he said.

More than 25 patients and families, from Pennsylvania to California, have sued Olympus alleging wrongful death, negligence or fraud. Federal prosecutors also are investigating Olympus and two smaller manufacturers over their potential roles in patient infections.

Richard Bigler was one of at least 35 patients in American hospitals to have died since 2013 after developing infections tied to Olympus duodenoscopes — snake-like tubes threaded down a patient’s throat. Doctors use the scope to diagnose and treat problems in the digestive tract, such as gallstones, cancers and blockages in the bile duct. About 700,000 such ERCP procedures are performed annually in the U.S.

Last year, Olympus recalled all 4,400 of its TJF-Q180V duodenoscopes — the model used in Bigler’s case — and made repairs to reduce the risk of bacteria becoming trapped inside after cleaning.

Bigler’s attorneys said Olympus had acted recklessly by not warning U.S. hospitals about previous outbreaks and failing to fix a design flaw that hindered cleaning and allowed dangerous bacteria to become trapped inside these reusable scopes.

Olympus had said its gastrointestinal scopes were safe and effective with proper cleaning and disinfection. At trial, the company said Virginia Mason was to blame for Bigler’s infection because the hospital didn’t follow the company’s cleaning instructions.

Olympus criticized Virginia Mason for not telling Bigler and other families about the scope-related infections, forcing them to find out from a newspaper account about the outbreak.

In his closing argument, Olympus attorney Mark Anderson told the jury that the Seattle outbreak would have occurred regardless of whether Olympus’ or another company’s scopes had been used.

“The proof in this case, from their witnesses, is there is no increased risk with the [Olympus scope],” Anderson told the jury.

Hospital officials said the faulty Olympus scopes were the cause of Bigler’s infection and others, and they implemented an expensive test-and-hold protocol for cleaning the devices that halted the spread.

“We’re sorry for the grief and anguish experienced by the Bigler family,” the hospital said in a brief statement. “This was a complicated trial that lasted more than eight weeks. The verdict includes multiple decisions and we will continue reviewing them over the next few days.”

Theresa Bigler was not available for comment, lawyers said.

Olympus is the industry leader for these devices and other specialty endoscopes, with an 85 percent share of the U.S. market.

One of the largest superbug outbreaks in the nation occurred at Virginia Mason, where 39 people’s infections were linked to Olympus scopes. Eighteen patients died. The Seattle hospital said the patients who died, including Richard Bigler, had other underlying illnesses.

The 12-member jury, which had begun deliberating July 18, said the damages to Virginia Mason amounted to $25.4 million. But jurors agreed the hospital had been negligent, so they sharply reduced the damages owed to Virginia Mason.

The plaintiffs’ attorneys repeatedly reminded jurors that three key Olympus executives declined to testify at trial and instead invoked their Fifth Amendment right against self-incrimination.

The three executives who declined to testify were Susumu Nishina, Hisao Yabe and Hiroki Moriyama. They hold top roles in regulatory affairs, quality assurance or medical manufacturing. All three have declined to comment, citing the pending litigation.

Several of Nishina’s internal company emails were introduced as evidence. In one email exchange in February 2013, Nishina told the company’s U.S. managers not to issue a broad warning to American hospitals despite reports of scope-related infections in Dutch, French and U.S. hospitals, court records show.

In addition to Olympus, device makers Pentax and Fujifilm sell these sorts of duodenoscopes, which can cost up to $40,000 apiece. Overall, as many as 350 patients at 41 medical centers worldwide were infected or exposed to contaminated scopes made by those three manufacturers from 2010 to 2015, according to the U.S. Food and Drug Administration.

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First Edition: July 25, 2017

Jul 25 2017

Today’s early morning highlights from the major news organizations.

Kaiser Health News: Price Transparency In Medicine Faces Stiff Opposition — From Hospitals And Doctors
Two years after it passed unanimously in Ohio’s state Legislature, a law meant to inform patients what health care procedures will cost is in a state of suspended animation. One of the most stringent in a group of similar state laws being proposed across the country, Ohio’s Healthcare Price Transparency Law stipulated that providers had to give patients a “good faith” estimate of what non-emergency services would cost individuals after insurance before they commenced treatment. (Bluth, 7/25)

Kaiser Health News: Over-The-Counter Devices Hold Their Own Against Costly Hearing Aids
Hearing aids that can cost more than $2,000 apiece are only slightly more effective than some over-the-counter sound-amplification devices that sell for just a few hundred dollars, according to a recent study. The study bolsters legislation pending in Congress, which would have the Food and Drug Administration set regulations for cheaper over-the-counter products and is designed to make the devices more widely accessible and safer. (Andrews, 7/25)

Kaiser Health News: Jump-Starting Hard Conversations As The End Nears
Frederick Bannon Jr. was by his mother’s side in intensive care as she fought a rare form of muscle cancer in late 2014. She was heavily sedated, but he felt confident making medical decisions for her, thanks to his family’s advance care planning. Bannon had difficult end-of-life-care conversations with his parents, both in their mid-80s, before his mother’s diagnosis. During those  discussions, held at Bannon’s urging, his parents decided how far they wanted doctors to go to keep them alive should they become too sick to communicate. Bannon then documented their wishes. (Browning, 7/25)

The Washington Post: McCain’s Return To Senate Injects Momentum Into GOP Health-Care Battle
McCain, who was recently diagnosed with an aggressive form of brain cancer, could provide a critical vote to open debate on the GOP bill. The senator had been recuperating from surgery and exploring treatment options in Arizona. McCain’s announcement came as some Senate GOP leaders expressed confidence in a newly emerging strategy of trying to pass smaller-scale changes to the Affordable Care Act, with an eye toward continuing negotiations into the fall. (Sullivan, Snell, O’Keefe and Wagner, 7/24)

Politico: McCain To Make Dramatic Return For Obamacare Vote
McConnell spent the day cajoling his members and meeting with Vice President Mike Pence to plot strategy. The majority leader was still short of the votes to even open debate, and Republicans still don’t know what they’d be voting to allow debate on if they agree to go along with McConnell on the procedural vote. (Everett, Kim and Haberkorn, 7/24)

The Wall Street Journal: Trump Urges GOP Senators To Overturn Affordable Care Act
Lawmakers typically vote with party leaders at least to begin debate on legislation, and failure to pass the motion would be a rebuke for Senate Majority Leader Mitch McConnell (R., Ky.), who has argued that allowing debate to begin would give senators unhappy with the bill a chance to amend it. (Armour, Peterson and Radnofsky, 7/24)

The New York Times: Senate Braces For Health Showdown With McCain On Hand But A Plan Unclear
Before Mr. McCain, an Arizona Republican, announced that he was jetting in to cast what is expected to be a vote in favor of starting debate, President Trump spent Monday ratcheting up pressure on Republican senators to get onboard. Mr. Trump criticized their inaction and warned that they risked betraying seven years’ worth of promises to raze and revamp the health law if they did not.“Remember ‘repeal and replace,’ ‘repeal and replace’ — they kept saying it over and over again,” Mr. Trump said at the White House, flanked by people who he said suffered as “victims” of the “horrible disaster known as Obamacare.” (Kaplan and Davis, 7/24)

The Washington Post: ‘Obamacare Is Death’: Trump Urges Republicans To Move Ahead With Health-Care Overhaul
President Trump on Monday made a late-hour appeal to senators — targeting members of his own party — to move forward with debate over faltering Republican legislation to overhaul the Affordable Care Act. “Any senator who votes against starting debate is telling America that you are fine with the Obamacare nightmare, which is what it is,” Trump said in an afternoon address from the White House on the eve of an anticipated Senate vote that could spell defeat of the long-sought legislation. (Wagner and Johsnon, 7/24)

The Associated Press: Trump Says Upcoming Health Vote Is GOP’s Chance To Keep Vow
At the White House, Trump lambasted Democrats who helped enact the 2010 health care law and uniformly oppose the GOP attempt to scrap and rewrite it. “They run out and say, ‘Death, death, death,’” Trump said, with a backdrop of families that he said have encountered problems getting affordable, reliable medical coverage because of Obama’s statute. “Well, Obamacare is death. That’s the one that’s death.” (Fram, 7/24)

The Associated Press: Burr-Hamilton? Angry Lawmaker Singles Out ‘Female Senators’
Passions are running high on Capitol Hill — but pistols at 10 paces over health care? GOP Rep. Blake Farenthold of Texas is angry with some fellow Republicans in the Senate who are balking at parts of legislation to overturn “Obamacare.” After GOP promises to repeal the law, that “is just repugnant to me,” he says. Who’s to blame? (7/24)

Politico: Farenthold Blames ‘Some Female Senators’ For Obamacare Repeal Failure
Rep. Blake Farenthold on Monday blamed “some female senators from the Northeast” for hampering Republican efforts to repeal and replace Obamacare, telling a local radio station that he might challenge them to a duel if the allegedly obstructive lawmakers were men. The Texas Republican’s remark appeared to be a reference to Sens. Susan Collins (R-Maine) and Shelley Moore Capito (R-W.Va.), both of whom have expressed some degree of hesitancy toward Senate Republicans’ specific plans to repeal and replace former President Barack Obama’s signature health care legislation. (Nelson, 7/24)

The Wall Street Journal: A Look At The Health-Care Provisions Senators May Vote On
Senate Republican leaders are pushing for a “motion to proceed” to debating their health-care legislation. But as of Monday, it remained unclear what that legislation would be. And if there is a debate, it’s likely to include a flurry of amendments that could reshape the bill. Here are some of the elements senators could vote on, either as part of the underlying bill or as amendments. (Armour, 7/24)

NPR: Trump Calls For A Senate Vote With Multiple Bills In Play
The Senate is expected to vote Tuesday on whether to advance health care legislation to the Senate floor. That would open up debate on an Obamacare repeal and/or replacement plan. … But it’s still not clear what the Senate will be voting on. There are multiple bills in play. (Grayson, 7/24)

The Wall Street Journal: Democrats Accuse HHS Of Using Improper Tactics In Health-Law Battle
Health and Human Services Secretary Tom Price and his department have been publicly panning the Affordable Care Act. Democrats call the campaign an improper use of federal resources to undermine the health law. The disagreement amounts to a low-profile skirmish on health care unfolding in the shadows of the attention-grabbing battle playing out on Capitol Hill. If Republicans in Congress fail to enact a sweeping health-care overhaul, Dr. Price’s battle with Democrats will take on far greater importance as the primary arena for the partisan back-and-forth on health care. (Armour and Hackman, 7/24)

The New York Times: Future Unclear For Veterans Choice Program After House Bill Falters
Congressional lawmakers struggled on Monday to reach an agreement to prop up a popular multibillion-dollar health care program that allows veterans to see a private doctor at government expense. This was supposed to be a relatively easy task, meant to buy lawmakers time as they debated the future of the program. As recently as last week, Republican leaders were considering using a bill temporarily funding the Veterans Choice Program as a vehicle to raise the debt ceiling, a perennially bitter pill for Republicans. (Fandos, 7/25)

Politico: House Democrats Stun GOP By Sinking Veterans, Intel Bills
Kicking off a busy week in the House, most Democrats and a handful of Republicans joined forces to deny GOP leaders big-enough majorities to pass an annual intelligence policy bill and legislation to restore funding for a key veterans health care program. (O’Brien, 7/24)

Politico: Democrats’ ‘Better Deal’ Would Penalize Drug Price Hikes
Democrats are going straight at one of the top concerns of voters, using the rising cost of drugs to strike a more populist tone and counter President Donald Trump, who campaigned hard against the power of the drug industry, but took a friendlier stance after taking office. Congressional Democrats today laid out a three-pronged approach to lower the cost of prescription drugs in the United States that aims to stop large price increases and give the federal government more power to influence what Medicare pays for medicines. (Karlin-Smith, 7/24)

Los Angeles Times: KKR’s Internet Brands Plans To Buy WebMD In A $2.8-Billion Deal
WebMD has found a remedy for its volatile business: A $2.8-billion sale to El Segundo online media company Internet Brands. The Internet’s leading destination for information about rashes, coughs and other ailments has gone through mergers and sales multiple times since its founding in the late 1990s. But investors made a fresh case for a deal earlier this year, contending that being at the cross-section of healthcare and the Internet should be more valuable than what traders were paying for WebMD shares on the stock market. (Dave, 7/24)

The New York Times: Economy Needs Workers, But Drug Tests Take A Toll
Just a few miles from where President Trump will address his blue-collar base here Tuesday night, exactly the kind of middle-class factory jobs he has vowed to bring back from overseas are going begging. It’s not that local workers lack the skills for these positions, many of which do not even require a high school diploma but pay $15 to $25 an hour and offer full benefits. Rather, the problem is that too many applicants — nearly half, in some cases — fail a drug test. (Schwartz, 7/24)

Los Angeles Times: Doctors And Drug Abuse: Why Addictions Can Be So Difficult
Allegations that Dr. Carmen A. Puliafito used methamphetamine and ecstasy while he was dean of USC’s medical school have opened a window into the pervasiveness of drug use and addiction among physicians and the challenges they face when confronting it. Experts say physicians become substance abusers at about the same rate as the general population. But they are often reluctant to seek treatment out of fear of losing their medical licenses and livelihoods. (Karlamangla, 7/24)

NPR: Centers That Counsel Women Against Abortion Help Them Enroll In Medicaid
When Taylor Merendo moved to Bloomington, Ind., nearly two years ago, fleeing an abusive marriage, she needed help. “I was six months pregnant and at that point in time, I really didn’t have a stable place to live,” Merendo says. That’s where the Hannah Center in Bloomington stepped in. It’s what’s known as a crisis pregnancy center, where women are counseled against abortion and often get support after their babies are born. (McCammon, 7/24)

The Washington Post: Monthly Shot Could Be The ‘Next Revolution’ In HIV Therapy, Replacing Daily Pills
HIV/AIDS is no longer the death sentence it once was, but maintaining the strict regimen required to keep the virus at bay — one or more pills daily — still poses a major challenge to many people who are infected. Adherence is low among some populations, given the effort that is required to obtain, keep and store the medications. That may soon change. On Monday, scientists reported an important advance in the development of a long-acting antiretroviral shot. According to an international study involving 309 patients, an injection that combines two drugs, cabotegravir and rilpivirine, appears to be as safe and effective at suppressing HIV as the daily oral regimen. (Cha, 7/24)

The Washington Post: New Zika Testing Recommendation Issued For Pregnant Women
Federal health officials are changing their testing recommendations for pregnant women who may be exposed to the Zika virus through travel or sex or because of where they live. In updated guidance released Monday, the Centers for Disease Control and Prevention is no longer recommending routine testing for pregnant women without any Zika symptoms but who may have been put at risk because they have traveled to a region where Zika is circulating. (Sun, 7/24)

The Washington Post: A New Way To Fulfill The Single Biggest Need Of Poor Patients: Teeth
Larry Bays has seen his share of hard times, but on this day he was blessed. The 71-year-old goat farmer from Gate City, Va., had come to the annual free medical clinic held over the weekend here in coal country so his wife, Joyce, could have her asthma and arthritis checked. When her doctor realized she had no teeth, he sent the couple over to a trailer operated by the Mission of Mercy dental team. (Schneider, 7/24)

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

Jump-Starting Hard Conversations As The End Nears

Frederick Bannon Jr. was by his mother’s side in intensive care as she fought a rare form of muscle cancer in late 2014. She was heavily sedated, but he felt confident making medical decisions for her, thanks to his family’s advance care planning.

Bannon had difficult end-of-life-care conversations with his parents, both in their mid-80s, before his mother’s diagnosis. During those  discussions, held at Bannon’s urging, his parents decided how far they wanted doctors to go to keep them alive should they become too sick to communicate. Bannon then documented their wishes.

Frederick Bannon’s parents, Frederick Sr. and Elvira (Courtesy of the Bannon family)

“That helped so much, because you knew at least one thing was going to be taken care of,” said Bannon, 65, of San Francisco, whose mother survived and lives with Bannon’s father in Wethersfield, Conn.

Most Americans avoid end-of-life decisions, although some people may be more likely to make them if a doctor or social worker starts the discussion. In California, the state’s attorney general’s office offers an end-of-life planning checklist on its website. In the past few years, other websites have encouraged those conversations, with their own suggestions on how to get started.

Rebecca Sudore, a geriatrician at the University of California-San Francisco, created prepareforyourcare.org, which provides step-by-step instructions and video stories to help people navigate the care they want at the end of their lives. She built the site in 2013 for families unsure how to broach sensitive questions. In a study published in JAMA Internal Medicine in May, she and other researchers found that the website — combined with the use of an “advance directive” form — prompted participants to plan ahead.

The website is free, and Sudore makes no money from it. She said she created it as a public service with the idea of studying its effectiveness.

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The site guides patients in drafting a “summary of wishes” to help families and other caregivers decide whether their loved ones should undergo life-sustaining medical interventions such as feeding tubes and ventilators.

For the study, Sudore approached 414 San Francisco-area military veterans — including Bannon — who were split into two groups: One received a simplified advance directive, a legal document allowing a patient to consent to or decline specific medical procedures well before they occur. The other group was given the directive but also was pointed to prepareforyourcare.org, which is publicly available in English and Spanish.

Almost none of the participants had documented their wishes in the six months before the study. But nine months after the study began, 35 percent of those who received access to the website and the directive had updated their medical record, while 25 percent who received just the directive had done so.

Sudore sees stark contrasts between “deer-in-headlights” families who arrive at the intensive care unit with outdated directives and no specified plans, and those who have had ongoing conversations.

Bannon, a Vietnam War veteran, X-ray technician and colon cancer survivor, praised the site’s simplicity and accessibility and said it persuaded him and his parents to document their wishes before his mother’s cancer treatment.

Frederick Bannon Jr. (Courtesy of the Bannon family)

The website appears to be a useful tool, according to Dr. VJ Periyakoil, associate professor of medicine and director of Stanford University’s Palliative Care Education and Training Program. (Periyakoil is friends with the UCSF researchers but was not involved in the study.)

“Clinicians are so hard-pressed for time, so when the patients get activated by web-based tools, I think it’s a wonderful thing,” she said.

Seventy percent of Americans lack an advance care plan, according to the U.S. Centers for Disease Control and Prevention, and lack of preparation can have undesirable effects, Periyakoil said.

Family members who have not gone through this process sometimes choose life-sustaining options for their loved ones that may cause unnecessary suffering, Periyakoil said.

Children “might be more lured by, ‘I really love Mom. I can’t allow anything bad to happen to her and I want to keep doing whatever I can to extend her life,’” she said. “And by doing so, they might end up subjecting Mom or Dad to a lot of measures that are ineffective and burdensome.”

Periyakoil, who has studied barriers to end-of-life care among eight ethnic groups, does not believe there’s a single solution to encouraging end-of-life conversations, because different groups have different approaches to discussing death. She suggested the website might be one of many strategies to consider.

Prepareforyourcare.org has logged more than 1.7 million page views and 85,000 users in 115 countries since its 2013 launch.

For Bannon, the site worked. “Now [my parents are] even more relaxed, because when they do face their final exit, everything’s in place,” he said.

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

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation, coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation, and coverage of aging and long-term care issues is supported by The SCAN Foundation.

Categories: Aging, California Healthline

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Over-The-Counter Devices Hold Their Own Against Costly Hearing Aids

Hearing aids that can cost more than $2,000 apiece are only slightly more effective than some over-the-counter sound-amplification devices that sell for just a few hundred dollars, according to a recent study.

The study bolsters legislation pending in Congress, which would have the Food and Drug Administration set regulations for cheaper over-the-counter products and is designed to make the devices more widely accessible and safer. Consumers with mild to moderate hearing loss would be able to purchase the devices without a prescription and without a medical exam, knowing they meet federal safety standards.

For the study, researchers compared how well 42 older adults with mild to moderate hearing loss repeated sentences spoken in the presence of background noise. The researchers first tested their ability to understand the speaker without any devices. Then they tested the subjects successively with a hearing aid and with five “personal sound amplification products” sold over the counter.

Michelle AndrewsInsuring Your Health

The hearing aid used in the study was a brand commonly dispensed in audiology clinics. The personal sound amplification products (PSAPs) that were selected either had the best electroacoustic properties or were commonly available in retail pharmacies. PSAPs perform like hearing aids but can’t be marketed as hearing aids because they don’t meet standards set by the FDA.

The results, published this month in JAMA, found very little difference between the hearing aid, which costs about $1,900 per ear, and some of the PSAPs, which mostly cost between $300 and $350 each.

On average, study participants were able to accurately repeat about three-quarters of the words spoken to them without using any device. Using the hearing aid boosted their understanding to an average 88.4 percent. And four out of the five PSAPs were nearly as effective as the hearing aid, with average word understanding ranging from 81.4 percent to 87.4 percent. The fifth PSAP performed poorly: People could hear better with their naked ears.

Age-related hearing loss is a common problem, but only about a quarter of the roughly 30 million people who have it use hearing aids, said Nicholas Reed, an audiology instructor at Johns Hopkins School of Medicine who was the study’s lead author.

“That’s a lot of people who aren’t getting in through the door,” he said.

Cost is a deciding factor for many consumers. Medicare doesn’t cover hearing aids, nor do most private health insurance plans.

Identical versions of the bipartisan Over-the-Counter Hearing Act of 2017 were introduced in the House and Senate this year. The text of those bills has been added as an amendment to the FDA Reauthorization Act of 2017, a bill that is key to FDA operations because it sets the government’s system for collecting fees during the drug approval process.

Not surprisingly, hearing aid manufacturers and distributors are against the bill. So are gun owners, who claim that regulating hearing amplifiers, which some hunters use to detect game, is in effect a way to regulate hunting and undermine their Second Amendment rights.

Reed said that by requiring the FDA to issue regulations on over-the-counter hearing aids, the proposed amendment would improve the products sold. Many of them, he said, are not effective and some are dangerous because there’s no control over amplification levels.

“When it gets to a certain amplification, it will just blow your hearing out,” he said. “Over-the-counter hearing measures would regulate these devices and force them to meet standards.”

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

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

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Price Transparency In Medicine Faces Stiff Opposition — From Hospitals And Doctors

COLUMBUS, Ohio — Two years after it passed unanimously in Ohio’s state Legislature, a law meant to inform patients what health care procedures will cost is in a state of suspended animation.

One of the most stringent in a group of similar state laws being proposed across the country, Ohio’s Healthcare Price Transparency Law stipulated that providers had to give patients a “good faith” estimate of what non-emergency services would cost individuals after insurance before they commenced treatment.

But the law didn’t go into force on Jan. 1 as scheduled. And its troubled odyssey illustrates the political and business forces opposing a common-sense but controversial solution to rein in high health care costs for patients: Let patients see prices.

Many patient advocates say such transparency would be helpful for patients, allowing them to shop around for some services to hold down out-of-pocket costs, as well as adjust their household budgets for upcoming health-related outlays at a time of high-deductible plans.

At the Ohio Statehouse, the law’s greatest champion in state government has been Rep. Jim Butler, a Republican and former Navy fighter pilot whose wife is a physician. He authored the legislation and has beat the drum for it since he got the idea in 2013, as he waited for a garage mechanic to repair his car and absorbed the shop’s posted rates for brake jobs, oil changes and tuneups.

Opposition has been formidable, led by the goliath Ohio Hospital Association. It has filed a court injunction that is currently delaying enactment, peppered local news media with editorials, and lobbied Republican Gov. John Kasich, who has eliminated funding that would allow implementation from the latest state budget.

Joining the hospital association in its legal action are a wide range of provider groups including the Ohio State Medical Association, the Ohio Psychological Association, the Ohio Physical Therapy Association, and the Ohio chapters of the American Academy of Pediatrics, the American College of Surgeons, and the American Osteopathic Association.

These groups say that the law, which applies only to elective procedures, is too broad and that forcing providers to create estimates before procedures would slow down patient care. “The only way to even try to comply with the law is to delay care to patients in order to track down information from insurance companies, who may or may not provide the requested information,” wrote Mike Abrams, the president and CEO of the Ohio Hospital Association, in an op-ed in The Columbus Dispatch in January.

But Jerry Friedman, a retired health policy adviser for the Ohio State University Wexner Medical Center, said the opposition doesn’t stem from genuine concern about patients but from a desire to keep the secret rates that providers have negotiated with insurers under wraps. Transparency would mean explaining to consumers why the hospital charged them $1,000 for a test, he said, adding that providers “don’t want to expose this house of cards they’ve built between hospital physician industry and the insurance industry.”

Ohio State Rep. Jim Butler (Chris Stewart/Courtesy of the Dayton Daily News)

Said Butler on his quest to see the law enacted: “The health care industry has a lot of political power and lots of money. It’s hard to fight on behalf of people against this kind of force.”

The law’s next test will come in August, when the first court hearing on the association’s lawsuit is scheduled. The Kasich administration said it couldn’t comment on the law because of the pending litigation.

Greater price transparency has been a popular policy prescription for America’s high health costs, especially at a time when many patients have high-deductible insurance plans and face larger copayments. Upfront estimates exist in other countries, such as Australia and, for patients facing out-of-pocket expenses, in France.

In Massachusetts, patients can get an estimate within two days of admission if they ask for it. Nebraska requires hospitals and surgical centers to provide a list of the average charges for services. New Hampshire has a website where consumers can compare costs.

Hospitals and doctors often oppose such measures. The American Hospital Association’s position is that health plans — not hospitals — are responsible for telling insured patients about their out-of-pocket costs, according to its website.

Aimee Winteregg, 35, of Troy, Ohio, said she would have liked such information before five miscarriages in four years left her buried in unexpected medical bills. She and her husband became first-time parents in November. Though they are well insured, tests and treatment cost the couple $4,000 out-of-pocket, demanded in bills that were sometimes no more descriptive than for “medical service.”

“We don’t want to deal with this, especially when the doctor tells you stress is bad for the pregnancy,” her husband, J.D., said. But imposing greater transparency has been controversial in both the medical industry and among some health care researchers, who say it puts patients in an untenable position.

The transparency law “was written by someone thinking about health care as a TV, and not as health care,” said Sandra Tanenbaum, a professor of health services management and policy at The Ohio State University College of Public Health.

She said people could not shop for procedures as they would for a TV or car repairs, since they often lack information on the quality of doctors and hospitals, and make health care decisions based on much more than cost.

Consumers are more likely to base their decisions on their doctors’ advice, not on cost alone, according to a report from the Health Policy Institute of Ohio.

Only around 10 percent of health care costs are even “shoppable” expenses — procedures that can be scheduled in advance, like an MRI or elective surgery — according to the HPIO.

Regardless, Butler maintains, the health care industry can give consumers better information upfront. “If you really want patients to be empowered, they really need the information,” he said.

In support of such access, Butler has written letters to the Ohio Hospital Association, the Ohio attorney general and the Dayton Daily News, all in defense of the transparency law.

The Ohio Hospital Association, along with seven other Ohio health organizations, went to court last December to block the law, a month before it was supposed to take effect.

Butler said Gov. Kasich’s administration is helping the hospital association stall by not writing regulations, eliminating funding for the law in the state budget, and declining to meet with Butler to discuss it.

State Rep. Michael Henne, also a Republican, has worked with Butler in the Ohio General Assembly on the transparency law. He called Butler a “driver” on the law, noting: “It’s frustrating. You don’t realize how much [influence] special interests have in the process.”

Categories: Cost and Quality, Health Care Costs, Health Industry, Insurance

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Viewpoints: Is Silicon Valley Losing The Lead In Medical Technology?; Doctors And Hand Writing

Here’s a review of editorials and opinions on a range of public health issues.

The Wall Street Journal: Silicon Valley Trails In Medical Tech
People who develop medical technology have long assumed that Silicon Valley would pioneer smartphone-based devices to make Americans fitter and healthier than ever. To some degree, that forecast is coming true: Tech giants are working with doctors and hospitals on highly sophisticated devices — automated radiology, supercomputer-based oncology, fitness-tracker-based analytics — to monitor the sick, provide better automated care, and keep people out of hospitals in the first place. But it turns out the biggest gains from mobile medicine will come from deploying it in poor countries across Africa and Asia. (Michael S. Malone, 7/23)

KevinMD: Doctor, We Can’t Read Your Writing
So to future pharmacists who will read my prescriptions, and other health care professionals who will read my notes: I pledge from here on in to write as neatly as possible within the time constraints allowed, for the safety of my patients, the posterity of cursive writing, and for the sake of my grandfather (who likes reading my blog on his iPad). (Sarah Fraser, 7/23)

USA Today: Veterans Affairs Secretary: VA Health Care Will Not Be Privatized On Our Watch
As a physician, my professional assessment is that the Department of Veterans Affairs has made significant progress over the past six months — but it still requires intensive care. In order to restore the VA’s health, we must strengthen its ability to provide timely and high quality medical care while improving experiences and outcomes for veterans. (David Shulkin, 7/24)

Lexington Herald Leader: A Woman’s Death, Kentucky’s Opioid Crisis
Jenny Fulton’s brief life and brutal death hold important lessons, especially for Kentuckians in positions of public trust. The 27-year-old woman died in 2014 in the Mason County jail where she was sent because she had relapsed into heroin use, violating her parole. Despite widespread recognition that incarceration is not the solution, Kentucky still spends millions of dollars jailing people who have drug use disorders when that money could be better spent on evidence-based treatment. (7/23)

St. Louis Post-Dispatch: Trump Takes A ‘Just Say No’ Approach To Sex Education
In today’s version of “Just Say No,” first lady Nancy Reagan’s approach to drug use in the 1980s, President Donald Trump’s administration is cutting more than $213 million in funding to help prevent teen pregnancy. The move eliminates evidence-based pregnancy prevention and research programs, and family planning services, but leaves money for abstinence-only education. In addition, Trump appointed a prominent abstinence-only advocate as assistant secretary of Health and Human Services. (7/22)

San Jose Mercury News: Reject Climate Change Skeptic For Top Science Post
President Trump’s disdain for science apparently knows no bounds. He has now nominated climate change skeptic Sam Clovis, a talk radio host, to serve as the Department of Agriculture’s chief scientist — a slap in the face of the scientific community and a disservice to those responsible for the integrity of the USDA’s research. (7/23)

Sacramento Bee: California Workers’ Comp System Remains Nation’s Most Expensive
Obviously, working in California is not inherently more dangerous than in other states, and cash benefits to disabled California workers are not out of line, so the enormous cost differential must be rooted in the system itself, which explains why its rules are the subject of constant political infighting. One factor in those costs is what officials say is an enormous amount of fraud, concentrated in Southern California. (Dan Walters,  7/23)

Los Angeles Times: Don’t Believe The American Heart Assn. — Butter, Steak And Coconut Oil Aren’t Likely To Kill You
Last month, the American Heart Assn. once again went after butter, steak and especially coconut oil with this familiar warning: The saturated fats in these foods cause heart disease. The organization’s “presidential advisory” was a fresh look at the science and came in response to a growing number of researchers, including myself, who have pored over this same data in recent years and beg to differ. A rigorous review of the evidence shows that when it comes to heart attacks or mortality, saturated fats are not guilty. (Nina Teicholz, 7/23)

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Parsing The Policies: What’s To Become Of Medicaid And Medicare?

Opinion writers offer their thoughts on how the current Affordable Care Act replacement debate impacts Medicaid and how governors should proceed in pursuing Medicaid waivers as well as current Medicare funding issues.

Daily Beast: Medicaid Delivers As Obamacare Survives
Medicaid got a reprieve from the budget axe with the GOP’s failure so far to repeal, let alone replace, Obamacare. Suddenly, the program for the poor that began in 1965 seems less like a scapegoat for politicians looking to score rhetorical points and to shore up state budgets, and like it may join Medicare and Social Security on the third rail in American politics—touch it and you die. (Eleanor Clift, 7/24)

RealClear Health: Republicans Are Tackling Medicaid Wrongly
The high decibel fight in the Senate over Medicaid is one more example–did we need more?–of why lasting changes in social programs require thoughtful legislative deliberation leading to bipartisan consensus. There should be hearings to gather input from all sides and serious debate in committees as well as on the floor. If one party rams through big changes in any program as important as Medicaid, the other party will demonize the result. In the case of Medicaid cuts, arousing public outrage won’t be hard. Individuals and families, state governments, rural hospitals and other health providers will all be vocal about their plight. One wonders why either party would seek such opprobrium when they could be working together on sensible Medicaid reform. (Alice M. Rivlin, 7/24)

Morning Consult: Governors: Avoid Harmful Insurance Practices In Medicaid Waivers
While our nation’s governors recently gathered in Rhode Island for the summer meeting of the National Governors Association, most of the country’s political attention remained focused on the debate in Washington, D.C. over the fate of the Affordable Care Act. Less noticed, but also critically important, is that fact that each governor holds in their hands today the ability to radically reshape Medicaid for their state’s most vulnerable citizens regardless of the outcome of that debate. (Donna Christensen, Scott Mulhauser and Jason Resendez, 7/24)

CBS News: Medicare Funding: Problems And Solutions
Medicare’s funding problems often get overlooked when the Social Security trustees issue their annual report on the funded status of the Social Security and Medicare programs. Yet together they form the twin pillars of financial security for retirees. That’s why it’s important to understand Medicare’s financial situation, so you can be an informed health care planner — and voter. (Steve Vernon, 7/24)

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The Big Picture: The Health Issues We Should Be Discussing; How To Move The Debate Forward

Even as the heated discourse over the future of the Affordable Care Act continues, some people offer their thoughts on the serious issues that are being overlooked and on how bad manners have soured the process.

Boston Globe: The Health Care Debate We Should Be Having
Most of the life expectancy gains of the last century can be chalked up to what we call public health, a catch-all term for those interventions aimed not at a single patient, but at a whole community or the entire population. …Which helps explain the great riddle of American health care: How come we spend more than everyone else, yet generally have worse outcomes? We overspend on medical care and underinvest in public health. (Horowitz, 7/22)

St. Louis Post-Dispatch: Collapse To Compromise: A Better Way To Health Care Reform
Republicans and Democrats disagree about the role of government; the trade-off between individual freedom and societal good; and about money and taxes. These long-standing disagreements play out repeatedly on the national stage, and today, health care is front and center. On our present course, these disagreements will turn our health care system upside down every time we vote to change party control of the White House and the Congress. (Steven H. Lipstein, 7/23)

The Washington Post: The GOP Cannot Fix Itself — Let Alone American Health Care
The inability of a Republican Congress and a Republican president to repeal Obamacare, or even just dial it back, is yet the latest demonstration that Republicans simply aren’t ready to govern. The facile explanation for this is the unresolved division, within the party, between its radical tea party populist wing and its more moderate, business-friendly establishment wing. But the bigger issue is that the party’s elected politicians are unwilling to make the trade-offs that are the essence of what governing is about. (Steven Pearlstein, 7/23)

The Washington Post: How Health Care Controls Us
If we learned anything from the bitter debate over the Affordable Care Act (Obamacare) — which seems doubtful — it is that we cannot discuss health care in a way that is at once compassionate and rational. This is a significant failure, because providing and financing health care have become, over the past half-century, the principal activity of the federal government. (Robert J. Samuelson, 7/23)

Huffington Post: Former CBO Directors Express ‘Strong Objection’ To GOP Attacks On Agency
Every economist who has previously served as director of the Congressional Budget Office has signed a letter registering “strong objection to recent attacks” on the agency. The letter, sent Friday morning and addressed to congressional leaders, does not specify who has been making those attacks. But only one political party is attacking the CBO right now ― and only one party has so brazenly questioned the agency’s methods to draw this kind of response from such a distinguished, bipartisan group of economists. It’s the Republicans, because they don’t like what the CBO has been saying about GOP proposals to repeal the Affordable Care Act. (Jonathan Cohn, 7/21)

Roll Call: How Bad Political Manners Fomented The Health Care Mess
[I]t’s not surprising that a secretive, churlish and entirely-outside-the-normal-channels approach has, from the start, distinguished [Senate Majority Leader Mitch McConnell’s] balky and now repudiated tackling of the defining legislative battle of Trump’s first year. Straightforward legislative etiquette would have required at least a few hearings and legislative markups on health care where Democrats could have gone on record in opposition and Republican skeptics, on the hard right and in the center, could have vented concerns and offered mollifying language — long before spreading anxieties at both ends of the GOP ideological spectrum crippled the bill. (David Hawkings, 7/24)

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Perspectives: Despite Senate Difficulties, ACA Is Still At Risk; The Paths Forward For The GOP’s BCRA

Editorial pages analyze the current state of play in Republicans’ push to replace Obamacare.

The New York Times: Health Care Is Still in Danger
Will Senate Republicans try to destroy health care under cover of a constitutional crisis? That’s a serious question, based in part on what happened in the House earlier this year. As you may remember, back in March attempts to repeal and replace the Affordable Care Act seemed dead after the Congressional Budget Office released a devastating assessment, concluding that the House Republican bill would lead to 23 million more uninsured Americans. Faced with intense media scrutiny and an outpouring of public opposition, House leaders pulled their bill, and the debate seemed over. (Paul Krugman, 7/24)

RealClear Health: A Narrow Path Forward For The BCRA
Following a week of high-level negotiations among GOP senators, Republican leadership is planning a Tuesday vote on the motion to proceed to the House-passed American Health Care Act (AHCA) — the vehicle for their health care reform efforts. The process has been shrouded in confusion and uncertainty, as it still remains unclear what legislation Senate leaders ultimately hope to move forward. And while knowing what’s in the Senate bill may be, as Senate Whip John Cornyn said, a “luxury we don’t have,” it’s worth acknowledging that there’s still a narrow path towards passage. (Shea McCarthy, 7/24)

Boston Globe: Republicans Must Challenge Trump On Health Care
But though he [Donald Trump] has browbeaten Republican senators for failing to follow through on repealing the Affordable Care Act, abandoning his own campaign commitments doesn’t seem to bother him at all. Months into the GOP’s repeal-and-replace effort, not one piece of legislation Trump has backed, in either the House or the Senate, would keep all of those promises. (7/23)

The Wall Street Journal: Force Congress’s Hand On Health Care
If President Trump is serious about repealing ObamaCare—about delivering a better policy with more choice and lower costs—there’s a simple move he could make that wouldn’t require congressional approval. It would align the interests of lawmakers and their staffers with the interests of voters. (Heather R. Higgins, 7/23)

The Wall Street Journal: Congress Won’t End ObamaCare, So Here’s How To Mend It
Having so far failed to repeal and replace the Affordable Care Act, the best way forward for Republicans would be to work with Democrats to improve the marketplaces set up by the 2010 law. While legislation could help, all that really is needed for the marketplaces to succeed is for the Trump administration to do no harm. This means continuing to implement the law without actively undermining it. (Jason Furman, 7/23)

Los Angeles Times: Under Senate’s Obamacare Repeal, Some Americans Would Have To Pay More Than Their Total Income For Health Coverage
One of the ostensibly brilliant ideas in Senate Republicans’ plan to repeal the Affordable Care Act is to move low-income families from Medicaid to the private insurance marketplace, allowing them to use the premium subsidies provided by the ACA. But there’s a catch, according to a new analysis of the proposal. For many low-income families, the marketplace premiums and deductibles combined would amount to more than their total income, even after subsidies. Moreover, despite shifting more of these costs to enrollees, the change would cost the federal government more than Medicaid.  (Michael Hiltzik, 7/21)

The Kansas City Star: Sens. Moran And Roberts: Don’t Endanger My Daughter’s Health
My beautiful daughter Hannah turns 26 this Saturday. Her birthdays are particularly special because she was diagnosed with stage 4 cancer at age 13. After successful treatment, her cancer returned when she was 14 and she had a less than 10 percent chance of survival. She wasn’t expected to be alive for her 15th birthday. Burkitt’s Lymphoma is a very aggressive cancer that doubles in size every two hours. We were fortunate to receive amazing care at Children’s Mercy Hosptital. Hannah endured dozens of surgeries, 69 days of intense chemotherapy and spent over 300 days in the hospital. She received hundreds of units of blood and platelets, had 38 spinal taps, 18 bone marrow biopsies, a stem cell transplant and countless other treatments and procedures. (Deedra Miller, 7/22)

Lincoln Journal-Star: Nebraska Needs Health Care Reform
Obamacare is failing in Nebraska. Proponents of the law argued that it would increase choice and lower costs, but the exact opposite has taken place. For instance, earlier this year, Blue Cross Blue Shield announced it would be leaving the state’s Obamacare exchange market. The last remaining Obamacare insurer — Medica Health — also announced it might pull out of the market by the end of the year, which would leave thousands of Nebraskans without health coverage. (Jarrett Stepman, 7/24)

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State Highlights: N.J. Raises Smoking Age To 21; Fall Out From Scandal Involving USC’s Former Med School Dean Continues

Media outlets report on news from California, Iowa, New Jersey, Tennessee, Florida, Ohio, Wisconsin, Minnesota and Georgia.

Los Angeles Times: USC Received More Than A Year Of Questions About Former Medical School Dean’s Conduct Before Scandal Broke
Four days after The Times published a story about drug use by the then-dean of USC’s medical school, the university announced it was moving to fire Dr. Carmen A. Puliafito and said it was “outraged and disgusted” by his conduct. USC Provost Michael Quick said the university decided to act because it had been shown “extremely troubling” information that same day about Puliafito’s behavior. Quick provided no details. But he said it was “the first time we saw such information firsthand.” (Pringle, Elmahrek, Hamilton and Parvini, 7/23)

Reveal: Lawmakers Call On Acosta To Address Latino Workplace Deaths
From meatpacking to agricultural fields, Latino immigrants often work the most menial jobs in America and their on-the-job death rate is 18 percent higher than the average worker, recent statistics show. The troubling trend has prompted a group of Democratic senators to call on the Labor Department to protect these workers. (Gollan, 7/23)

Nashville Tennessean: As Medical Bills Rise, D.C. Battle Hinges On Federal Dollars — Not Health
Frustration about health care reform rhetoric is palpable as Tennessee leaders grapple with high rates of chronic disease taking a toll on both the state’s people and economy. But competing health care proposals at the center of the war raging in Washington don’t directly address the stated goals of improving the quality of care and making it more affordable.  (Fletcher, 7/23)

Kaiser Health News: In Appalachia, Two Hospital Giants Seek State-Sanctioned Monopoly
Looking out a fourth-floor window of his hospital system’s headquarters, Alan Levine can see the Appalachian Mountains that have defined this hardscrabble region for generations. What gets the CEO’s attention, though, is neither the steep hills in the distance nor one of his Mountain States Health Alliance hospitals across the parking lot. Rather, it’s a nearby shopping center where his main rival ­— Wellmont Health System, which owns seven area hospitals — runs an urgent care and outpatient cancer center. Mountain States offers the same services just up the road. (Galewitz, 7/24)

California Healthline: California Valley Fever Cases Highest On Record
The number of Valley Fever cases in California rose to a record level in 2016, with 5,372 reported — a jump of 71 percent from the previous year. Historically, about three-quarters of cases have been in the state’s heavily agricultural San Joaquin Valley. The fungal infection, known as coccidioidomycosis, or “cocci,” is most common in the southern portion of the Valley and along the Central Coast of California. (Bartolone, 7/24)

San Francisco Chronicle: Under-Radar Bill Focuses On Polluters In Poverty Areas
AB617 by Assemblywoman Cristina Garcia, D-Bell Gardens (Los Angeles County), was touted as the less-grandiose partner to cap and trade, whose expansive reach allows California polluters to offset their emissions by reducing them in another state. Garcia’s measure is aimed closer to home, attempting to “address air pollution in the most burdened communities,” she said. (Cart, 7/23)

Cleveland Plain Dealer: Law Would Require Nearly All Older Cleveland Homes To Be ‘Lead Safe’
Cleveland homes, childcare centers and schools built before 1978 would have to be certified as safe from lead hazards by 2021 under legislation City Councilman Jeff Johnson will introduce next month. Johnson, along with Cleveland Lead Safe Network (CLSN), created the proposed ordinance as part of a sweeping Lead Safe Cleveland Initiative that would first tackle lead paint hazards in homes and then go after reducing the risk from the toxin in soil and water. (Dissell and Zeltner, 7/23)

San Jose Mercury News: Former Oakland Army Base: Feds Probe Civil Rights Complaint
For years, advocates at the West Oakland Environmental Indicators Project (WOEIP) have lamented the soot on their blinds and the hacking coughs that result from breathing in toxic diesel fumes spewing out of trucks as they enter and exit the Port of Oakland. Now, two federal agencies — the Department of Transportation and Environmental Protection Agency — are launching a formal investigation into whether the city and the Port of Oakland are doing enough to mitigate air pollution in the neighborhood, which has historically been burdened by elevated levels of black carbon, nitric oxide and other toxic particles. (Baldassari, 7/22)

Atlanta Journal-Constitution: Drug Screening Lab Under Federal Investigation Heads For Auction
A drug testing lab in Gwinnett County that had been in the center of a campaign donation bundling scandal is up for auction amid a federal investigation. …In 2014, employees and executives with the company came under federal scrutiny when they combined to give more than $80,000 to U.S. Rep. Jack Kingston, who was seeking the Republican nomination to the U.S. Senate. (Joyner, 7/21)

San Francisco Chronicle: State Bill Aimed At “Big Weed” Marketing Hits Small Businesses Too
State Sen. Ben Allen, D-Santa Monica, is the sponsor of SB162, which would prohibit licensed cannabis businesses from selling or giving away promotional hats, T-shirts or any branded merchandise that bears the name or logo of a cannabis company or product. Allen and his allies say the bill, which in May passed the Senate in a 40-0 vote, is meant to protect children from potentially harmful marketing practices. But for some whose businesses would be affected, the bill is seen as quashing free speech. (Mitchell, 7/23)

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A Cure For HIV? One Child May Give The World Hope

Scientists presented the case study of a boy who has remained HIV-free since his early treatment as an infant. But Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, struck notes of both optimism and caution when speaking about him. In other public health news: gene therapy, vaccinations, arrest in old age, concussions, inflammation and a flesh-eating bacteria.

The Washington Post: New Hope For HIV Cure As Child Remains Virus-Free Years After Final Treatment
A South African boy, believed to have been infected with HIV around the time of his birth, has remained free of the virus for 8½ years after early treatment — renewing hope among scientists that such outliers may hold clues to help end the decades-old epidemic. The case study, described by researchers before a presentation Monday at an international AIDS conference in Paris, suggests a paradigm shift in the treatment of those infected. It establishes that HIV may be controllable in some way other than a daily and lifelong regimen of antiretroviral drugs. (Cha, 7/24)

The New York Times: Companies Rush To Develop ‘Utterly Transformative’ Gene Therapies
The approval of gene therapy for leukemia, expected in the next few months, will open the door to a radically new class of cancer treatments. Companies and universities are racing to develop these new therapies, which re-engineer and turbocharge millions of a patient’s own immune cells, turning them into cancer killers that researchers call a “living drug.” One of the big goals now is to get them to work for many other cancers, including those of the breast, prostate, ovary, lung and pancreas. (Grady, 7/23)

NPR: Alternatives To Vaccination Shots Are In Development
News this summer of a flu vaccine patch sparked a lot of chatter. Could getting vaccinated be as easy as putting on a bandage? Could there be fewer, or at least smaller, needles in our future? Some companies and academic labs are working to make those things happen. (Columbus, 7/23)

The New York Times: Another Possible Indignity Of Age: Arrest
It was the sort of incident that happens at facilities that care for people with dementia. At a residence for older adults in San Francisco last summer, Carol King momentarily left a common sitting area. When Ms. King returned, she found that another resident had taken her chair, a nurse who witnessed the episode later reported. She grabbed the usurper’s wrist. (Span, 7/21)

NPR: Concussions May Hit Female Brains Harder, Research Suggests
Thanks to research on boxers and football players, both athletes and the public are becoming more aware of the dangers of sports-related head injuries. Yet there is little data on participants like Mazany. That’s because, unlike the vast majority of athletes studied, she is a woman. “We classically have always known the male response to brain injury,” says Mark Burns, at Georgetown University. But there have been remarkably few studies of females. The bias runs throughout the scientific literature, even in studies of mice. (Hamilton, 7/24)

NPR: Inflammation Can Be Bad For Your Health, Or Good
Chronic, low-level inflammation seems to play a role in a host of diseases, including type 2 diabetes, heart disease, Alzheimer’s, cancer and even depression. And even though the science on inflammation and disease is far from settled, tests and treatments are being promoted that claim to reduce that risk. (Hobson, 7/21)

The Washington Post: He Thought He Just Had Blisters From A Hike. He Had Flesh-Eating Bacteria And Nearly Died.
Wayne Atkins thought little of the blisters he had gotten while hiking. He was trekking up and down the 4,500-foot-high Mount Garfield in New Hampshire — 10-miles round-trip — and blisters were no surprise. He was in the Granite State for a family member’s early June wedding, which went off without a hitch, even with the blisters. But things soured when he returned to Miami, according to Manchester, N.H., ABC affiliate WMUR-TV. (Wootson, 7/23)

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States Urged To Sue Drug Companies Over Painkiller Epidemic By Lawyers Who Drove Tobacco Litigation

The Wall Street Journal reports on a one-time attorney general who is aiding in lawsuits filed by Mississippi and Ohio against pharmaceutical makers. In another story on the business front of the drug crisis, McKesson’s board will be greeted by picketing teamsters organized by the father of an overdose victim.

The Wall Street Journal: Lawyers Hope To Do To Opioid Makers What They Did To Big Tobacco
The legal front widening against makers of opioid painkillers has something in common with landmark tobacco litigation of the 1990s: attorney Mike Moore. As Mississippi’s attorney general in 1994, Mr. Moore filed the first state lawsuit against tobacco companies, saying they harmed public-health systems by misrepresenting smoking’s dangers. He helped marshal the subsequent spate of state litigation and then the talks that led to a $246 billion settlement. (Whalen, 7/23)

Bloomberg: Overdose Victim’s Dad Rallies Teamsters In Fight With McKesson 
When McKesson’s board and executives gather near Dallas for their annual shareholders meeting on July 26, they’ll be greeted by a throng of picketing Teamsters. Representatives of the union, which owns more than $30 million of McKesson shares, will call on investors to reject the company’s executive-pay plan and for the board to claw back some of Chief Executive Officer John Hammergren’s compensation. (Melin, 7/21)

State efforts to combat the epidemic are reported from Massachusetts, New Jersey, Virginia, Colorado and Connecticut —

The Associated Press: Tool To Help Police In Opioid Crisis Draws Privacy Concern
New Jersey is the latest state amid a national opioid crisis to consider allowing police and law enforcement officials to access its prescription drug monitoring database without a court order, pitting patient rights to privacy against the government’s ability to investigate so-called doctor shopping. (Catalini, 7/23)

Boston Globe: Key Part Of Opioid Legislation Is Not Working
As originally proposed by Governor Charlie Baker, the law would have required those taken to the emergency room after an overdose to be held involuntarily for up to 72 hours to receive treatment. But the final version approved by the Legislature excised that requirement, dictating instead that hospitals must simply offer substance abuse treatment to these patients after a voluntary assessment. (Edmondson, 7/23)

Denver Post: Colorado Medicaid Program Reduces Opioid Dosages To Combat Addiction
Colorado’s Medicaid program is reducing the amount of opioid painkillers it allows its recipients to receive, part of a growing campaign to restrict how many of the highly addictive drugs are in circulation. The new policy, announced this month, will roll out in two phases. The first, which goes into place in August, applies to Medicaid recipients who are prescribed opioids for the first time in at least a year. The policy will limit those patients to receiving only a seven-day supply to start, with two additional one-week refills possible if the patient requests them. Another refill request beyond that will require additional scrutiny. (Ingold, 7/24)

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Both Sides Rack Up Wins On Battlefield Over Women’s Health In The States

While some states are stripping Planned Parenthood of funds, others are passing laws to protect contraception for women. Outlets report on other women’s health news out of Kentucky, Texas, Tennessee, Georgia and Texas.

Stateline: Flurry Of Laws Enacted On Women’s Access To Health Care
As Washington moved to reduce federal funding for women’s health this year, adversaries in the war over affordable birth control and other women’s health services shifted the battleground to state capitals — resulting in a spate of new laws that both expand and contract women’s access to care. … Medicaid pays for three-quarters of all publicly supported women’s health programs. So when Iowa abruptly cut off Medicaid dollars to Planned Parenthood, it was game over, said Jodi Tomlonovik, executive director of the Family Planning Counsel of Iowa, which oversees distribution of federal and state money to women’s health clinics. (Vestal, 7/24)

Reuters: U.S. Abortion Support Groups Put On More Public Face
Patricia Canon drives poor rural Kentucky women to distant abortion clinics each week, part of a national army of volunteers who are growing bolder even as abortion foes ratchet up opposition to the activists they have branded as “accomplices to murder.” The Kentucky Health Justice Network, where she volunteers, is one of dozens of non-profit U.S. abortion funds providing money for procedures or covering travel costs to help women obtain abortions, particularly in states where Republican-backed laws have narrowed options. (Kenning, 7/22)

The Washington Post: Dying After Childbirth: Women In Texas Are At High Risk, Especially If They’re Black
Black women in Texas are dying with frightening frequency after childbirth — at a rate up to nearly three times higher than that of white women. And no one has figured out why. In a state with the worst overall maternal mortality in the nation, the Texas legislature opened a special session this week that will address the issue as one of 20 items that Gov. Gregg Abbott (R) listed in calling lawmakers back to work. The most they may do, however, is extend and expand the scope of a task force that started studying the problem a few years ago. (Murgia, 7/21)

The Associated Press: Tennessee Inmates Get Reduced Sentences For Birth Control
A program in a Tennessee county reduces inmates’ jail time if they voluntarily undergo birth control procedures, in a move that has drawn criticism from the local district attorney and the American Civil Liberties Union. WTVF-TV reports General Sessions Judge Sam Benninfield signed a standing order in May that provides 30 days’ credit toward jail time for men who agree to free vasectomies in White County and women who agree to receive free Nexplanon implants, which prevent pregnancies for up to four years. (7/21)

Atlanta Journal-Constitution: Fed Cuts In Teen Pregnancy Grants Hamstrings Georgia Recipients
Quest for Change, a youth and family development-focused nonprofit run out of tiny Dawson, Ga., trained Jackson and other teenagers in how to discuss pregnancy, sexually transmitted diseases and healthy relationships with their peers. … [Shaunae] Motley’s organization and 80 others across the country were recently notified by the federal Department of Health and Human Services that the five-year grants they applied for and won in 2015 would be cut off two years ahead of schedule.

Austin American-Statesman: Abortion-Related Bills Sent To Full Senate For A Vote
The state Senate Health and Human Services Committee approved five bills Friday, the first of the legislative session to be sent to a full chamber for a vote since Gov. Greg Abbott expanded the scope of the agenda early Thursday. Three of the bills dealt with abortion and passed on a party-line 6-3 vote. (Chang and Silver, 7/21)

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Committee’s Plan To Shift Money To Veterans’ Choice Program Draws Immediate Backlash

Eight major organizations spoke out against the proposal, saying it was unacceptable privatization of veterans’ health care.

The Associated Press: House Unveils Plan To Fix VA’s Budget Gap As Deadline Looms
A House committee unveiled a disputed plan Friday to allow the Department of Veterans Affairs to shift $2 billion from other programs to cover a sudden budget shortfall that could threaten medical care for thousands of patients in the coming weeks. The proposal by the House Veterans Affairs Committee would provide a six-month funding fix to the department’s Choice program, which offers veterans federally paid medical care outside the VA and is a priority of President Donald Trump. To offset spending, the VA would trim pensions for some veterans and collect fees for housing loans. (Yen, 7/21)

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Pharma Cracked Open Massive War Chest To Lobby Congress On Pricing, Importation, Drug Approvals

The industry has spend $14 million so far this year.

Stat: Drug Industry Is Lobbying The U.S. Government At Record-Setting Pace
The drug industry’s war chest is going a long way. The two big trade groups for drug makers, the Pharmaceutical Research and Manufacturers of America and the Biotechnology Innovation Organization, spent more lobbying the federal government in the first six months of this year than they have in that period since at least 1999, according to lobbying disclosure filings updated this week. (Robbins and Mershon, 7/21)

Kaiser Health News: Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount
Two federal investigations — one examining opioid sales, another about a multiple sclerosis drug whose price had soared to $34,000 a vial — were only part of the troubles Mallinckrodt faced as the year began. The stock of the drugmaker, whose United States headquarters are in St. Louis, was tanking. Wall Street worried that Medicare might reduce the half-billion dollars it was spending yearly on a Mallinckrodt drug with limited evidence of effectiveness. (Hancock, Lucas and Lupkin, 7/24)

CQ HealthBeat: CQ.Com – Health Care, Tax Overhauls Drive Lobbying In Trump Era
During the turbulent first six months of the Trump administration, some of the biggest lobbying groups scaled back their spending as his signature initiatives collapsed. But major agenda items, including a tax overhaul, will continue to fuel K Street work. …The drug industry lobby Pharmaceutical Research and Manufacturers of America increased its federal lobbying tab to $14 million during the first half of the year as lawmakers debated dismantling the 2010 health care law (<a href=”http://www.cq.com/law/111/148″>PL 111-148</a>; <a href=”http://www.cq.com/law/111/152″>PL 111-152</a>). Its lobbying spending is up from $10.6 million during the first six months of 2016. (Ackley, 7/21)

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Health Care Efforts Edge Toward Chaos As Senators ‘Don’t Even Know’ What Their Voting On

Jul 24 2017

“I don’t know whether we’re proceeding to the House bill, a new version of the Senate bill, the old version of the Senate bill, the 2015 repeal-and-hope-that-we-come-up-with something-in-two-years bill. I truly don’t,” Sen. Susan Collins (R-Maine) said. Senate Majority Leader Mitch McConnell (R-Ky.) is continuing his push for some vote this week.

The Washington Post: Senate Republicans Plan To Plow Ahead With Health-Care Vote This Week
The Senate returns to Washington on Monday with its GOP leaders determined to vote this week on their years-long quest to demolish the Affordable Care Act, even though the goal remains mired in political and substantive uncertainties. Central questions include whether enough Senate Republicans will converge on any version of their leaders’ health-care plan and whether significant aspects of the legislation being considered can fit within arcane parliamentary rules. (Goldstein, 7/23)

The Associated Press: GOP Health Bill Still A Mystery Before Planned Vote
The Senate will move forward with a key vote this week on a Republican health bill but it’s not yet known whether the legislation will seek to replace President Barack Obama’s health care law or simply repeal it. Sen. John Thune of South Dakota, the third-ranking Republican, said Senate Majority Leader Mitch McConnell will make a decision soon on which bill to bring up for a vote, depending on ongoing discussions with GOP senators. (7/24)

The Wall Street Journal: Senate Republicans Unsure Of What Health-Care Measure They Will Vote On
Some senators said Majority Leader Mitch McConnell (R., Ky.) has told them they would know before the vote whether they would be asked to allow debate on some version of a bill to repeal and replace the Affordable Care Act, or legislation that would repeal the ACA with a two-year expiration date. GOP leaders’ current strategy is to lean heavily on lawmakers to at least vote to allow debate on the bill, in the hopes that amendments and other tweaks could yield an agreement. (Andrews, Armour and Peterson, 7/23)

The Hill: Senate Heads To New Healthcare Vote With No Clear Plan 
The two leading options are a repeal-only bill or an updated version of the Senate’s repeal-and-replacement measure. But there has not been a breakthrough on either, despite senators holding a late-night meeting on Wednesday to try to revive the replacement bill. (Sullivan, 7/21)

Los Angeles Times: ‘I Don’t Even Know What We’re Proceeding To Next Week.’ Obamacare Vote Nears With Key Details Still Missing
The uncertainty so close to a major vote is feeding a growing sense of chaos on Capitol Hill, where GOP senators are openly fretting about the lack of information about legislation that could leave anywhere from 22 million to 32 million more Americans without health insurance. “I don’t even know what we’re proceeding to next week,” said Maine Sen. Susan Collins, a centrist Republican who has called on her party’s leaders to take a more measured approach to fixing the current healthcare law. (Levey, 7/21)

Politico: McConnell’s Last-Ditch Obamacare Strategy
Talking is no longer working. It’s time to vote. Senate Majority Leader Mitch McConnell is taking the rare step of forcing his members to take a tough vote on an Obamacare repeal bill, H.R. 1628 (115), that is on track to fail, making them own their votes. (Haberkorn and Kim, 7/21)

Meanwhile, in other health care legislation news —

CQ Roll Call: Repeal Debate Clouds Next Important Health Bill
The day-to-day uncertainty over the Republican health care effort is causing angst among the supporters of the next high-priority health policy item on the Senate’s agenda: a bill to renew crucial Food and Drug Administration funding authorizations before they expire in September. The bill would give the FDA the ability to collect about $1.4 billion in fees from the prescription drug and medical device industries, money which pays the salaries of employees who review product applications. If the fee collection authority is not renewed before Sept. 30, those employees could be furloughed. In the meantime, the FDA would start making plans for reducing staff and would begin notifying affected employees. (Siddons, 7/21)

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First Edition: July 24, 2017

Jul 24 2017

Today’s early morning highlights from the major news organizations.

Kaiser Health News: 5 Ways White House Can Use Its Muscle To Undercut Obamacare
President Donald Trump has vowed to “let Obamacare fail,” after legislative efforts to undo the Affordable Care Act have stalled. He and congressional Republicans have repeatedly portrayed the Affordable Care Act insurance marketplaces, also known as exchanges, as being in a “death spiral.” But independent analyses have concluded that such spontaneous disintegration isn’t happening. (Luthra, 7/24)

Kaiser Health News: Senate Parliamentarian Upends GOP Hopes For Health Bill
The official rules keeper in the Senate Friday tossed a bucket of cold water on the Senate Republican health bill by advising that major parts of the bill cannot be passed with a simple majority, but rather would require 60 votes. Republicans hold only 52 seats in the Senate. Senate Parliamentarian Elizabeth MacDonough said that a super-majority is needed for the temporary defunding of Planned Parenthood, abortion coverage restrictions to health plans purchased with tax credits and the requirement that people with breaks in coverage wait six months before they can purchase new plans. (Rovner, 7/21)

Kaiser Health News: Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount
Two federal investigations — one examining opioid sales, another about a multiple sclerosis drug whose price had soared to $34,000 a vial — were only part of the troubles Mallinckrodt faced as the year began. The stock of the drugmaker, whose United States headquarters are in St. Louis, was tanking. Wall Street worried that Medicare might reduce the half-billion dollars it was spending yearly on a Mallinckrodt drug with limited evidence of effectiveness. (Hancock, Lucas and Lupkin, 7/24)

Kaiser Health News: In Appalachia, Two Hospital Giants Seek State-Sanctioned Monopoly
Looking out a fourth-floor window of his hospital system’s headquarters, Alan Levine can see the Appalachian Mountains that have defined this hardscrabble region for generations. What gets the CEO’s attention, though, is neither the steep hills in the distance nor one of his Mountain States Health Alliance hospitals across the parking lot. Rather, it’s a nearby shopping center where his main rival ­— Wellmont Health System, which owns seven area hospitals — runs an urgent care and outpatient cancer center. Mountain States offers the same services just up the road. (Galewitz, 7/24)

Kaiser Health News: Opioid Treatment Funds In Senate Bill Would Fall Far Short Of Needs
At a lunch last week, President Trump tried to persuade some reluctant senators to endorse repealing the Affordable Care Act. During the meeting, he mentioned a provision in the Senate Republican proposal that allocates funding for opioid treatment, saying, “We’re committing $45 billion to help combat the opioid epidemic, and some states in particular like that. ”But addiction treatment specialists warn that sum of money is far from enough to address a crisis that has escalated across the United States in recent years, killing tens of thousands of people. (Allen, 7/24)

California Healthline: California Valley Fever Cases Highest On Record
The number of Valley Fever cases in California rose to a record level in 2016, with 5,372 reported — a jump of 71 percent from the previous year. Historically, about three-quarters of cases have been in the state’s heavily agricultural San Joaquin Valley. The fungal infection, known as coccidioidomycosis, or “cocci,” is most common in the southern portion of the Valley and along the Central Coast of California. (Bartolone, 7/24)

The New York Times: Senate Parliamentarian Challenges Key Provisions Of Health Bill
The provisions appear to violate Senate rules, the parliamentarian said, giving Democrats grounds to challenge them as the Senate prepares for a battle next week over the future of the Affordable Care Act. One provision questioned by the parliamentarian, Elizabeth MacDonough, and cherished by conservatives would cut off federal funds for Planned Parenthood for one year. Another would prohibit use of federal subsidies to buy insurance that includes coverage for abortions. (Pear and Kaplan, 7/21)

The Wall Street Journal: Parliamentary Rules Likely To Prevent Senate GOP From Defunding Planned Parenthood
Ms. MacDonough’s recommendations were released by Senate Democrats. “The parliamentarian’s decision today proves once again that the process Republicans have undertaken to repeal the Affordable Care Act and throw 22 million Americans off of health insurance is a disaster,” Sen. Bernie Sanders (I., Vt.), the most senior member of the Democratic caucus on the Budget Committee, said in a statement Friday. (Peterson, 7/21)

Politico: Parliamentarian Rules Against Key Provisions In Obamacare Repeal Bill
The parliamentarian’s guidance — provided as part of a process known on Capitol Hill as a “Byrd bath” — amounts to a significant win for Democrats, who are aiming to eliminate as much from the health care bill as possible. But Republicans cautioned that the rulings apply to a prior version of the Senate bill, and GOP aides are already reworking some of the provisions flagged by the parliamentarian, according to one source familiar with the effort. GOP lawmakers faced similar obstacles over language eliminating Obamacare’s individual and employer mandates when they drafted the 2015 repeal bill but overcame them through rewrites. (Haberkorn and Kim, 7/21)

The Washington Post: Senate Republicans Plan To Plow Ahead With Health-Care Vote This Week
The Senate returns to Washington on Monday with its GOP leaders determined to vote this week on their years-long quest to demolish the Affordable Care Act, even though the goal remains mired in political and substantive uncertainties. Central questions include whether enough Senate Republicans will converge on any version of their leaders’ health-care plan and whether significant aspects of the legislation being considered can fit within arcane parliamentary rules. (Goldstein, 7/23)

The Associated Press: GOP Health Bill Still A Mystery Before Planned Vote
The Senate will move forward with a key vote this week on a Republican health bill but it’s not yet known whether the legislation will seek to replace President Barack Obama’s health care law or simply repeal it. Sen. John Thune of South Dakota, the third-ranking Republican, said Senate Majority Leader Mitch McConnell will make a decision soon on which bill to bring up for a vote, depending on ongoing discussions with GOP senators. (7/24)

The Wall Street Journal: Senate Republicans Unsure Of What Health-Care Measure They Will Vote On
Some senators said Majority Leader Mitch McConnell (R., Ky.) has told them they would know before the vote whether they would be asked to allow debate on some version of a bill to repeal and replace the Affordable Care Act, or legislation that would repeal the ACA with a two-year expiration date. GOP leaders’ current strategy is to lean heavily on lawmakers to at least vote to allow debate on the bill, in the hopes that amendments and other tweaks could yield an agreement. (Andrews, Armour and Peterson, 7/23)

Los Angeles Times: ‘I Don’t Even Know What We’re Proceeding To Next Week.’ Obamacare Vote Nears With Key Details Still Missing
The uncertainty so close to a major vote is feeding a growing sense of chaos on Capitol Hill, where GOP senators are openly fretting about the lack of information about legislation that could leave anywhere from 22 million to 32 million more Americans without health insurance. “I don’t even know what we’re proceeding to next week,” said Maine Sen. Susan Collins, a centrist Republican who has called on her party’s leaders to take a more measured approach to fixing the current healthcare law. (Levey, 7/21)

Politico: McConnell’s Last-Ditch Obamacare Strategy
Talking is no longer working. It’s time to vote. Senate Majority Leader Mitch McConnell is taking the rare step of forcing his members to take a tough vote on an Obamacare repeal bill, H.R. 1628 (115), that is on track to fail, making them own their votes. (Haberkorn and Kim, 7/21)

Politico: GOP Despairs At Inability To Deliver
The Republican Party is more powerful than it’s been in more than a decade — and yet it has never seemed so weak. Continuing chaos in the White House has been punctuated by the failure to deliver on the GOP’s seven-year pledge to overhaul Obamacare, and has many asking whether the party can capitalize on the sweeping victories it has achieved at the federal, state, and local levels. (Johnson and Dawsey, 7/23)

The Associated Press: Mixed Signals From Trump White House On Health Care Strategy
Repeal and replace “Obamacare.” Just repeal. Or let it fail — maybe with a little nudge. President Donald Trump has sent a flurry of mixed messages, raising questions about the White House strategy on health care. Democrats say Trump’s confusing signals are part of a strategy to destabilize the Affordable Care Act, as a way to force recalcitrant Republicans in Congress to repeal former President Barack Obama’s signature law. (7/22)

USA Today: Trump To Speak Monday On Health Care
President Trump on Monday will speak to the press at the White House about health care, minutes after meeting with what he calls “victims of Obamacare. ”The statement, announced late Sunday by the White House, comes nearly a week after Trump pressed Republican senators to agree to an alternative to the Affordable Care Act, otherwise known as Obamacare, before taking an August recess. (Toppo, 7/23)

The Associated Press: Trump Tweets Frustration With Republicans, Health Care
President Donald Trump expressed his frustration with Republicans on Sunday, saying they “do very little to protect their President.” In one of several tweets issued in the afternoon and evening, Trump said the lack of support happens even with “some that were carried over the line on my back.” (7/23)

Politico: Former CBO Directors Hit Back At GOP Criticism Of Agency
All eight former directors of the Congressional Budget Office fired back Friday at Republican attacks on the nonpartisan scorekeeping agency over its projections that Obamacare repeal would leave millions more uninsured. In a letter to congressional leaders, the former chiefs wrote that the CBO has a long track record of producing high-quality and nonpartisan reports. (Cancryn, 7/21)

The Associated Press: Doctors’ Group Tells Senate To Fix, Not Repeal ‘Obamacare’
The nation’s largest doctors’ group urged senators on Friday to stop trying to repeal or replace Barack Obama’s Affordable Care Act and instead begin a bipartisan effort to stabilize the insurance marketplace. The American Medical Association said proposed Republican bills — one to repeal and replace the 2010 health law, the other to repeal only — would cause too many people to lose coverage. (7/21)

The New York Times: Small Businesses Split Over Republican Health Plans
Small-business owners have been some of the most vocal opponents of the Affordable Care Act. One trade group fought the overhaul all the way to the Supreme Court. But for many solo entrepreneurs and freelancers, the seeming collapse of the Senate’s efforts to repeal and replace the law came as a relief. (Cowley, 7/23)

The Washington Post: Fear Of Medicaid Cuts Looms At School That Serves Students With Disabilities
With a mailbag slung across his small frame and a wide-brim hat perched atop his head, Mason Wade stepped up to the catwalk. Clasping his aide’s hand for support, he sashayed across the gym, a sprawling red carpet under his feet. For the 6-year-old dressed as a mail carrier, his favorite community helper, the end-of-year fashion show at St. Coletta Special Education Public Charter School in Southeast Washington was a chance to strut his stuff. For the school-based therapists looking on, it was a moment years in the making. (McLaren, 7/22)

The New York Times: When Health Law Isn’t Enough, The Desperate Line Up At Tents
Anthony Marino, 54, reached into his car trunk to show a pair of needle-nosed pliers like the ones he used to yank out a rotting tooth. Shirley Akers, 58, clutched a list of 20 medications she takes, before settling down to a sleepless night in the cab of a pickup truck. Robin Neal, 40, tried to inject herself with a used-up insulin pen, but it broke, and her blood sugar began to skyrocket. (Gabriel, 7/23)

The Washington Post: To Get Treatment At A Free Clinic, The Crowds Come Early — Sometimes The Night Before
Parked at the edge of the field, they covered the windows so the little girls could sleep inside the car. The grown-ups slept on blankets outside on the grass. Before 5 a.m. Saturday, the family joined the sleepy crowds drifting toward the fence of the Wise County fairgrounds. Soon day two of the Remote Area Medical clinic would begin letting people in. Some had camped overnight, others were just arriving in the dark. The day before, more than 1,250 people from all over Appalachia showed up for free medical, dental and vision care. (Schneider, 7/22)

USA Today: Many Of Key Players On Trump Health Care Reform Team Are Hoosiers
Several Hoosiers in key positions in the Trump administration, led by Vice President Mike Pence, are negotiating the future of federal health policy despite the state’s mixed reputation on health care. Indiana spends less on public health funding than any other except Nevada, a handicap when Indiana was home to the nation’s first HIV outbreak linked to the injection of oral painkillers in 2015. In addition, the state for years has ranked among the least healthy. Hoosiers smoke more, are less active and die sooner than most Americans. (Groppe, 7/23)

The New York Times: New C.D.C. Chief Saw Coca-Cola As Ally In Obesity Fight
When she was health commissioner of Georgia, the state with one of the highest rates of child obesity, Dr. Brenda Fitzgerald faced two enormous challenges: How to get children to slim down and how to pay for it. Her answer to the first was Power Up for 30, a program pushing schools to give children 30 minutes more exercise each day, part of a statewide initiative called Georgia Shape. The answer to the second was Coca-Cola, the soft drink company and philanthropic powerhouse, which has paid for almost the entire Power Up program. (Kaplan, 7/22)

The Associated Press: House Unveils Plan To Fix VA’s Budget Gap As Deadline Looms
A House committee unveiled a disputed plan Friday to allow the Department of Veterans Affairs to shift $2 billion from other programs to cover a sudden budget shortfall that could threaten medical care for thousands of patients in the coming weeks. The proposal by the House Veterans Affairs Committee would provide a six-month funding fix to the department’s Choice program, which offers veterans federally paid medical care outside the VA and is a priority of President Donald Trump. To offset spending, the VA would trim pensions for some veterans and collect fees for housing loans. (Yen, 7/21)

Reuters: U.S. Abortion Support Groups Put On More Public Face
Patricia Canon drives poor rural Kentucky women to distant abortion clinics each week, part of a national army of volunteers who are growing bolder even as abortion foes ratchet up opposition to the activists they have branded as “accomplices to murder.” The Kentucky Health Justice Network, where she volunteers, is one of dozens of non-profit U.S. abortion funds providing money for procedures or covering travel costs to help women obtain abortions, particularly in states where Republican-backed laws have narrowed options. (Kenning, 7/22)

The Wall Street Journal: Lawyers Hope To Do To Opioid Makers What They Did To Big Tobacco
The legal front widening against makers of opioid painkillers has something in common with landmark tobacco litigation of the 1990s: attorney Mike Moore. As Mississippi’s attorney general in 1994, Mr. Moore filed the first state lawsuit against tobacco companies, saying they harmed public-health systems by misrepresenting smoking’s dangers. He helped marshal the subsequent spate of state litigation and then the talks that led to a $246 billion settlement. (Whalen, 7/23)

The Washington Post: Dying After Childbirth: Women In Texas Are At High Risk, Especially If They’re Black
Black women in Texas are dying with frightening frequency after childbirth — at a rate up to nearly three times higher than that of white women. And no one has figured out why. In a state with the worst overall maternal mortality in the nation, the Texas legislature opened a special session this week that will address the issue as one of 20 items that Gov. Gregg Abbott (R) listed in calling lawmakers back to work. The most they may do, however, is extend and expand the scope of a task force that started studying the problem a few years ago. (Murgia, 7/21)

The Associated Press: Tennessee Inmates Get Reduced Sentences For Birth Control
A program in a Tennessee county reduces inmates’ jail time if they voluntarily undergo birth control procedures, in a move that has drawn criticism from the local district attorney and the American Civil Liberties Union. WTVF-TV reports General Sessions Judge Sam Benninfield signed a standing order in May that provides 30 days’ credit toward jail time for men who agree to free vasectomies in White County and women who agree to receive free Nexplanon implants, which prevent pregnancies for up to four years. (7/21)

The New York Times: Companies Rush To Develop ‘Utterly Transformative’ Gene Therapies
The approval of gene therapy for leukemia, expected in the next few months, will open the door to a radically new class of cancer treatments. Companies and universities are racing to develop these new therapies, which re-engineer and turbocharge millions of a patient’s own immune cells, turning them into cancer killers that researchers call a “living drug.” One of the big goals now is to get them to work for many other cancers, including those of the breast, prostate, ovary, lung and pancreas. (Grady, 7/23)

The Washington Post: New Hope For HIV Cure As Child Remains Virus-Free Years After Final Treatment
A South African boy, believed to have been infected with HIV around the time of his birth, has remained free of the virus for 8½ years after early treatment — renewing hope among scientists that such outliers may hold clues to help end the decades-old epidemic. The case study, described by researchers before a presentation Monday at an international AIDS conference in Paris, suggests a paradigm shift in the treatment of those infected. It establishes that HIV may be controllable in some way other than a daily and lifelong regimen of antiretroviral drugs. (Cha, 7/24)

NPR: Alternatives To Vaccination Shots Are In Development
News this summer of a flu vaccine patch sparked a lot of chatter. Could getting vaccinated be as easy as putting on a bandage? Could there be fewer, or at least smaller, needles in our future? Some companies and academic labs are working to make those things happen. (Columbus, 7/23)

The New York Times: Another Possible Indignity Of Age: Arrest
It was the sort of incident that happens at facilities that care for people with dementia. At a residence for older adults in San Francisco last summer, Carol King momentarily left a common sitting area. When Ms. King returned, she found that another resident had taken her chair, a nurse who witnessed the episode later reported. She grabbed the usurper’s wrist. (Span, 7/21)

NPR: Concussions May Hit Female Brains Harder, Research Suggests
Thanks to research on boxers and football players, both athletes and the public are becoming more aware of the dangers of sports-related head injuries. Yet there is little data on participants like Mazany. That’s because, unlike the vast majority of athletes studied, she is a woman. “We classically have always known the male response to brain injury,” says Mark Burns, at Georgetown University. But there have been remarkably few studies of females. The bias runs throughout the scientific literature, even in studies of mice. (Hamilton, 7/24)

NPR: Inflammation Can Be Bad For Your Health, Or Good
Chronic, low-level inflammation seems to play a role in a host of diseases, including type 2 diabetes, heart disease, Alzheimer’s, cancer and even depression. And even though the science on inflammation and disease is far from settled, tests and treatments are being promoted that claim to reduce that risk. (Hobson, 7/21)

Los Angeles Times: USC Received More Than A Year Of Questions About Former Medical School Dean’s Conduct Before Scandal Broke
Four days after The Times published a story about drug use by the then-dean of USC’s medical school, the university announced it was moving to fire Dr. Carmen A. Puliafito and said it was “outraged and disgusted” by his conduct. USC Provost Michael Quick said the university decided to act because it had been shown “extremely troubling” information that same day about Puliafito’s behavior. Quick provided no details. But he said it was “the first time we saw such information firsthand.” (Pringle, Elmahrek, Hamilton and Parvini, 7/23)

The Washington Post: He Thought He Just Had Blisters From A Hike. He Had Flesh-Eating Bacteria And Nearly Died.
Wayne Atkins thought little of the blisters he had gotten while hiking. He was trekking up and down the 4,500-foot-high Mount Garfield in New Hampshire — 10-miles round-trip — and blisters were no surprise. He was in the Granite State for a family member’s early June wedding, which went off without a hitch, even with the blisters. But things soured when he returned to Miami, according to Manchester, N.H., ABC affiliate WMUR-TV. (Wootson, 7/23)

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Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount

Two federal investigations — one examining opioid sales, another about a multiple sclerosis drug whose price had soared to $34,000 a vial — were only part of the troubles Mallinckrodt faced as the year began.

The stock of the drugmaker, whose United States headquarters are in St. Louis, was tanking. Wall Street worried that Medicare might reduce the half-billion dollars it was spending yearly on a Mallinckrodt drug with limited evidence of effectiveness.

This year, the company left the industry trade group Pharmaceutical Research and Manufacturers of America, or PhRMA, after the group threatened to kick out companies that did not spend enough on research.

Mallinckrodt, however, has been increasing its spending in another area: It has been writing checks to politicians.

After making meager donations in 2015, the company’s political action committee began raising its contributions for congressional campaigns last year. Lawmakers in both the House and Senate collected $44,000 from Mallinckrodt in 2017’s first quarter, nearly nine times what they got from the company in the same period two years ago.

Mallinckrodt also spent $610,000 lobbying Congress, triple the amount of 2015’s first quarter. The company, which makes pain-control drugs as well as H.P. Acthar, an injectable gel prescribed for multiple sclerosis and other diseases, has lobbied on issues related to opioids, patents, Medicare and other matters, regulatory filings show.

Mallinckrodt is far from unique. This year, a critical and risky one for drug companies, the industry as a whole is ratcheting up campaign donations and its presence on Capitol Hill, a new database compiled by Kaiser Health News shows.

“The stakes are really high right now,” said David Maris, who follows pharmaceutical stocks for Wells Fargo, given that President Donald Trump has joined Democrats to demand action on drug costs.

Mallinckrodt acknowledges that it has increased its political spending to help its particular causes. “We actively participate in the political process on issues that matter to us and our patients,” Rhonda Sciarra, a Mallinckrodt spokeswoman, said by email. “Our PAC’s absolute spend remains small in relation to other companies in our industry.”

Congressional donations from pharmaceutical PACs rose 11 percent in this year’s first quarter, compared with the first three months of 2015 (the comparable point in the previous election cycle), according to a Kaiser Health News analysis. The increase accompanied a spike in pharma lobbying for the period.

Contributions to powerful committee members who handle health policy matters also increased in the face of public anger over the opioid crisis as well as anticipated renewal of legislation that determines the “user fees” companies pay for regulatory drug approval.

A dozen Republican committee heads and ranking Democrats on health-related panels collected $281,600 from pharma-related PACs in the first quarter, up 80 percent from what people in the same positions collected in the first quarter of 2015, the data show. Such initial donations often set the pace for a two-year election cycle, and suggest whom corporate interests are trying to cultivate in a new Congress, with implied promises of more to come, analysts say.

For pharma companies, “now would be the time to give out the money, ahead of a piece of legislation that may come down the road,” said Kent Cooper, a former Federal Election Commission official who has tracked political money for decades. “You want to get your name out there and make a connection with these members’ legislative assistants — so you are known to them and you can get in their door.”

Other drugmakers increasing their congressional donations include AbbVie — whose blockbuster rheumatoid arthritis injection, Humira, faces threats from competition — and Alexion Pharmaceuticals. A six-figure price tag for Soliris, Alexion’s treatment for a rare blood disorder, makes it one of the world’s most expensive drugs.

Pfizer, the No. 2 pharma donor in the first quarter after Sanofi, gave $130,900 to congressional campaigns, three times its contribution for the same period two years ago. So far this year, the company has raised the price of dozens of drugs by an average of 20 percent, The Financial Times reported.

PhRMA, a big giver in the past, has not yet joined individual companies in increasing donations for this election cycle. Congressional campaigns collected $7,000 in the first quarter from PhRMA, which Politico reported had raised member dues to prepare for the drug-price fight. They got $31,500 two years ago.

Methodology

The totals do not include contributions from individual executives and lobbyists, or donations to leadership PACs. Leadership PACs associated with a particular member of Congress often spend money on other members’ campaigns, as well as on things that a campaign committee cannot finance. Details on contributions to leadership PACs take longer to become available.

Outrage was still bubbling last year over moves by Turing Pharmaceuticals and Mylan to raise prices of cheap-to-make, lifesaving drugs to hundreds of dollars a dose, when the country elected a Republican president who vowed: “I’m going to bring down drug prices.” Nearly 8 in 10 Americans said in a September poll they believed prescription drug prices were unreasonable.

Evidence has grown that pharma companies helped fuel the nation’s addiction and overdose crisis with sales of powerful painkillers, prompting calls for an overhaul. Drug developers are also preparing for renewal of the Prescription Drug User Fee Act, which generates revenue to pay for government review and approval of drugs.

At the same time, drug companies anticipated Republican efforts to repeal and replace the Affordable Care Act, which finances billions in drug sales. That process has stalled in the Senate. All of this gives drugmakers the most powerful incentives in years to cultivate policymakers, analysts say.

Tense politics may also be prompting members of Congress to be energetic about soliciting donations.

“My sense is that Republicans are nervous in the House — especially given the long-term record of the presidential party losing seats in the midterm,” said David Magleby, a political scientist at Brigham Young University who studies campaign finance. “I would be surprised if Republican incumbents across the board aren’t more aggressive in raising money in the first and second quarters.”

In the past six months, Mallinckrodt has come under pressure for both painkiller sales and price increases for non-narcotic drugs. Earlier this month, the Justice Department announced the company would pay $35 million to resolve an investigation into whether it ignored enormous volumes of its oxycodone moving through distributors and pharmacies. Over several years, The Washington Post reported, Mallinckrodt was responsible for two-thirds of all the oxycodone sold in Florida.

Mallinckrodt denied it violated the law and said the settlement was not an acknowledgment of liability.

In January, it agreed to pay $100 million to settle Federal Trade Commission allegations that a company it bought three years ago had illegally quashed competition, enabling it to raise the price of Acthar, the multiple sclerosis drug, which the FTC said cost only $40 per vial in 2001, to $34,000. Mallinckrodt disputed the agency’s complaint but said it settled to put the matter to rest.

The drug is prescribed to treat a rare form of epilepsy as well as multiple sclerosis and other ailments. Even Mallinckrodt acknowledges that “clinical trials demonstrating the efficacy for Acthar are limited.”

But in part because of price increases, global sales of the drug soared from $123 million in the 2014 fiscal year to $1.2 billion in the 2016 fiscal year. It was Medicare’s most expensive drug per patient in 2015 — $162,371 for the year — and now makes up a third of the company’s revenue.

Company shareholders have worried that Medicare will crack down on sales of Acthar. Mallinckrodt has pledged to keep future price increases for all drugs to single-digit percentages per year, though that could still be well above the current inflation rate of less than 3 percent.

Mallinckrodt’s biggest donations on Capitol Hill, of $5,000 each, went to Ann Wagner, a House member from its home state, Missouri, and Sen. Orrin Hatch, the powerful chairman of the Senate Finance Committee. That amount is the maximum a PAC can give to a campaign committee for each primary and general election.

Ever since it was spun off as an independent company in 2013, Mallinckrodt has made its legal home in Ireland, which allows it to take advantage of lower income tax rates. Hatch favors cutting U.S. corporate taxes to eliminate incentives to make such moves.

Mallinckrodt gave lesser amounts to 16 other congressional campaigns, including that of Paul Ryan, the House speaker. Ryan, who has played down Trump’s attacks on the pharmaceutical industry, was the top recipient of industry money in the first quarter, with $82,750 collected, the data show.

The White House has made no proposals on drug costs. Trump has said little about the issue since January, when he said drug sellers were “getting away with murder.”

Drug companies are hedging their bets, writing checks to individual Democrats and Republicans. With Trump breaking ranks with Republicans to favor reform, “you can’t tell who’s your friend and who’s not,” said Maris, the Wells Fargo analyst. “So you have to go to a ground game — a more one-on-one legislator basis.”

Naema Ahmed contributed to this report.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Categories: Cost and Quality, Health Industry, Pharmaceuticals

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5 Ways White House Can Use Its Muscle To Undercut Obamacare

President Donald Trump has vowed to “let Obamacare fail,” after legislative efforts to undo the Affordable Care Act have stalled.

He and congressional Republicans have repeatedly portrayed the Affordable Care Act insurance marketplaces, also known as exchanges, as being in a “death spiral.” But independent analyses have concluded that such spontaneous disintegration isn’t happening.

In a number of ways, the Trump administration’s policies are pushing Obamacare into the vortex.

Reports from Standard & Poor’s, the Congressional Budget Office and the Kaiser Family Foundation all suggest that the exchanges — where people can shop for coverage, often with the help of a government subsidy — are stabilizing. (Kaiser Health News is an editorially independent program of the foundation.)

Use Our Content

But, like every piece of legislation, Obamacare faces a difficult political reality: Its marketplaces require active maintenance and federal support.

The White House can take a number of behind-the-scenes steps to sabotage the exchanges and hasten their undoing. Already, it’s deploying some of those tactics.

“The administration has a lot of power to undermine the markets and make them dysfunctional,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, who specializes in private insurance markets.

Here’s a look at five ways the White House is already working to weaken the health law, and what that means for consumers.

‘Cost-Sharing Reductions’

Under the ACA, when someone’s income falls between 100 and 250 percent of the federal poverty level — up to about $29,000 for an individual or around $61,000 for a family of four — marketplace carriers must offer a plan with “cost-sharing reductions” (CSRs) that reduce consumers’ out-of-pocket expenses.

Reducing cost-sharing — generally copayments and deductibles — makes plans more expensive for the insurers. The Obama administration used its rule-making power to set up direct payments to carriers to help offset this burden. The Trump White House has inherited that responsibility but also has the power to end the payment program.

The nonpartisan Congressional Budget Office estimated CSR subsidies in 2017 would total about $7 billion. Without that money, analysts say, more insurers might choose to exit, limiting options for consumers, and letting the insurers who remain charge higher prices.

Trump has been committedly noncommittal, publicly indicating he would like to halt the subsidies, but so far — on a month-to-month basis — letting them continue.

The uncertainty makes insurance companies skittish about participating, analysts noted. It’s also one reason some plans say they have had to increase their rates, noted Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups. For instance: When filing plans for the 2018 marketplace, carriers on average raised premiums by about 34 percent — with about 20 points stemming from CSR uncertainty, Gaba said, based on an analysis of 21 states’ initial rate filings. Dropping the subsidies altogether would be even more damaging.

Weaken The Mandate

The White House has already signaled it does not want to enforce the individual mandate — the health law’s requirement that all people have coverage. And administration officials have repeated that position.

Meanwhile, in January, it issued an executive order that encouraged U.S. agencies to grant exemptions and waive or defer health law provisions that could put financial strain on companies or individuals — which could also be applied to the individual mandate.

For 2016 tax returns, though, the Internal Revenue Service continued to impose a financial penalty on people who didn’t have health insurance and who didn’t qualify for an exemption.

But enforcement may be waning. This year, the IRS was supposed to reject tax returns if people didn’t indicate whether they had coverage, flagging them for a potential penalty. Instead, it continued processing them, citing Trump’s executive order.

If the IRS has already processed any tax refunds for consumers, then they “don’t have much leverage” when attempting to collect the mandate fee, said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform.

Enforcement of the mandate enforcement, economists note, is crucial to ensuring that enough healthy people buy coverage to balance the costs of sicker beneficiaries.

But even with the mandate in effect, the efforts to defang it bring confusion.

“A lot of people believe the Trump administration is not enforcing it,” Jost said.

As a result, healthy people may become less likely to buy insurance, even as sick ones continue seeking it. That means higher prices, and a shakier pool.

“If they don’t think they’re going to get healthy people in the risk pool, they’re going to increase their rates further to protect themselves,” Jost said. “And as they raise their rates further to protect themselves, people … start to drop out.”

Thus, the president’s position on the mandate is leaving insurance carriers and commissioners “apprehensive,” noted Mike Kreidler, Washington state’s insurance commissioner.

A Bare Market

Skittishness on the part of insurers could lead them to drop out of some marketplaces, leaving consumers in some areas with few or no choices. Those “bare markets” are possible under even stable circumstances — and preventing them requires active federal involvement.

Under the Obama administration, high-level officials were “on the phone daily with insurance company executives … trying to get them to participate,” Corlette said. “It was very much an all-hands-on-deck, ‘we’re going to make it work for you guys’ kind of communication.”

And so far Trump’s Department of Health and Human Services doesn’t appear to be emphasizing this kind of essential outreach, both Corlette and Jost suggested. A few months ago, Kreidler agreed, HHS staffers appeared interested in helping states fill their bare counties — but that support has since dwindled.

“This may be sort of under the radar, but it can have real, lasting effects” for consumer choice, Corlette said.

All Quiet On The Enrollment Front

The administration could further undermine the marketplace by dropping outreach to consumers. It’s already a shorter enrollment period this year — spanning six weeks instead of three months, from Nov. 1 to Dec. 15 — though that change was already slated to eventually take effect.

That shorter period means people may miss the memo on signing up — or at least need an extra push, Corlette said. And that’s another way the administration could undermine the marketplaces: simply choosing not to advertise them.

Last sign-up season, HHS stopped open enrollment advertising in January, pulling ads a few days before the period ended. Enrollment dropped compared with previous years, Jost and Gaba noted, with young, healthy people being more likely not to buy coverage.

The administration also just stopped funding federal contractors that supported efforts by community groups and other organizations in some of the nation’s largest cities to sign up people.

Dropping advertising, shortening open enrollment or simply scaling back on technical maintenance for the marketplace website could all have significant impact, Corlette said. People who are sick and need insurance will likely seek it out, but those who are healthier — for whom health insurance is a less pressing priority — could miss the boat.

Again, Jost said, that affects insurer participation.

“Insurance is a product that need to be sold,” he said. “If the insurers believe they’re not going to get any help at all in marketing their product,” he added, fewer will want to enter the marketplace.

Word of (Bad) Mouth

HHS has taken an active role in criticizing the health law — pushing press releases and videos that argue it has helped more than hurt. That strategy could do a lot of harm, experts said.

If consumers keep hearing the law is failing, Jost noted, some will ultimately believe it, buying coverage only if they need it and thereby skewing the insurance risk pool.

Perceived hostility also has an effect on insurers, steering them away from marketplace participation.

“When you undermine confidence in the marketplace, you don’t need a Ph.D. in economics to know it’s not good long term,” Corlette said.

Categories: Insurance, Repeal And Replace Watch, The Health Law

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5 Ways White House Can Use Its Muscle To Undercut Obamacare

President Donald Trump has vowed to “let Obamacare fail,” after legislative efforts to undo the Affordable Care Act have stalled.

He and congressional Republicans have repeatedly portrayed the Affordable Care Act insurance marketplaces, also known as exchanges, as being in a “death spiral.” But independent analyses have concluded that such spontaneous disintegration isn’t happening.

In a number of ways, the Trump administration’s policies are pushing Obamacare into the vortex.

Reports from Standard & Poor’s, the Congressional Budget Office and the Kaiser Family Foundation all suggest that the exchanges — where people can shop for coverage, often with the help of a government subsidy — are stabilizing. (Kaiser Health News is an editorially independent program of the foundation.)

Use Our Content

But, like every piece of legislation, Obamacare faces a difficult political reality: Its marketplaces require active maintenance and federal support.

The White House can take a number of behind-the-scenes steps to sabotage the exchanges and hasten their undoing. Already, it’s deploying some of those tactics.

“The administration has a lot of power to undermine the markets and make them dysfunctional,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, who specializes in private insurance markets.

Here’s a look at five ways the White House is already working to weaken the health law, and what that means for consumers.

‘Cost-Sharing Reductions’

Under the ACA, when someone’s income falls between 100 and 250 percent of the federal poverty level — up to about $29,000 for an individual or around $61,000 for a family of four — marketplace carriers must offer a plan with “cost-sharing reductions” (CSRs) that reduce consumers’ out-of-pocket expenses.

Reducing cost-sharing — generally copayments and deductibles — makes plans more expensive for the insurers. The Obama administration used its rule-making power to set up direct payments to carriers to help offset this burden. The Trump White House has inherited that responsibility but also has the power to end the payment program.

The nonpartisan Congressional Budget Office estimated CSR subsidies in 2017 would total about $7 billion. Without that money, analysts say, more insurers might choose to exit, limiting options for consumers, and letting the insurers who remain charge higher prices.

Trump has been committedly noncommittal, publicly indicating he would like to halt the subsidies, but so far — on a month-to-month basis — letting them continue.

The uncertainty makes insurance companies skittish about participating, analysts noted. It’s also one reason some plans say they have had to increase their rates, noted Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups. For instance: When filing plans for the 2018 marketplace, carriers on average raised premiums by about 34 percent — with about 20 points stemming from CSR uncertainty, Gaba said, based on an analysis of 21 states’ initial rate filings. Dropping the subsidies altogether would be even more damaging.

Weaken The Mandate

The White House has already signaled it does not want to enforce the individual mandate — the health law’s requirement that all people have coverage. And administration officials have repeated that position.

Meanwhile, in January, it issued an executive order that encouraged U.S. agencies to grant exemptions and waive or defer health law provisions that could put financial strain on companies or individuals — which could also be applied to the individual mandate.

For 2016 tax returns, though, the Internal Revenue Service continued to impose a financial penalty on people who didn’t have health insurance and who didn’t qualify for an exemption.

But enforcement may be waning. This year, the IRS was supposed to reject tax returns if people didn’t indicate whether they had coverage, flagging them for a potential penalty. Instead, it continued processing them, citing Trump’s executive order.

If the IRS has already processed any tax refunds for consumers, then they “don’t have much leverage” when attempting to collect the mandate fee, said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform.

Enforcement of the mandate enforcement, economists note, is crucial to ensuring that enough healthy people buy coverage to balance the costs of sicker beneficiaries.

But even with the mandate in effect, the efforts to defang it bring confusion.

“A lot of people believe the Trump administration is not enforcing it,” Jost said.

As a result, healthy people may become less likely to buy insurance, even as sick ones continue seeking it. That means higher prices, and a shakier pool.

“If they don’t think they’re going to get healthy people in the risk pool, they’re going to increase their rates further to protect themselves,” Jost said. “And as they raise their rates further to protect themselves, people … start to drop out.”

Thus, the president’s position on the mandate is leaving insurance carriers and commissioners “apprehensive,” noted Mike Kreidler, Washington state’s insurance commissioner.

A Bare Market

Skittishness on the part of insurers could lead them to drop out of some marketplaces, leaving consumers in some areas with few or no choices. Those “bare markets” are possible under even stable circumstances — and preventing them requires active federal involvement.

Under the Obama administration, high-level officials were “on the phone daily with insurance company executives … trying to get them to participate,” Corlette said. “It was very much an all-hands-on-deck, ‘we’re going to make it work for you guys’ kind of communication.”

And so far Trump’s Department of Health and Human Services doesn’t appear to be emphasizing this kind of essential outreach, both Corlette and Jost suggested. A few months ago, Kreidler agreed, HHS staffers appeared interested in helping states fill their bare counties — but that support has since dwindled.

“This may be sort of under the radar, but it can have real, lasting effects” for consumer choice, Corlette said.

All Quiet On The Enrollment Front

The administration could further undermine the marketplace by dropping outreach to consumers. It’s already a shorter enrollment period this year — spanning six weeks instead of three months, from Nov. 1 to Dec. 15 — though that change was already slated to eventually take effect.

That shorter period means people may miss the memo on signing up — or at least need an extra push, Corlette said. And that’s another way the administration could undermine the marketplaces: simply choosing not to advertise them.

Last sign-up season, HHS stopped open enrollment advertising in January, pulling ads a few days before the period ended. Enrollment dropped compared with previous years, Jost and Gaba noted, with young, healthy people being more likely not to buy coverage.

The administration also just stopped funding federal contractors that supported efforts by community groups and other organizations in some of the nation’s largest cities to sign up people.

Dropping advertising, shortening open enrollment or simply scaling back on technical maintenance for the marketplace website could all have significant impact, Corlette said. People who are sick and need insurance will likely seek it out, but those who are healthier — for whom health insurance is a less pressing priority — could miss the boat.

Again, Jost said, that affects insurer participation.

“Insurance is a product that need to be sold,” he said. “If the insurers believe they’re not going to get any help at all in marketing their product,” he added, fewer will want to enter the marketplace.

Word of (Bad) Mouth

HHS has taken an active role in criticizing the health law — pushing press releases and videos that argue it has helped more than hurt. That strategy could do a lot of harm, experts said.

If consumers keep hearing the law is failing, Jost noted, some will ultimately believe it, buying coverage only if they need it and thereby skewing the insurance risk pool.

Perceived hostility also has an effect on insurers, steering them away from marketplace participation.

“When you undermine confidence in the marketplace, you don’t need a Ph.D. in economics to know it’s not good long term,” Corlette said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Categories: Insurance, Repeal And Replace Watch, The Health Law

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In Appalachia, Two Hospital Giants Seek State-Sanctioned Monopoly

JOHNSON CITY, Tenn. — Looking out a fourth-floor window of his hospital system’s headquarters, Alan Levine can see the Appalachian Mountains that have defined this hardscrabble region for generations.

What gets the CEO’s attention, though, is neither the steep hills in the distance nor one of his Mountain States Health Alliance hospitals across the parking lot. Rather, it’s a nearby shopping center where his main rival ­— Wellmont Health System, which owns seven area hospitals — runs an urgent care and outpatient cancer center. Mountain States offers the same services just up the road.

“Money is being wasted,” Levine said, noting that duplication of medical services is common throughout northeastern Tennessee and southwestern Virginia where Mountain States and Wellmont have been in a health care “arms race” for years, each trying to outduel the other for the doctors and services that will bring in business.

The companies now want to merge, which would create a monopoly on hospital care in a 13-county region that studies have placed among the nation’s least healthy places. The merger’s savings would pay for a range of public health services that they can’t afford now, the companies project. And they are trying to pull it off without Washington regulators’ approval, breaking with hospitals’ usual path to consolidation.

In a typical case, a plan that eliminates so much competition in a market would almost certainly provoke a court battle with the Federal Trade Commission, which enforces antitrust laws and challenges anti-competitive behavior in the health industry.

To avert such a fight, the hospitals are using an obscure legal maneuver available in Tennessee and Virginia and some other states.

The view of mountains is everywhere in Johnson City, Tenn. (Phil Galewitz/KHN)

Generally known as a Certificate of Public Agreement (COPA), the process works like this: If regulators in Virginia and Tennessee agree that the merger is in the public interest, Wellmont and Mountain States would operate as one company under a state-supervised agreement governing key parts of their operations, including setting prices. The states’ approval would prevent the FTC from challenging the merger under federal antitrust law.

Their decisions could come as soon as this month.

In exchange for approval, Mountain States and Wellmont promise to use money saved from the merger to offer mental health and addiction treatment services and attack public health concerns, such as obesity and smoking — areas previously neglected by the systems that don’t increase hospital admissions and bring in big revenue, hospital officials said

“The question that needs to be asked is whether tight state oversight of a monopoly is better than failed competition,” said Robert Berenson, a health policy expert at the Urban Institute.

Little-Used And Rarely Challenged Mechanism

The federal antitrust exemption made possible under a COPA dates to a Supreme Court ruling in the 1940s used only about a dozen times to allow hospital mergers. One was an hour away from here, in Asheville, N.C.

There’s little scholarly research on COPAs’ results.

Last summer, the FTC dropped its challenge to a merger of two West Virginia hospitals after the state adopted a COPA law and permitted the deal.

In recent years, hospital mergers and acquisitions have created behemoth health systems that have used their status to demand high payments from insurers and patients. Studies by health economists have repeatedly found that consolidation means higher prices.

But the same calculus may not apply here and in other regions where a preponderance of patients are poor or uninsured, officials from both Mountain States and Wellmont say.

While President Donald Trump and Republicans in Congress stress the value of free-market principles in health care, both hospitals argue that in their part of Appalachia the market has led to unnecessary spending, driven up health costs and forced them to focus on services that produce the highest profits rather than meet the community’s most pressing health needs. In this deeply conservative region where death rates from cancer and heart disease are among the nation’s highest, the hospitals say only a state-sanctioned monopoly can help them control rising prices and improve their population’s health.

Without their proposed merger, Levine said, both hospital systems would likely have to sell to an out-of-market chain. That would likely eliminate local control of the facilities and could lead to massive layoffs and the closure of hospitals and services, he said. Together, the two hospital systems employ about 17,000 people.

Alan Levine, CEO of Mountain States Health Alliance, outside his Johnson City, Tenn., office. (Phil Galewitz/KHN)

The FTC, which is urging the states to reject the hospitals’ plan, contends the hospitals could form an alliance or take other steps short of a merger to accomplish the benefits they say one will bring. The agency says the hospitals’ market probably would be no worse off if one chain merged with a company outside the area.

Feds Wary Of Promises

The hospitals are making big promises to sell their deal. They say no hospitals would close for at least five years, although some could be converted to specialized health facilities to treat problems such as mental health or drug addiction. After the merger, all qualified doctors would have staff privileges at all hospitals to treat patients. No insurer would pay lower rates than others. The new hospital system would spend at least $160 million over 10 years to improve public health, expand medical research and support graduate medical education for work in rural areas.

The FTC maintains the hospitals’ pledges are unreliable and dismissed them as having “significant shortcomings, gaps and ambiguities” in an analysis filed with state regulators in January.

Levine said the plan is the best deal for the community given the factors that handicap the hospitals. Those include declining populations and Medicare reimbursement rates that are lower here than other parts of the country because of lower average wages. Another concern is the cost of caring for uninsured people — neither Virginia nor Tennessee expanded Medicaid under the health law, which would have lowered uninsured rates.

“Competition is and should be the first choice, but in an area where competition becomes irrational and there are limited choices, there has to be a Plan B. If not this, then what?” he said.

Blue Cross and Blue Shield of Tennessee, the state’s largest health insurer, is not opposing the hospitals’ combination, a spokesman said. But its counterpart in Virginia, Anthem, hasn’t been persuaded.

“Anthem does not believe that there are any commitments that will protect Southwest Virginia and Northeast Tennessee health care consumers from the negative impact of a state-sanctioned monopoly,” the company said in a statement.

Wanted: Better Job Prospects

The proposed COPA has strong support among large employers in the region, including Eastman, a Kingsport, Tenn., chemical company with $9 billion in annual revenue that employs more than 7,000 people locally. “We get local governance, input and control … and that’s a lot better situation for us,” said David Golden, a senior vice president at Eastman.

Still, walking around Johnson City — the region’s largest city with almost 67,000 people — it’s easy to feel an unease among small employers and residents about a merger. Many worry about possible job cuts.

“Eliminating duplication of services means eliminating people,” said Dick Nelson, 60, who runs a coffee and art shop downtown and has lived here for 27 years. “I don’t care how much health care costs because my insurance will pay it,” he said.

In Kingsport, where Wellmont and Mountain States each has a hospital, Thorp is leery about a merger, too. “It’s an economic move, not an enhancement of medical care,” said Thorp, who runs a newsstand downtown. “We pride ourselves here for having good education and health care. They say there won’t be any services or jobs cut, but if that’s the case then what’s the point of the merger?”

Tom Throp owns Wallace News, a staple in downtown Kingsport, Tenn. Of the hospital consolidation plan, he says: “They say there won’t be any services or jobs cut, but if that’s the case then what’s the point of the merger?” (Phil Galewitz/KHN)

Levine said no place better supports the case for a hospital merger than Wise County in southwestern Virginia, a scenic area with about 40,000 people whose three hospitals all operate below half their capacity. Mountain States and Wellmont each own a hospital in Norton, the county seat with 4,000 residents. Despite few patients, the hospitals still bear hard-to-cut costs for buildings, equipment and adequate staffing levels, Levine said.

On a recent weekday morning, Lonesome Pine Hospital, a Wellmont facility in Big Stone Gap, Va., looked nearly deserted. No volunteers or staffers were visible inside its main entrance and fewer than a fifth of its 70 acute-care beds were being used.

A five-minute drive away, Mountain States’ Norton Community Hospital’s 129 beds are about a quarter filled. Its maternity unit delivers fewer than five babies a week. The hospital offers hyperbaric oxygen therapy — a treatment that pays well under Medicare’s reimbursement rates — to help diabetics heal their wounds. But it has no endocrinologists to help diabetics manage their disease to avoid such complications. Despite a high rate of heart disease in the community, there’s no cardiologist on staff.

Whether a state-sanctioned merger will resolve the incongruities — here or in other poor regions — depends on how firmly regulators hold the hospitals to their pre-merger commitments. If the merger plan gets rejected, Mountain States and Wellmont will resume arch-competitive business practices that do not always put community interests first, said Bart Hove, Wellmont’s CEO.

“It’s about competing for the dollar in any way you can and extracting a dollar from your competition,” Hove said. “You do what you can to drive patients to your hospital.”

Categories: Cost and Quality, Health Care Costs, Health Industry

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