From Medicine and Health

As The Coronavirus Spreads, Americans Lose Ground Against Other Health Threats

For much of the 20th century, medical progress seemed limitless.

Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the greatest success stories in public health are unraveling.

Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as halting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy inched up slightly in 2018, it hasn’t yet regained the lost ground, according to the Centers for Disease Control and Prevention.

“These trends show we’re going backwards,” said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

“We’ve had an overwhelming investment in doctors and medicine,” said Dr. Sandro Galea, dean of the Boston University School of Public Health. “We need to invest in prevention — safe housing, good schools, living wages, clean air and water.”

The country has split into two states of health, often living side by side, but with vastly different life expectancies. Americans in the fittest neighborhoods are living longer and better — hoping to live to 100 and beyond — while residents of the sickest communities are dying from preventable causes decades earlier, which pulls down life expectancy overall.

Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a “post-antibiotic era.” Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic, and the CDC warns that “little now stands between us and untreatable gonorrhea.”

That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the “failure of American public health,” said Dr. Cornelius “Neil” Clancy, a spokesperson for the Infectious Diseases Society of America. “It should be a global embarrassment.”

The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptions as well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. “The antibiotic market is on life support,” Clancy said. “That shows the real perversion in how the health care system is set up.”

A Slow Decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, “the gains we’re making at the tail end of life cannot make up for what’s happening in midlife.”

Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.

“It’s not that we don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any good if people don’t have access to them.”

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the “tobacco endgame.”

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.

FDA officials say they’ve taken “vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed or sold to kids.” But Myers said FDA officials were slow to recognize the threat to children.

With more than 5 million teens using e-cigarettes, Myers said, “more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of progress.”

Ignoring Science

Where children live has long determined their risk of infectious disease. Around the world, children in the poorest countries often lack access to lifesaving vaccines.

Yet in the United States — where a federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents disregard the medical evidence that vaccinating kids is safe.

Studies show that vaccination rates are drastically lower in some private schools and “holistic kindergartens” than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

By 2000, measles cases had fallen to 86, and the United States declared that year that it had eliminated the routine spread of measles.

“Now, mothers say, ‘I don’t see any measles. Why do we have to keep vaccinating?’” Schaffner said. “When you don’t fear the disease, it becomes very hard to value the vaccine.”

Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status. “Measles is still out there,” Schaffner said. “It is our obligation to understand how fragile our victory is.”

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV can live into old age.

“It’s important to highlight the enormous successes,” Redfield said. “We’re on the verge of ending the HIV epidemic in the U.S. in the next 10 years.”

Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a 2016 study in JAMA.

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. “Personal choices are part of it. But the choices people make depend on the choices they’re given. For far too many people, their choices are extremely limited.”

The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.

In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the poverty that erodes mental and physical health.

“So many of the changes in life expectancy are related to changes in opportunity,” Besser said. “Economic opportunity and health go hand in hand.”

Several policies have been shown to improve health.

Children who receive early childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Improving a person’s environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America’s Health.

“If we think we can treat our way out of this, we will never solve the problem,” Auerbach said. “We need to look upstream at the underlying causes of poor health.”

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Trusting Injection Drug Users With IV Antibiotics At Home: It Can Work

Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He sets out a few rolls of tape and some gauze, then waits for a knock on his front door.

“This is Brenda’s desk,” Jackson said with a chuckle.

Brenda Mastricola is his visiting nurse. After she arrives at Jackson’s home in Boston, she joins him on the couch and starts by taking his blood pressure. Then she changes the bandages on Jackson’s right foot. His big toe was amputated at Brigham and Women’s Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.

Jackson is still taking intravenous penicillin to stop the infection. He came home from the hospital wearing a small medication pump that delivers a steady dose of penicillin via a PICC line. PICC stands for a “peripherally inserted” or “percutaneous indwelling” central catheter, and it resembles a flexible IV tube, inserted into Jackson’s chest.

“This all looks good,” Mastricola said, after making sure the line was clean and in place. “You don’t need me.”

When patients need weeks or months of IV antibiotic treatment but otherwise don’t need to be hospitalized, the standard protocol is to discharge them with a PICC line and allow them to finish the medication at home. It saves money and is much more convenient for patients.

But this arrangement is almost never offered to patients with a history of addiction. The fear is that such patients might be tempted to use the PICC line as a fast and easy way to inject drugs like heroin, cocaine or methamphetamine.

Jackson, 69, was addicted to heroin for 40 years. Although he’s been sober for years, most U.S. hospitals would force patients like Jackson to stay in the hospital, sometimes for eight weeks or more. But Brigham and Women’s in Boston, along with a few others in the U.S., is challenging that protocol, allowing some patients with a history of addiction to go home.

Supporters of the change argue that doing so boosts the chances these patients will stay on their antibiotics and beat the infection.

A Path To Safe At-Home Treatment

A small team of Brigham doctors and nurses started planning this unusual option shortly after opening the Bridge Clinic, a walk-in health center in Boston for patients seeking treatment for a substance use disorder. Dr. Christin Price, one of the clinic’s directors, said virtually every patient who injects drugs develops some kind of infection. It’s difficult to avoid injecting bacteria into the bloodstream when using drugs in an alley or a public bathroom. The national opioid epidemic has led, in many cases, to a parallel increase in diseases related to injection drug use, such as HIV, hepatitis C and bacterial infections of the heart and bones. A study of North Carolina hospitals found a twelvefold increase in cases of bacterial endocarditis, a heart infection, from 2010 to 2015.

“Every time someone uses injection drugs, they’re putting themselves at risk for a very complicated infection,” Price said.

Treatment options for endocarditis patients with a history of drug use are limited. Some skilled nursing facilities, home care agencies and antibiotic infusion companies decline to work with these patients once they’re released from a hospital. And, Price said, some of her patients aren’t willing to remain in a hospital for weeks on end just to finish a round of IV antibiotics.

“They kind of get stir crazy,” she said. “You can imagine it’s almost like being held captive for six weeks, especially when you’re feeling fine now because the infection is clearing. A huge problem is that some of them can’t last — and so they leave before the six weeks are over.”

Patients who don’t complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital.

Doctors and nurses affiliated with the Bridge Clinic wondered if there was a way to send patients with a history of drug use home — safely. They mapped out three requirements: First, patients would have to be taking an addiction treatment medication such as buprenorphine, or be willing to start one. Second, patients would have to check in weekly at the Bridge Clinic. Third, patients would need to have stable housing, and live with a sober friend or loved one. Price and colleagues began months of discussions with specialists in heart, bone and joint conditions, seeking buy-in from surgeons and nurses, so their patients could participate.

“A lot of people did sort of look aghast,” Price said. “It was just their policy that people with a history of injection drug use would not go home.”

When Dr. Daniel Solomon, who is also with Brigham and Women’s, encountered those looks, he said, he’d remind colleagues that “the alternatives aren’t that good either.”

Holding patients for weeks in a hospital room is hard on both the patients and medical providers, he said. And if patients want to use drugs, they’ll find a way to do it, even in a hospital bed.

In spring 2018, Price, Solomon and others enrolled a few of the first qualified patients, then a few more — intentionally cherry-picking those who wanted to be in treatment and had a sober, stable home.

Brenda Mastricola checks on the PICC line through which Arthur Jackson, a former drug user, is receiving penicillin to treat a bone infection.(Jesse Costa/WBUR)

‘I’m Not Going Back’

Arthur Jackson met the requirement that at-home PICC line candidates take addiction treatment medication. He had been on methadone for 10 years, used heroin again, then switched to Suboxone, a combination medication containing buprenorphine and naloxone, which he has been taking for two years. And, in fact, Jackson said he was insulted when one of the doctors presented the home treatment option to him but said she was worried the PICC line might entice him to inject heroin.

“Stop right there,” Jackson recalled telling the nurse. “When it comes to my recovery, I’m serious because I’ve done so much to lick this — this thing.”

Although the possibility did cross Jackson’s mind.

“First thing I thought was, ‘Oh, I could inject heroin in here easily,’” Jackson said. “But I dismissed that thought because I’m not going back” — back to winters on the streets and living from one heroin fix to the next.

Other Bridge patients scoff at the concerns about PICC lines.

“Everyone makes such a big deal about this PICC line,” said Stephen Connolly, 36, who went home with the open port last year, while being treated for endocarditis. “If I want to get high, I know how to do it. I’m not going to mess around with a PICC.”

Connolly said that when he first came to Brigham and Women’s Hospital he was focused on his heart, ignoring his other disease: addiction. He said he was surprised when every doctor he saw, even his cardiologist, wanted to talk about addiction.

“I’m like, ‘Listen, dude. My heart’s falling apart here, so let’s hold up with the drug talk,’” Connolly recalled. He assured the cardiologist he had his addiction under control, even though he wasn’t so sure. “Obviously, I didn’t, but my mind tells me that. It’s just crazy.”

Connolly said he realizes now that the conversation around drug use was relevant and related to his heart infection.

Connolly finished his antibiotic treatment while staying with family members in Abington, Massachusetts. Brigham doctors say the housing requirement excludes otherwise eligible patients. Recent research shows homeless patients who have HIV or hep C do take their antiviral medicines; there are no equivalent robust studies on treating homeless patients who have bacterial infections.

Nevertheless, a few other hospitals are testing ways to continue outpatient treatment for patients who don’t have a stable home. In Portland, Oregon, a medical center tried providing IV antibiotics inside addiction treatment programs. A hospital in Kentucky combines addiction treatment, counseling and outpatient IV antibiotics. In Vancouver, British Columbia, the Canadian national health program pays for small apartments, staffed with a nurse 24 hours a day, where patients can stay while they complete antibiotic treatment.

“People who use drugs deserve the same standard of care,” said Dr. Christy Sutherland, medical director at the Portland Hotel Society in Vancouver. “We can’t change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users.”

Promising Early Signs

Arthur Jackson lives alone in his studio apartment (he does not live with a sober friend or loved one), but he convinced doctors he’d be better off there than in the hospital, so he could visit his 93-year-old mother daily, feed his tankful of tropical fish and his cat, and attend regular Narcotics Anonymous meetings.

“I guess the best way to put it is, I have a life and I need to get back to it,” he said.

Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital to complete IV antibiotic treatment at home. The team is paying particular attention to 21 patients within that group who, unlike Jackson, are active drug users. So far, these men and women have finished their antibiotic treatment via a PICC line with no complications. One had to be readmitted because he had trouble administering the antibiotics. Price said three patients relapsed into drug use, but no one used the PICC line to inject illegal drugs.

“I think we’ve shown, through this pilot, that it is safe and feasible for certain patients,” Price said.

Brigham doctors have not yet published these initial results in a medical journal, though they plan to. But already, Price said, the pilot program is helping to cut health care costs.

Taken as a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility. Not including the cost of home care visits by a home nurse, the savings tally more than $850,000, based on estimates of $1,500 per hospital day.

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

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Democrats Sharpen Health Care Attacks As Primaries Heat Up

The ideal began to get real on Tuesday, as seven of the top contenders for the Democratic presidential nomination sparred over the price tag on health care reform and even revealed similarities on issues like marijuana legalization.

With Democrats in 15 states and American Samoa set to cast their primary votes in the next week, the candidates eagerly seized their chances on the debate stage in Charleston, S.C., to jab Sen. Bernie Sanders of Vermont, the current frontrunner, during the party’s tenth debate.

For all of their interruptions and talking over each other, though, the candidates offered a few thoughtful answers and, seemingly in spite of themselves, agreed on at least decriminalizing marijuana and expunging past, small-scale marijuana possession charges from Americans’ criminal records.

Sanders said he would remove marijuana from the list of controlled substances on the first day of his presidency and added that he would empower black, Latino, and Native American communities to start businesses selling the drug legally, rather than leave corporations to fill what is already a lucrative market.

Mike Bloomberg, the former mayor of New York City, expressed the most skepticism of full legalization because of his concerns about the drug’s effect on the brains of young people. Until we know the science, it’s just nonsensical to push ahead,” he said.

Rural health was also a topic, giving Sen. Amy Klobuchar of Minnesota the opportunity to tout her leadership on bipartisan legislation that would help rural hospitals as well as an immigration bill that would encourage foreign-born doctors trained in the United States to practice in rural areas.

And though the candidates were not asked about abortion rights, the subject came up, briefly and jarringly. Describing how she lost her job as a young teacher when she became pregnant and had no union or legal support to fight back, Sen. Elizabeth Warren of Massachusetts abruptly turned to the allegations of sexual harassment against Bloomberg.

“At least I didn’t have a boss who said to me, ‘Kill it,’ the way that Mayor Bloomberg is alleged to have said to one of his pregnant employees,” Warren said, eliciting gasps.

“I never said that,” Bloomberg said.

Let’s look at what else the candidates claimed.

‘The Incredible Shrinking Price Tag’

Pete Buttigieg, the former mayor of South Bend, Ind., took issue with Sanders’ changing cost estimates for his “Medicare for All” plan.

“Senator Sanders at one point said it was going to be $40 trillion, then 30, then 17. It’s an incredible shrinking price tag,” Buttigieg said. “At some point he said it is unknowable to see what the price tag will be.”

Sanders has indeed cited differing estimates of what Medicare for All would cost.

The $30 to $40 trillion figure alludes to work done by the Urban Institute, a Washington think-tank. It is the only analysis to factor in the price of long-term care — one of the most expensive components of Medicare for All — and finds the program would cost $34 trillion in new federal spending over 10 years. (In terms of national health spending — both public and private dollars, that is — it would result in an increase of just $7 trillion over a decade.) The research makes assumptions that Sanders’ bill leaves open-ended, for instance, estimating what Medicare for All would ultimately pay hospitals and health professionals. Experts note that this is a major hole in Sanders’ plan.

The $17 trillion comes from a paper released this month in the medical journal, The Lancet. The researchers say Medicare for All would save $450 billion annually. That would drop the cost significantly, to just about $17 trillion over 10 years.

This figure is what Sanders relies on in calculating his own plan to finance the single-payer plan. His proposed set of revenues would raise about $17.14 trillion in a decade. (For more information on the Lancet study — whose methodology prompted skepticism from many policy analysts — see our full fact-check.)

Sanders has also said in at least one interview that the price of Medicare for All is “impossible to predict.” This is perhaps the most correct. As analysts repeatedly have told us, the switch to single-payer would represent a shift of unprecedented magnitude in American history. And before you can predict what it would cost, you need to decide what you would pay hospitals and doctors.

Pandemic Specialists: Where Are You Now’?

When the debate turned to the global threat of the new coronavirus, COVID-19, Bloomberg, Klobuchar, and former Vice President Joe Biden used similar talking points: that President Donald Trump cut global health experts from his national security team, leaving the U.S. unprepared to face the virus outbreak either globally or domestically.

“The president fired the pandemic specialists in this country two years ago,” Bloomberg said.

It’s true that, in May 2018, the top White House official who was in charge of the U.S. response to pandemics left the administration. Rear Admiral Timothy Ziemer was the senior director of global health and biodefense on the National Security Council and oversaw global health security issues. That global health team was disbanded after Ziemer’s departure and reorganized as part of a streamlining effort headed by then-National Security Adviser John Bolton.

Ziemer’s position on the NSC has not been filled in the last two years. Tom Bossert, a homeland security adviser who recommended strong defenses against disease and biological warfare, also departed in 2018.  

Last month, Trump announced that Health and Human Services Secretary Alex Azar would be the chair of the coronavirus task force that’s in charge of the U.S. response to the disease. But many are still urging that this position be filled to coordinate the federal response. 

Last week a group of 27 senators sent a letter to current National Security Adviser Robert O’Brien to ask him to appoint a new global health security expert to the NSC.

Preparedness Funding For Global Infections 

Former Vice President Joe Biden said President Donald Trump “cut the funding for CDC.”

Trump has consistently proposed funding cuts to the Centers for Disease Control and Prevention. But Congress has consistently overruled him. 

Because the comment came during a discussion of the United States’ preparedness for emerging global infections like the coronavirus, we looked at the budgets for emerging and zoonotic infectious diseases at CDC, rather than for the CDC as a whole.

The Trump administration’s initial budget proposal has consistently been lower than what was spent the previous year. The administration proposed $61.7 million less in 2018 than 2017; $96.4 million less in 2019 than in 2018; $114.4 million less in 2020 than in 2019; and $85.3 million less in 2021 than 2020.

However, Congress usually treats any president’s budget proposal as an opening volley, with lawmakers reshaping the federal budget as they see fit when they craft final spending bills.

Every year since Trump has been president, lawmakers have passed bills — bills that were eventually signed by the president — that not only exceeded what Trump had asked for on emerging infections but also exceeded what had been spent the previous year.

The next debate, the eleventh of what the Democratic National Committee has said will be 12 presidential primary debates, is scheduled for Sunday, March 15.

PolitiFact’s Louis Jacobson contributed to this story.`

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Bernie Sanders Embraces A New Study That Lowers ‘Medicare For All’s’ Price Tag, But Skepticism Abounds

Defending his signature health plan — a single-payer system known “Medicare for All” that would move all Americans to government-funded coverage  — Vermont Sen. Bernie Sanders argued that the massive health care expansion would actually save the system hundreds of billions of dollars.

Sanders’ figures come from a study published Feb. 15 in The Lancet, a British medical journal.

“It said ‘Medicare for All’ will lower health care costs in this country by $450 billion a year and save the lives of 68,000 people who would otherwise have died,” Sanders said at the Feb. 25 Democratic presidential debate.

The price tag of Medicare for All has been fiercely debated, and some previous analyses have suggested that the proposal would increase health spending, not decrease it. But Sanders is relying on the Lancet paper — which has a cost estimate that is the lowest, in the neighborhood of $17 trillion over 10 years — to argue that the suite of financing mechanisms he has proposed would more than cover the cost of his health bill. (Funding would include taxes on high earners, a new payroll tax, and 4% income premiums for the majority of families.) Most other estimates place the cost between $30 trillion and $40 trillion over a decade, which would make paying for it far more difficult.  So we decided to take a closer look.

We reached out to one of the study’s authors, but never heard back. 

A spokesperson for the Sanders campaign said the paper is “similar to 22 other recent studies that have also shown that moving to a single-payer healthcare system will cost less than our current dysfunctional healthcare system.” (We asked for those 22 other studies but, as of publication, hadn’t received them.)

But independent experts were skeptical of the study’s estimate — arguing it exaggerates potential savings, cherry-picks evidence and downplays some of the potential tradeoffs.

“I don’t think this study, albeit in a prestigious, peer-reviewed journal, should be given any deference in the Medicare for All debate,” said Robert Berenson, a fellow at the Urban Institute who studies hospital pricing.

So, Savings?

Largely, the Lancet paper is more generous in its assumptions than other Medicare for All analysis, noted Jodi Liu, an economist at the RAND Corp., who studies single-payer plans. To the researchers’ credit, she said, they acknowledge that their findings are based on uncertain assumptions.

For instance, the researchers calculate $78.2 billion in savings from providing primary care to uninsured people — $70.4 billion from avoided hospitalizations and $7.8 from avoided emergency room visits. But previous evidence suggests that logic is suspect at best. 

When states expanded Medicaid under the Affordable Care Act, providing new insurance to people who had previously lacked coverage, avoidable hospitalizations and emergency room visits didn’t disappear because people could suddenly use preventive care, noted Ellen Meara, a professor at the Harvard T.H. Chan School of Public Health. That evidence doesn’t appear anywhere in the Lancet paper.

“The notion that we’re going to get rid of all these avoidable visits — that’s not been borne out,” she said. 

The researchers also assume that a Medicare for All system would pay hospitals at a maximum of Medicare rates.

That’s tricky. In 2017, the nonpartisan Medicare Payment Advisory Commission estimated that, on average, a hospital has a -9.9% margin on a patient who is insured through Medicare. (Private pay helps make up that difference.) Some hospitals certainly would be able to swallow this cost. But others would struggle to stay afloat, said Adrianna McIntyre, a health policy researcher at Harvard University 

Given the political influence hospitals in particular carry in Congress — where most members are sensitive to their concerns — passing a plan offering such a low payment rate would be politically challenging.

Sanders’ bill doesn’t actually  specify the rates at which hospitals would be paid.

Beyond the lower payments, the researchers also suggest hospitals would spend less money on overhead, only having to navigate a single insurance plan. That change accounts for $219 billion in their estimated savings.

But again, that ignores some of the reality of how hospitals work. While a single-payer system would undoubtedly cost less to administer — requiring a smaller back-end staff, for instance — it would not eliminate the need for expensive items like electronic health records, which coordinate care between hospitals.

The assumptions are unrealistic,” said Gerard Anderson, a health economist at Johns Hopkins University in Baltimore. “You are never going to save that much money from the various providers.” 

The Cost-Sharing Question

Medicare for All would enroll all Americans in coverage far more generous than what most experience now — eliminating virtually all cost-sharing associated with using health care. 

That’s a major change, researchers told us. Previous evidence suggests that such a shift would encourage consumers to use health care more than they currently do. 

The Lancet paper acknowledges that — but only partially. It allows that people who are uninsured or “underinsured” — that is, who have particularly high levels of cost-sharing now — would use more medical care under Sanders’ system than they currently do. It factors that into the price tag. 

But its estimate does not account for people who already have decent or adequate insurance and who would still be moving to a richer benefit, and therefore more likely to use their insurance. 

“It drastically underestimates the utilization increases we would expect to see under Medicare for All,” McIntyre said. “People have different views on whether the increased utilization is good or bad,” she added — it makes the program more expensive, but also means more people are getting treatment.

Other Estimates?

Context is helpful, too. Other estimates — namely, a projection by the Urban Institute — of Medicare for All have suggested it would increase federal health spending by about $34 trillion over 10 years. But elimination of other health spending would make the overall change smaller. 

To implement the Sanders proposal, national health spending — public and private dollars, both — would increase by $7 trillion over a decade, Urban said. And Medicare for All would be bringing new services: more insurance for more people, and more generous coverage for those already covered.

Urban’s estimate of $7 trillion more in spending over 10 years is far removed from the study’s estimate of $450 billion less annually. And, experts said, relying on the latter figure isn’t a good idea.

“I think they need more work to prove” the savings, Meara said. “They’re not being complete, and by not being complete, they’re not being honest.”

It’s also worth noting that the study’s lead author was also an informal unpaid adviser to the Sanders staff in drafting its 2019 version of the Medicare for All bill, according to the paper’s disclosures section.

The “Lives Saved”

Experts agree that expanding access to health insurance would probably reduce early mortality. But the 68,000 figure is another example of cherry-picking, Meara said.

The figure is based on a 2009 paper. It doesn’t acknowledge a body of research that came after, including multiple studies that examined how expanding Medicaid  affected mortality — and maybe offered less dramatic numbers.

“When they so clearly are cherry-picking, when they clearly have all the  information on studies in front of them, it’s concerning,” Meara said. “It’s a situation where you’re going to overpromise and underdeliver.”

Our Ruling

Sanders said a recent study suggested Medicare for All would save $450 billion annually and saves 68,000 lives.

That study does exist. And it cites some evidence. But many of its assumptions are flawed, and experts uniformly told us it overestimates the potential savings. It cherry-picks data in calculating mortality effects.

This statement has some truth, but ignores context that would create a dramatically different impression. We rate it Mostly False.

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Past As Prologue: Questioning Buttigieg’s Claim About Keeping Your Health Care

As the Democratic presidential campaign moves to the battleground of South Carolina this weekend, candidate Pete Buttigieg, the former mayor of South Bend, Indiana, is highlighting his health plan as he seeks to slow the momentum of the front-runner, Vermont Sen. Bernie Sanders.

In a video ad airing across the state, Buttigieg argues that his health plan — called “Medicare for All Who Want It” — offers Americans their choice of insurance plans, in a way he says Sanders’ more sweeping “Medicare for All” plan does not.

The Sanders plan would eliminate private insurance and move everyone into a government-run program.

Under Buttigieg’s proposal, the ad says, “Everyone gets access to Medicare, if they choose.” Specifically, according to campaign documents, people or employers could buy into a government-provided health plan, which the campaign says would provide an “affordable, comprehensive alternative” to what is sold on the private market.

But, the voiceover adds, “if you like your private plan, you can keep it.”

This isn’t the first time a politician has made such a promise. Arguing in favor of the Affordable Care Act, then-President Barack Obama repeatedly said the health law would let people keep their private health plans, if they liked them.

That didn’t pan out: Millions of Americans’ plans were canceled, spawning months of controversy. In 2013, PolitiFact rated Obama’s statement the “Lie of the Year.”

With that context, we decided to look deeper at Buttigieg’s remark. We reached out to his campaign but never heard back.

An Uncertain Market

Experts we talked to said the former mayor’s remark is remarkably similar to Obama’s ― right down to the pitfalls it encounters.

Those policy analysts said Buttigieg is trying to differentiate his plan from Sanders’ sweeping proposal, arguing his offering is more moderate than Sanders’ and preserves choice. He suggests many Americans would be able to pick between buying private insurance or opting into the government plan.

But does that mean that if you like your plan, you can keep it? As the Obama White House learned, not necessarily.

“It’s like déjà vu all over again,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

The problem is that private insurance availability isn’t up to the government. To be sure, state and federal regulators have the power to dictate, for example, the inclusion of certain benefits and to set basic consumer protections. But the government cannot specifically require insurance companies to offer plans, and any carrier has the option to stop providing coverage.

Already, market forces dictate what health insurance is available from year to year. For example, negotiations between an insurer and physicians could mean that an insurer drops doctors from its network. Changing profit margins could drive a private carrier to exit a certain market. An employer looking to trim expenses might decide to change health insurers, changing coverage offerings for employees.

Buttigieg’s health plan — which would more generously subsidize people buying private insurance than the ACA does and create a public health insurance option that individuals and employers could buy ― wouldn’t change any of those economic scenarios.

“When you have private plans offered and sold by private companies, those private companies are going to make business decisions that might affect your coverage,” Corlette said. “They can opt to get out of the business.”

That’s been especially clear in the ACA individual marketplace. In many counties, only one private insurer sells coverage on the marketplace. It’s impossible to predict, but a competing public option might change the financial incentives for those plans and push some of those carriers to abandon the exchange. If that happened, people using that plan would lose the insurance they have, regardless of how they feel about it.

Put more forcefully, “There’s no way the government can guarantee a private plan will continue, without mandating it will,” said Cynthia Cox, a vice president at the Kaiser Family Foundation.

So, she added, suggesting that people who like their private plans will have the option to keep them under Buttigieg’s proposal is “probably not true.” (KHN is an editorially independent program of the foundation.)

The Employer Question

This is especially the case when it comes to the nearly 160 million people who get their insurance from an employer.

Already, that group experiences volatility when it comes to their health insurance. In 2019, 53% of employers providing coverage considered changing the plan or the carrier they offered, according to a KFF survey. Of that group, almost a fifth — 18% ― ultimately did change insurance carriers.

That flux would likely increase under a plan like Buttigieg’s. Already, many employers (particularly smaller ones) indicate frustration with providing a health benefit that is increasingly complex and expensive. If a public option were cheaper, more might shift employees into that pool, dropping private insurance.

“Even if you don’t want the public option, your employer might decide that they do,” Cox said.

How big the change would be is difficult to gauge. It depends, for instance, on how generous the public option is, how much it costs employers and whether current private insurance trends continue.

Still, “any change you make to the health care environment would cause changes to reverberate throughout the system,” said Sherry Glied, a health economist and dean of New York University’s Wagner School of Public Service. “Any government action will cause change to happen more than they would otherwise.”

It’s worth noting that many people may not be affected. Under the ACA, for instance, 4 million lost their plans, or fewer than 2% of all people who had coverage.

Most people who move from private insurance to the public option would likely have better benefits, said Benjamin Sommers, a health economist at the Harvard T.H. Chan School of Public Health. But, some would be unhappy to lose the existing, private coverage that they know.

“The more accurate soundbite would be most people with private insurance would be able to keep it,” he added. “That would beg the question of who isn’t included there — and the answer is, we don’t know.”

And, in contrast with Sanders’ Medicare for All single-payer proposal, Buttigieg’s plan would preserve much of the current private insurance. But Buttigieg suggests that Medicare for All Who Want It — if administered well — could function as a “glide path” to a Medicare for All world, eventually bringing everyone into the public system.

“There’s good reason to think some of the private insurance competition won’t fare well against ‘Medicare for All Who Want It,’ ” Sommers said. “You might see some of the private plans dropping out. And that may be a sign the policy is working.”

Our Ruling

In a new campaign ad, Buttigieg claims that under his proposal to overhaul the health care system, “if you like your private plan, you can keep it.”

This may be true for some Americans who have private coverage, but it is not true for all. It ignores the inherent instability of the private insurance markets — in which plans are canceled or changed all the time, people often don’t get to pick which private plan is even available to them, and government intervention would likely exacerbate that volatility.

Introducing a public option, as Buttigieg intends to do, could create more incentives for employers to drop private coverage and switch to the public Medicare plan — and, in some cases, for private carriers to exit the individual marketplace. The fact that it would be less disruptive than Medicare for All doesn’t change this.

Buttigieg’s claim has some truth to it, but leaves out key facts and context. We rate it Mostly False.

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U.S. Medical Panel Thinks Twice About Pushing Cognitive Screening For Dementia

A leading group of medical experts on Tuesday declined to endorse cognitive screening for older adults, fueling a debate that has simmered for years.

The U.S. Preventive Services Task Force said it could neither recommend nor oppose cognitive screening, citing insufficient scientific evidence of the practice’s benefits and harms and calling for further studies.

The task force’s work informs policies set by Medicare and private insurers. Its recommendations, an accompanying scientific statement and two editorials were published Tuesday in the Journal of the American Medical Association.

The task force’s new position comes as concern mounts over a rising tide of older adults with Alzheimer’s disease and other dementias and treatments remain elusive. Nearly 6 million Americans have Alzheimer’s disease; that population is expected to swell to nearly 14 million by 2050.

Because seniors are at higher risk of cognitive impairment, proponents say screening ― testing people without any symptoms — is an important strategy to identify people with unrecognized difficulties and potentially lead to better care.

“This can start a discussion with your doctor: ‘You know, you’re having problems with your cognition, let’s follow this up,’” said Stephen Rao of Cleveland Clinic’s Lou Ruvo Center for Brain Health.

Opponents say the benefits of screening are unproven and the potential for harm is worrisome. “Getting a positive result can make someone wary about their cognition and memory for the rest of their life,” said Benjamin Bensadon, an associate professor of geriatric medicine at the University of Florida College of Medicine.

The task force’s stance is controversial, given how poorly the health care system serves seniors with memory and thinking problems. Physicians routinely overlook cognitive impairment and dementia in older patients, failing to recognize these conditions at least 50% of the time, according to several studies.

When the Alzheimer’s Association surveyed 1,954 seniors in December 2018, 82% said they thought it was important to have their thinking or memory checked. But only 16% said physicians regularly checked their cognition.

What’s more, Medicare policies appear to affirm the value of screening. Since 2011, Medicare has required that physicians assess a patient’s cognition during an annual wellness visit if the patient asks for a checkup of this kind. But only 19% of seniors took advantage of this benefit in 2016, the most recent year for which data is available.

Dr. Ronald Petersen, co-author of an editorial accompanying the recommendations, cautioned that they shouldn’t discourage physicians from evaluating older patients’ memory and thinking.

“There is increased awareness, both on the part of patients and physicians, of the importance of cognitive impairment,” said Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center. “It would be a mistake if physicians didn’t pay more attention to cognition and consider screening on a case-by-case basis.”

Similarly, seniors shouldn’t avoid addressing worrisome symptoms.

“If someone has concerns or a family member has concerns about their memory or cognitive abilities, they should certainly discuss that with their clinician,” said Dr. Douglas Owens, chair of the task force and a professor at Stanford University School of Medicine.

In more than a dozen interviews, experts teased out complexities surrounding this topic. Here’s what they told me:

Screening basics. Cognitive screening involves administering short tests (usually five minutes or less) to people without any symptoms of cognitive decline. It’s an effort to bring to light problems with thinking and memory that otherwise might escape attention.

Depending on the test, people may be asked to recall words, draw a clock face, name the date, spell a word backward, relate a recent news event or sort items into different categories, among other tasks. Common tests include the Mini-Cog, the Memory Impairment Screen, the General Practitioner Assessment of Cognition and the Mini-Mental Status Examination.

The task force’s evaluation focuses on “universal screening”: whether all adults age 65 and older without symptoms should be given tests to assess their cognition. It found a lack of high-quality scientific evidence that this practice would improve older adults’ quality of life, ensure that they get better care or positively affect other outcomes such as caregivers’ efficacy and well-being.

A disappointing study. High hopes had rested on a study by researchers at Indiana University, published in December. In that trial, 1,723 older adults were screened for cognitive impairment, while 1,693 were not.

A year later, seniors in the screening group were not more depressed or anxious — important evidence of the lack of harm from the assessment. But the study failed to find evidence that people screened had a better health-related quality of life or lower rates of hospitalizations or emergency department visits.

Two-thirds of seniors who tested positive for cognitive impairment in her study declined to undergo further evaluation. That’s consistent with findings from other studies, and it testifies to “how many people are terrified of dementia,” said Dr. Timothy Holden, an assistant professor at Washington University School of Medicine in St. Louis.

“What seems clear is that screening in and of itself doesn’t yield benefits unless it’s accompanied by appropriate diagnostic follow-up and care,” said Nicole Foster, associate director of the Center for Aging Research at Indiana University’s Regenstrief Institute.

Selective screening. “Selective screening” for cognitive impairment is an alternative to universal screening and has gained support.

In a statement published last fall, the American Academy of Neurology recommended that all patients 65 and older seen by neurologists get yearly cognitive health assessments. Also, the American Diabetes Association  recommends that all adults with diabetes age 65 and older be screened for cognitive impairment at an initial visit and annually thereafter “as appropriate.” And the American College of Surgeons now recommends screening older adults for cognitive impairment before surgery.

Why test select groups? Many patients with diabetes or neurological conditions have overlapping cognitive symptoms and “it’s important to know if a patient is having trouble remembering what the doctor said,” said Dr. Norman Foster, chair of the workgroup that developed the neurology statement and a professor of neurology at the University of Utah.

Physicians may need to alter treatment regimens for older adults with cognitive impairment or work more closely with family members. “If someone needs to manage their own care, it’s important to know if they can do that reliably,” Foster said.

With surgery, older patients who have preexisting cognitive impairments are at higher risk of developing delirium, an acute, sudden-onset brain disorder. Identifying these patients can alert medical staff to this risk, which can be prevented or mitigated with appropriate medical attention.

Also, people who learn they have early-stage cognitive impairment can be connected with community resources and take steps to plan for their future, medically and financially. The hope is that, one day, medical treatments will be able to halt or slow the progression of dementia. But treatments currently available don’t fulfill that promise.

Steps after screening. Screening shouldn’t be confused with diagnosis: All these short tests can do is signal potential problems.

If results indicate reason for concern, a physician should ask knowledgeable family members or friends what’s going on with an older patient. “Are they depressed? Having problems taking care of themselves? Asking the same question repeatedly?” said Dr. David Reuben, chief of geriatrics at UCLA’s David Geffen School of Medicine and director of UCLA’s Alzheimer’s and Dementia Care program.

A comprehensive history and physical examination should then be undertaken to rule out potential reversible causes of cognitive difficulties, implicated in about 10% of cases. These include sleep apnea, depression, hearing or vision loss, vitamin B12 or folic acid deficiencies, alcohol abuse and side effects from anticholinergic drugs or other medications, among other conditions.

Once other causes are ruled out, neuropsychological tests can help establish a diagnosis.

“If I detect mild cognitive impairment, the first thing I’ll do is tell a patient I don’t have any drugs for that but I can help you compensate for deficits,” Reuben said. The good news, he said: A substantial number of patients with MCI ― about 50% — don’t develop dementia within five years of being diagnosed.

The bottom line. “If you’re concerned about your memory or thinking, ask your physician for an assessment,” said Dr. David Knopman, a neurologist at the Mayo Clinic. If that test indicates reason for concern, make sure you get appropriate follow-up.

That’s easier said than done if you want to see a dementia specialist, noted Dr. Soo Borson, a professor emerita of psychiatry at the University of Washington. “Everyone I know who’s doing clinical dementia care says they have wait lists of four to six months,” she said.

With shortages of geriatric psychiatrists, geriatricians, neuropsychologists and neurologists, there aren’t enough specialists to handle demands that would arise if universal screening for cognitive impairment were implemented, Borson warned.

If you’re a family member of an older adult who’s resisting getting tested, “reach out privately to your primary care physician and express your concerns,” said Holden of Washington University. “And let your doctor know if the person isn’t seeing these changes or is resistant to talk about it.”

This happens frequently because people with cognitive impairments are often unaware of their problems. “But there are ways that we, as physicians, can work around that,” Holden said. “If a physician handles the situation with sensitivity and takes things one step at a time, you can build trust and that can make things much easier.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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First Edition: February 25, 2020

Needy Patients ‘Caught In The Middle’ As Insurance Titan Drops Doctors

BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.

Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.

“She knows my kids, answers the phone, is open on Saturdays and is everything for me,” she said.

But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.

Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don’t want to accept the rates insurers are willing to pay. It sometimes occurs when insurers’ business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.

But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians’ practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group.  UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.

Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.

Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.

“It seems like they are steering patients away from small, community-based doctors to large groups that they own,” he said.

Good For Profits

That raises questions about whether this type of “vertical consolidation” — the term for a practice occurring across the country — is a strategy that is good for profits but bad for patients.

UnitedHealthcare said the changes are not part of a campaign to get as many patients as possible to the Riverside practice. It points out that it is retaining the community-based doctors, like Wassef, in its networks to treat its Medicare Advantage and commercial plan members.

But, experts say, traumatic disruptions in doctor-patient relationships are an inevitable result of ongoing shifts in the complicated business of U.S. health care.

Salerno’s main office is in a three-story, 19th-century house in East Orange that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.(Phil Galewitz/KHN)

Facing a rapid consolidation of doctors’ practices and hospital systems — which have hefty negotiating power to demand high fees — insurers have limited options to control costs and maintain a positive balance sheet, said Jacob Wallace, an assistant professor of public health at Yale University. Medicaid plans are especially affected because, unlike commercial plans or even Medicare, they can’t increase premiums or demand copayments.

“Plans face a challenging landscape to keep costs down,” Wallace said. As a result, health plans have taken other approaches, including narrowing provider networks and buying their own physician practices, he said.

But further complicating matters, many Medicaid and Medicare managed-care programs are contracted out to private, for-profit insurers such as UnitedHealthcare. They are looking to create returns for shareholders. With surging enrollment in government programs, UnitedHealthcare has enjoyed rising profits and a stock price that has soared tenfold since 2010.

Wassef and about two dozen other physicians filed a federal lawsuit in September to get reinstated. Wassef, whose termination is scheduled in May, said the move could seriously affect her practice because 80% of her patients are insured by UnitedHealthcare.

UnitedHealthcare gained millions of new customers after the Affordable Care Act led New Jersey and 35 other states and the District of Columbia to expand Medicaid and states turned to private insurers to handle the business. Salama and some other UnitedHealthcare customers said they like their insurance plan because it offers richer benefits than other Medicaid options and covers the medications they use.

The company operates New Jersey’s second-largest Medicaid health plan, with 418,000 members. (The state Department of Human Services has blocked UnitedHealthcare from enrolling any additional Medicaid members, a severe and rare penalty. That move — which is not related to the termination of doctors’ contracts — stems from complaints related to care management and discharge planning, the health plan’s call center and other issues.)

A company spokesperson acknowledged the health plan is dropping 2% of its Medicaid doctors, saying the move was designed to help control costs.

“As health care costs continue to rise, we are working to mitigate the impact on the customers, states and members we serve by negotiating with care providers on their behalf to keep reimbursement rates affordable,” the company said in a statement. “We understand that our members have personal relationships with their doctors and that network changes can be difficult.”

A Practice Destroyed

New Jersey Medicaid officials refused to comment on whether they are concerned about UnitedHealthcare’s actions. But patients caught up in the standoff have reason to worry, said Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute, a coalition of health plans, providers and a variety of health trade groups.

“Once you have a trusted relationship with a provider, it means a lot and it goes to the quality [of your care] because if you are seeing the same providers and you trust them, you are more likely to take your medication and adhere to whatever care plan you have,” she said.

Velylia McIver switched to a new Medicaid health plan after Salerno was initially dropped by UnitedHealthcare in order to keep seeing him.(Phil Galewitz/KHN)

Dr. Alexander Salerno, an internist who runs a 17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff in the lawsuit, is helping lead the court fight. Salerno’s main office is in a three-story, 19th-century house that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.

Until the dispute began last year, Salerno advised his patients to sign up for UnitedHealthcare because of its broad array of benefits, including vision and dental care, and because of the ease in referring to specialists.

And UnitedHealthcare never complained about this group’s skill. In fact, the group received a $130,000 bonus last year for its good care to patients. Salerno said Riverside Medical offered to buy his group practice in 2018, but he declined.

Since UnitedHealthcare announced it would drop his group from the network, more than 500 of his practices’ patients have already changed doctors to stay with the UnitedHealthcare plan, Salerno said.

“It’s not a bad insurance company. It just seems like they have become greedy trying to control both ends of the pendulum — wanting to be the payer and provider,” Salerno said.

A federal judge ordered the case to be heard by a neutral arbitrator, which in late November granted an emergency injunction that will keep Salerno from being removed from UnitedHealthcare’s network until an arbitrator makes a decision on a permanent injunction, which is expected in March.

But that leaves patients in limbo.

Glorida Rivera, 68, said UnitedHealthcare’s decision to drop Salerno was upsetting because she relied on him to care for her diabetes, thyroid and heart conditions. She credits Salerno for referring her to a cardiologist, who put stents in her heart to clear a blockage.

“He knows my whole story, so why do I have to change?” wondered Rivera. Nonetheless, she is sticking with UnitedHealthcare.

Velylia McIver, 83, decided in November to search for another plan so she could stay with Salerno. But it took her more than a month to get coverage for some medications.

“I feel caught in the middle of all this, and it’s the pits,” McIver said.

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The Golden State’s Mixed Record On Lung Cancer

It was a bewildering moment for Zach Jump, the American Lung Association’s national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:

How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?

“It’s like you’d found the needle in the haystack of results,” said Jump. “I don’t know if anyone knew this was going to show up.”

It was right there in the association’s annual “State of Lung Cancer” report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among state residents diagnosed with the disease, nearly a quarter received no treatment — a dismal showing that landed California near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.

Nationally, the report showed a dramatic increase in the five-year survival rate of people diagnosed with the disease. That finding was reinforced by an American Cancer Society report released last month showing that from 2016 to 2017, the U.S. experienced the largest single-year drop in cancer mortality ever reported — driven by a decline in deaths from lung cancer.

California’s low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between 85% and 90% of people who die of lung cancer in the U.S. were smokers, and “California is the poster child for tobacco control,” said Jump.

But what explains the state’s dramatically weaker performance on early diagnosis and treatment?

The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state’s large income inequality, broad cultural and linguistic diversity, inconsistency of health care access by region — and neighborhood — and a financial reluctance by many medical professionals to treat poor people, who smoke at higher rates than those of the general population.

“People aren’t getting screened in the places where the incidence of smoking is the highest,” said Dr. Jorge Nieva, an oncologist with Keck Medicine of the University of Southern California.

A low-dose CT scan, the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it reduced lung cancer deaths by 20% among people at high risk, who were defined as those between ages 55 and 80 with a history of heavy smoking, even if they had quit within the previous 15 years.

The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it — seen as an alarmingly low figure by those who work in the area of prevention. But compared with that low national figure, California’s screening rate is woefully inadequate: just 0.9%.

Performing the exam is profitable — but only if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates far below the national average.

Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. “Unfortunately, it’s the population that doesn’t have great insurance that needs the screening the most,” said Nieva.

Medical experts say the state’s low screening numbers help explain why 24% of California’s diagnosed lung cancer patients receive no treatment at all, well above the national average of around 15%. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren’t offered.

Other factors weigh heavily on California’s ability to boost screening and treatment, according to people with deep experience in the field. Among them:

Cultural barriers. Especially among immigrant groups, “we need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,” said Laurie Fenton Ambrose, president and CEO of the GO2 Foundation for Lung Cancer, a patient advocacy group.

Homelessness. As California’s unhoused population has swelled to over 150,000, health care providers have more difficulty reaching those in need of services. “Many of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,” said Dr. Steven Dubinett, a pulmonologist at UCLA.

Access to primary care. “California has some uniqueness in how hard it is to see a doctor in lots of parts of the state,” Nieva said. “That’s incredibly important when it comes to getting things early on, like that persistent cough you’ve had for a few months.”

Lack of statewide coordination. The state’s Comprehensive Cancer Control Plan hasn’t been updated in almost a decade. “It is inefficient and slow to improve. You don’t even have a plan that lays out its goals for fighting lung cancer,” Fenton Ambrose said.

Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease — including medical problems unrelated to lung cancer that the exam might uncover.

Nieva and Fenton Ambrose said the stigma attached to lung cancer — the notion that patients caused it themselves by smoking — can contribute to a sense of fatalism in both patients and their doctors.

Dubinett favors rolling out screening programs throughout the state, especially in areas where access to health care is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve upon its five-year survival rate for lung cancer patients, which stands at 21.5% — roughly matching the national average of 21.7%, according to the lung association.

Such an initiative may fall to the state, with help from academic medical systems including USC and UCLA.

Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.

“This should be getting done everywhere, and at a 100% rate,” Nieva said. The fact that it’s not is “a real indictment of our health care system.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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