From Health Care

Hurricane Maria Still Taking A Toll On Puerto Rico’s Seniors

The question of who will care for Puerto Rico’s aging population is a growing crisis, says Dr. Angel Muñoz, a clinical psychologist and researcher at the Pontifical Catholic University of Puerto Rico in Ponce. The island’s elderly population is particularly at risk amid the new Atlantic hurricane season, which runs through Nov. 30.

Earlier this year, a study by Harvard researchers estimated that 4,600 Puerto Ricans died in the months after Hurricane Maria hit last September. Many were seniors who faced delays in getting medical care.

Meanwhile, projections show that one-third of Puerto Rico’s population will be 60 or older by 2020, even as the number of young people are increasingly fleeing to the mainland in search of employment, often leaving behind aging parents.

“We have more [older adults] being left alone to almost fend for themselves, or being cared for by other seniors, instead of a younger family member,” said Muñoz. In addition, Medicaid does not pay for long-term nursing home care in Puerto Rico.

KHN senior correspondent Sarah Varney reports in collaboration with “PBS NewsHour” on how difficult daily life has become for this population.

Rural Hospitals Closing At Dangerous Rate For Pregnant Women Stuck Hundreds Of Miles From Care

Researchers estimate that fewer than half of the country’s rural counties still have a hospital that offers obstetric care. “We can’t keep a hospital. What is our community coming to?” Kela Abernathy said. In other women’s health news, a judge rules in favor of the Trump administration over its proposed funding rules for the family-planning program, and many women treated for early-stage breast cancer aren’t getting the recommended follow-up care.

If Defendants With Substance Abuse Disorders Relapse They Can Be Sent To Jail, Court Unanimously Rules

The case was closely watched because it pitted the traditional method of punishment versus the new thinking that treatment is best for drug addiction. Justice David A. Lowy wrote that a judge has the power and discretion to determine probation requirements tailored to an individual and that further probation’s twin goals: rehabilitation and public safety. Judges, he said, “stand on the front lines of the opioid epidemic” and are “faced with difficult decisions that are especially unpalatable.”

States Attacking ACA Would Hurt Most If Shield On Preexisting Conditions Were Axed

If the Affordable Care Act’s protections for people with preexisting medical conditions are struck down in court, residents of the Republican-led states that are challenging the law have the most to lose.

“These states have been opposed to the ACA from the beginning,” said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “They’re hurting their most vulnerable citizens.”

Twenty Republican state attorneys general and governors challenged the constitutionality of the ACA in federal court in February. Last month, U.S. Attorney General Jeff Sessions and the Department of Justice made the unusual decision not to defend key portions of the law against this legal challenge.

The states’ lawsuit argues that because Congress eliminated the Obamacare tax penalty for not having insurance coverage, effective next year, the entire law is unconstitutional. By extension, the suit calls on federal courts to find the health law’s protections for people with preexisting conditions unconstitutional — and Sessions agrees.

Nine of the 11 states with the highest rates of preexisting conditions among adults under 65 have signed onto the lawsuit to strike down the ACA, according to data from insurance companies and the U.S. Centers for Disease Control and Prevention. The 2015 data, the most recent available, were analyzed by the Kaiser Family Foundation in 2016. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Those who support the lawsuit contend that there are other means of protecting people with preexisting conditions.

“If a court strikes down the constitutionality of the ACA, there are ways to repeal and replace without Arizonans with preexisting conditions losing their coverage,” said Katie Conner, a spokeswoman for Arizona Attorney General Mark Brnovich.

Conner said her boss, who is party to the lawsuit, believes preexisting conditions should “always be covered.” In Arizona, more than 1 in 4 adult adults under 65 have a preexisting condition, according to the data.

The state with the highest rate of adults with preexisting conditions is West Virginia — 36 percent of those under age 65. That means that about 1 in 3 of them could have a hard time buying insurance through the individual marketplace without the ACA protections.

The office of West Virginia Attorney General Patrick Morrisey, who joined the legal challenge against the ACA, declined to comment. But a spokesman for Morrisey’s re-election campaign told PolitiFact last month that “help should be provided to those who need it most, including those with preexisting conditions.”

Plaintiffs in the lawsuit “are paying lip service to these critical protections for people, but they are in fact engaged in a strategy that would get rid of those protections,” said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms. “Frankly, it’s hard to square what they’re saying on the one hand and what they’re arguing in the courts on the other.”

According to a poll released in June, also by the Kaiser Family Foundation, three-quarters of Americans say that maintaining protections for people with preexisting conditions is “very important.” This includes majorities of Democratic, Republican and independent voters.

Before the health law was adopted, insurance companies routinely denied coverage to millions of people with preexisting conditions who purchased insurance through the individual marketplace. If they didn’t deny coverage outright, some health plans charged consumers exorbitant premiums, or offered policies that excluded coverage for pricey conditions. (Although many people got insurance through their employers or public plans that covered preexisting conditions, they could have been left vulnerable if their employment status or other circumstances changed.)

The ACA ended those practices.

Common conditions that led insurance companies to deny coverage included high blood pressure, cancer, obesity, diabetes and depression, among many others. Some people were denied for having acne, asthma or for being pregnant.

The KFF analysis estimated that at least 27 percent of adults under 65 — more than 50 million Americans — had at least one preexisting condition that would have jeopardized their coverage pre-ACA. The foundation said its estimates were an undercount because some diseases that insurers cited when declining coverage are not in the survey data. Also, each insurance company set its own rules and conditions for denials, making accurate counts of those who could be affected hard to nail down.

Less precise estimates by other researchers and the Department of Health and Human Services show that up to half of all adults under age 65 have at least one preexisting condition.


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

Staggering Prices Slow Insurers’ Coverage Of CAR-T Cancer Therapy

Patients whose blood cancers have failed to respond to repeated rounds of chemotherapy may be candidates for a new type of gene therapy that could send their cancers into remission for years.

But the two approved therapies, with price tags of hundreds of thousands of dollars, have roiled the insurance approval process, leading to delays and, in some cases, denials of coverage, clinicians and analysts say.

The therapy involves collecting patients’ own T cells, a type of white blood cell, genetically modifying them, and then infusing them back into patients, where they hunt down and kill cancer cells. Known as CAR T-cell therapy, it has been called a “living drug.”

Two drugs, Kymriah and Yescarta, were approved last year to treat patients whose blood cancers haven’t responded to at least two other rounds of treatment. Kymriah is approved for people up to age 25 with a form of acute lymphoblastic leukemia, the most common cancer in children. Kymriah and Yescarta are both approved for adults with advanced lymphomas.

Researchers report that some critically ill patients who received the therapy have remained cancer-free for as long as five years.

“This is what patients need,” said Dr. Yi Lin, a hematologist who oversees the CAR-T cell practice and research for the Mayo Clinic. “With the likelihood of getting patients into durable survival, we don’t want to deny them the therapy.” She said she receives no personal financial support from the drugs’ makers.

But it comes at a cost. The drugs are hugely expensive. Kymriah and Yescarta cost $373,000 to treat adults with advanced lymphomas, while Kymriah costs $475,000 to treat acute lymphoblastic leukemia in children and young adults. In addition, many patients experience serious side effects that can land them in a hospital intensive care unit for weeks, pushing treatment costs more than $1 million.

All of this gives government and private insurers pause.

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time, said cancer experts. Large insurers that are already familiar with  complicated therapies like stem-cell transplants are getting speedier at handling CAR-T treatment requests, they said. But that’s not always the case at smaller or regional plans, where delays can add weeks to the approval process.

“A request for CAR-T may end up with somebody on the payer authorization team who doesn’t understand the technology or the urgency of the request, when somebody has only weeks or months to live,” said Stephanie Farnia, director of health policy and strategic relations at the American Society for Blood and Marrow Transplantation.

Farnia is in contact with many of the more than 50 medical centers that are authorized to provide treatment. The process of getting to a treatment center and evaluated for therapy is involved, she said, “to then be substantially delayed due to paperwork is incredibly frustrating” for patients.

Medicare and Medicaid often pose greater coverage challenges than do private insurers, according to insurance experts.

Some Medicaid programs don’t cover the treatment, said Dr. Michael Bishop, director of the cellular therapy program in the hematology-oncology section at the University of Chicago. Medicaid, the state-federal health program, covers children in low-income households and some adults.

“Medicaid has been very tough,” he said. “Certain states just deny coverage, even states with balanced budgets.”

Matt Salo, executive director of the National Association of Medicaid Directors, said states have to evaluate the cost as well as the drugs’ effectiveness. “Medicaid is a finite pot of money, and it’s stretched threadbare even on a good day,” he said.

People who are on Medicare, the health insurance program for people age 65 and older and some people with disabilities, typically haven’t faced coverage denials to date, clinicians say. But the government’s reimbursement rates are raising concerns for providers.

Last spring, Medicare announced payment rates for providers who administer Yescarta and Kymriah on an outpatient basis. The payments would more than cover the costs of the drugs. Medicare beneficiaries’ out-of-pocket costs would be capped at $1,340 plus their Part B deductible, if it hasn’t been met, the agency said.

The problem with this plan: Facilities typically provide treatment on an inpatient basis, because of the potential for severe, systemic side effects.

“There’s a lot of toxicity and questions about whether it can even be provided in an outpatient setting,” said Gary Goldstein, the business manager at the blood and marrow transplant program at Stanford Health Care in Stanford, Calif.

For inpatient care, “CAR T-cell therapy … would be paid at a much lower amount compared to outpatient hospital use,” according to officials at the Centers for Medicare & Medicaid Services.

The agency is considering how to handle payment for inpatient CAR-T care for the upcoming fiscal year that starts in October. For now, some medical centers are absorbing whatever Medicare doesn’t pay.

“How can you tell a patient who’s 66, ‘If only you’d gotten lymphoma when you were 64’? Goldstein asked.

But the current approach can’t continue indefinitely, he said.

“Even if there aren’t any centers that are making that decision today, if coverage doesn’t change for Medicare, it absolutely is going to be a problem tomorrow,” said Goldstein.


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