From Medicine and Health

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

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

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

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

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

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

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

Every proposal brings its own trade-offs.

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

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

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

Not quite. But also, kind of.

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

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

And they are talking about this on the campaign trail.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So what other options are Democrats talking about?

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

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

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

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

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

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

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

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

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

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

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

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

There has been a lot of brouhaha on this.

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

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

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

It just isn’t that simple.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sexual-medicine experts say such exclusions are unreasonable.

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

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

The North American Menopause Society applauded the change.

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

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

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

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

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

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

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

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

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

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

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

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

Must-Reads Of The Week From Brianna Labuskes

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

On to the news from the week.

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

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

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

The Associated Press: Parkland Anniversary Highlights Democratic Shift on Guns

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

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

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

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


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

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

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

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

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


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

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


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

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


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

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


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

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

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

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

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

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

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


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

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


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

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

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

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


In the miscellaneous file for the week:

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

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

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

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

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

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

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

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


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

Ambivalence Over Motherhood Could Reshape Practices Around Family Planning

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

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

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

Following Gene-Editing Scandal That Sparked Worldwide Outrage, WHO To Develop Global Ethics Standards For The Tech

Chinese scientist He Jiankui shocked the world when he announced that he’d used gene-editing technology on human embroyos–crossing a line that many had looked at as uncrossable in terms of ethics. In response, the World Health Organization will be forming a committee to offer guidance on the technology.

Insys Founder To Former CEO: ‘You’re Going To Be The Fall Guy’

While Insys Therapeutics, which profited wildly from the sale of a powerful fentanyl spray known as Subsys, was under investigation by federal prosecutors for its marketing practices in 2015. At that time the company’s founder, John Kapoor told then-CEO Michael Babich that Babich would be the one who was going to shoulder the blame — according to Babich, who has pleaded guilty to one count of mail fraud and one count of conspiracy. He is now a key witness in the racketeering prosecution of Kapoor and four other former executives and sales directors.

Glimpsing The Future At Gargantuan Health Tech Showcase

ORLANDO, Fla. — Imagine going to the doctor and finding out before you leave the exam room how much your prescribed drug will cost, avoiding sticker shock at the pharmacy.

Or what if you could wear a tiny device at the top of your back that would gently nudge you to sit up straight whenever you slump.

How about not having to sign by hand a raft of hospital registration papers — instead, doing it all online — and using a laptop computer during your stay for health education purposes?

Innovations like these geared to help consumers were on display here this week at the nation’s largest health technology conference, the Healthcare Information and Management Systems Society meeting — popularly known at HIMSS. More than 40,000 health industry professionals gathered at the Orange County Convention Center, one of only a few in the country large enough to handle the conference.

How big was the meeting?

Attendees could use a 10-minute bus ride to get from one side of the mile-long center to the other. Just touring the exhibit hall was a full-day affair — not counting sitting in on the dozens of educational sessions meant to spur transactions among health businesses.

The exhibit hall had more than 1,300 companies showcasing their latest and greatest products. Traditional technology stalwarts such as IBM and Hewlett Packard Enterprise were on hand, but so were Uber and Lyft. Microsoft, Google and Amazon were selling services amid start-ups, too. Countries — such as Israel — had their own spaces.

Most of the technology on display was geared for the insurers, hospitals and doctors who command more than $3 trillion in annual U.S. health spending.

Terms like artificial intelligence, machine learning and predictive analytics ruled the day here as much as the stuffed animals, candy and other knickknacks attracting visitors. Who knew there were Chrome- and Google-themed socks?

But if you looked closer you could see new devices and systems geared toward changing the consumer experience — whether in the home, doctor’s office or hospital.

“Alexa, I’ve burned my hand what should I do?” asked an exhibitor from the Intelligent Health Association into the Amazon-owned device. “Is it a major burn or minor burn?” Alexa replied, then cited tips on how to treat the hand, such as running the wound under cold water.

A tabletop robot called Pillo showed how consumers could connect to a health coach via video conferencing, submit their latest blood pressure readings electronically to their doctors and dispense that day’s medications.

Around the corner, Surescripts, out of Arlington, Va., was showing how its technology allowed doctors to tap into a patient’s health insurance information to see what the copay would be for medication — and discover if a less expensive alternative existed. Tens of thousands of doctors already make use of the feature, although that represents barely 10 percent of all providers, a Surescripts representative said.

Google had an extensive exhibit showing it could offer a variety of its products, ranging from an indoor map that would help patients navigate through massive medical centers to an online registration tool using Google Cloud that would speed the sign-in process at hospitals. The hospital could then offer a Google Chromebook to provide medical education and other entertainment during a patient’s stay.

One of the products promoted by Google was an online registration tool to speed the sign-in process at hospitals. Upright, an Israeli company, displayed a 2-inch posture trainer that attaches to users’ backs and gently vibrates when they slouch.(Phil Galewitz/KHN)

One feature being offered by Microsoft would appeal to anyone whose doctor spends more time typing notes into a computer during patients’ visits than listening to their problems. The company was showcasing a new speech-to-text program that could convert the entire patient visit into easily readable medical notes. “This has [the] power to save doctors hours of work — each day,” a Microsoft engineer said.

Nearby, Upright Inc. was one of 20 start-up companies at the Israel booth. For $80, it was selling a 2-inch sensor that people could put on their backs, and it would gently vibrate when the user assumed poor posture. An app can provide daily data on posture — call that the slouch rate?

As happy hours kicked into gear in the exhibit hall — free mimosas, wine and beer to go along with all the free coffee, fruit slushies and cookies — I thought it would be great if only I had the indoor Google app to find my way out of the convention center to my car.

One consumer health benefit from the conference already kicked in. My Fitbit showed I had walked nearly 15,000 steps.

Discharged, Dismissed: ERs Often Miss Chance To Set Overdose Survivors On ‘Better Path’

The last time heroin landed Marissa Angerer in a Midland, Texas, emergency room — naked and unconscious — was May 2016. But that wasn’t her first drug-related interaction with the health system. Doctors had treated her a number of times before, either for alcohol poisoning or for ailments related to heavy drug use. Though her immediate, acute health issues were addressed in each episode, doctors and nurses never dealt with her underlying illness: addiction.

Angerer, now 36 and in recovery, had been battling substance use disorder since she started drinking alcohol at age 16. She moved onto prescription pain medication after she broke her ankle and then eventually to street opiates like heroin and fentanyl.

Just two months before that 2016 overdose, doctors replaced an infected heart valve, a byproduct of her drug use. She was discharged from the hospital and began using again the next day, leading to a reinfection that ultimately cost her all 10 toes and eight fingers.

“[The hospital] didn’t have any programs or anything to go to,” Angerer said. “It’s nobody’s fault but my own, but it definitely would have been helpful if I didn’t get brushed off.”

This scenario plays out in emergency departments across the country, where the next step — a means to divert addicted patients into treatment — remains elusive, creating a missed opportunity in the health system.

A recent study of Medicaid claims in West Virginia, which has an opioid overdose rate more than three times the national average and the highest death rate from drug overdoses in the country, documented this disconnect.

Researchers analyzed claims for 301 people who had nonfatal overdoses in 2014 and 2015. By examining hospital codes for opioid poisoning, researchers followed the patients’ treatment, seeing if they were billed in the following months for mental health visits, opioid counseling visits or prescriptions for psychiatric and substance abuse medications.

They found that fewer than 10 percent of people in the study received, per month, medications like naltrexone or buprenorphine to treat their substance use disorder. (Methadone is another option to treat substance use, but it isn’t covered by West Virginia Medicaid and wasn’t included in the study.) In the month of the overdose, about 15 percent received mental health counseling. However, on average, in the year after the overdose, that number fell to fewer than 10 percent per month.

“We expected more … especially given the national news about opioid abuse,” said Neel Koyawala, a second-year medical student at Johns Hopkins School of Medicine in Baltimore, and the lead author on the study, which was published last month in the Journal of General Internal Medicine.

It’s an opportunity that’s being missed in emergency rooms everywhere, said Andrew Kolodny, the co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University outside Boston.

“There’s a lot of evidence that we’re failing to take advantage of this low-hanging fruit with individuals who have experienced a nonfatal overdose,” Kolodny said. “We should be focusing resources on that population. We should be doing everything we can to get them plugged into treatment.”

He compared it to someone who came into the emergency room with a heart attack. It’s taken for granted that the patient would leave with heart medication and a referral to a cardiac specialist. Similarly, he wants patients who come in with an overdose to start buprenorphine in the hospital and leave with a referral to other forms of treatment.

Kolodny and Koyawala both noted that a lack of training and understanding among health professionals continues to undermine what happens after the overdose patient is stabilized.

“Our colleagues in emergency rooms are not particularly well trained to be able to help people in a situation like this,” said Dr. Margaret Jarvis, the medical director of a residential addiction treatment center in Pennsylvania.

It was clear, Angerer said, that her doctors were not equipped to deal with her addiction. They didn’t know, for instance, what she was talking about when she said she was “dope sick,” feeling ill while she was going through withdrawal.

“They were completely unaware of so much, and it completely blew my mind,” she said.

When she left the hospital after her toe and finger amputations, Angerer recalls her next stop seemed to be a tent city somewhere in Midland, where she feared she would end up dead. Instead, she persuaded her mother to drive her about 300 miles to a treatment facility in Dallas. She had found it on her own.

“There were a lot of times I could have gone down a better path, and I fell through the cracks,” Angerer said.

The bottom line, Jarvis said, is that when a patient comes into the emergency room with an overdose, they’re feeling sick, uncomfortable and “miserable.” But surviving that episode, she emphasized, doesn’t necessarily change their perilous condition.

“Risk for overdose is just as high the day after as the day before an overdose,” said Dr. Matt Christiansen, an assistant professor in the Department of Family & Community Health at the Marshall University Joan C. Edwards School of Medicine in West Virginia.

Podcast: KHN’s ‘What The Health?’ “Medicare-For-All” For Dummies

Republicans are still in charge of the White House and the Senate, but the “Medicare-for-all” debate is in full swing. Democrats of every stripe are pledging support for a number of variations on the theme of expanding health coverage to all Americans.

This week, KHN’s “What the Health?” podcast takes a deep dive into the often-confusing Medicare-for-all debate, including its history, prospects and terminology.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Paige Winfield Cunningham of The Washington Post and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Medicare-for-all is a new rallying cry for progressives, but the current Medicare program has big limitations. It does not cover most long-term care expenses, and includes no coverage of hearing, dental, vision or foot care. Medicare also includes no stop-loss or catastrophic care limit that protects beneficiaries from massive bills.
  • Though recent comments by Sen. Kamala Harris on eliminating private insurance with a move to Medicare-for-all stirred controversy, private insurance is indeed involved in many aspects of the government program. Private companies provide the Medicare Advantage plans used by more than a third of beneficiaries, the Medicare drug plans and much of the bill processing for the entire program.
  • Many consumers — and politicians — are confused by the terms being thrown around in the current debate about Medicare-for-all. The plan offered by Sen. Bernie Sanders (I-Vt.) and some of his supporters would be a “single-payer” system, in which the government would be in charge of paying for all health care — although doctors, hospitals and other health care providers would remain private. Others often use the term Medicare-for-all to mean a much less drastic change to the U.S. health care system, such as a “public option” that would offer specific groups of people — perhaps those over age 50 or consumers purchasing coverage on the insurance marketplaces — the opportunity to buy into Medicare coverage.
  • Sanders’ vision of Medicare-for-all is based on Canada’s system. But even there, hospitals and doctors are private businesses, drugs are not covered everywhere, and benefits vary among the provinces.
  • The health care industry is nearly united in opposing the talk of moving to a Medicare-for-all program because of concerns about disruption to the system and less pay. Currently, Medicare reimbursements are about 40 percent lower than private insurance.

If you want to know more about the next big health policy debate, here are some articles to get you started:

Vox’s “Private Health Insurance Exists in Europe and Canada. Here’s How It Works,” by Sarah Kliff

The Washington Post’s “How Democrats Could Lose on Health Care in 2020,” by Ronald A. Klain

The American Prospect’s “The Pleasant Illusions of the Medicare-for-All Debate,” by Paul Starr

The Week’s “Why Do Democrats Think Expanding ObamaCare Would Be Easier Than Passing Medicare-for-All?” by Jeff Spross

Vox’s “How to Build a Medicare-for-All Plan, Explained By Somebody Who’s Thought About It for 20 Years,” by Dylan Scott

The New York Times’ “The Best Health Care System in the World: Which One Would You Pick?” By Aaron E. Carroll and Austin Frakt

The Nation’s “Medicare-for-All Isn’t the Solution for Universal Health Care,” by Joshua Holland

The New York Times’ “’Don’t Get Too Excited’ About Medicare for All,” by Elisabeth Rosenthal and Shefali Luthra

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too.

Julie Rovner: Yahoo News’ “What Trump Got Wrong About ‘Right to Try,’” by Kadia Tubman

Joanne Kenen: STAT News’ “The Modern Tragedy of Fake Cancer Cures,” by Matthew Herper

Rebecca Adams: The Texas Tribune’s “Thousands of Texans Were Shocked By Surprise Medical Bills. Their Requests for Help Overwhelmed the State,” by Jay Root and Shannon Najmabadi

Paige Winfield Cunningham: STAT News’ “The ‘Big Pharma’ Candidate? As He Runs for President, Cory Booker Looks to Shake His Reputation for Drug Industry Coziness,” by Lev Facher

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Podcast: KHN’s ‘What The Health?’ “Medicare-For-All” For Dummies

Republicans are still in charge of the White House and the Senate, but the “Medicare-for-all” debate is in full swing. Democrats of every stripe are pledging support for a number of variations on the theme of expanding health coverage to all Americans.

This week, KHN’s “What the Health?” podcast takes a deep dive into the often-confusing Medicare-for-all debate, including its history, prospects and terminology.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Paige Winfield Cunningham of The Washington Post and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Medicare-for-all is a new rallying cry for progressives, but the current Medicare program has big limitations. It does not cover most long-term care expenses, and includes no coverage of hearing, dental, vision or foot care. Medicare also includes no stop-loss or catastrophic care limit that protects beneficiaries from massive bills.
  • Though recent comments by Sen. Kamala Harris on eliminating private insurance with a move to Medicare-for-all stirred controversy, private insurance is indeed involved in many aspects of the government program. Private companies provide the Medicare Advantage plans used by more than a third of beneficiaries, the Medicare drug plans and much of the bill processing for the entire program.
  • Many consumers — and politicians — are confused by the terms being thrown around in the current debate about Medicare-for-all. The plan offered by Sen. Bernie Sanders (I-Vt.) and some of his supporters would be a “single-payer” system, in which the government would be in charge of paying for all health care — although doctors, hospitals and other health care providers would remain private. Others often use the term Medicare-for-all to mean a much less drastic change to the U.S. health care system, such as a “public option” that would offer specific groups of people — perhaps those over age 50 or consumers purchasing coverage on the insurance marketplaces — the opportunity to buy into Medicare coverage.
  • Sanders’ vision of Medicare-for-all is based on Canada’s system. But even there, hospitals and doctors are private businesses, drugs are not covered everywhere, and benefits vary among the provinces.
  • The health care industry is nearly united in opposing the talk of moving to a Medicare-for-all program because of concerns about disruption to the system and less pay. Currently, Medicare reimbursements are about 40 percent lower than private insurance.

If you want to know more about the next big health policy debate, here are some articles to get you started:

Vox’s “Private Health Insurance Exists in Europe and Canada. Here’s How It Works,” by Sarah Kliff

The Washington Post’s “How Democrats Could Lose on Health Care in 2020,” by Ronald A. Klain

The American Prospect’s “The Pleasant Illusions of the Medicare-for-All Debate,” by Paul Starr

The Week’s “Why Do Democrats Think Expanding ObamaCare Would Be Easier Than Passing Medicare-for-All?” by Jeff Spross

Vox’s “How to Build a Medicare-for-All Plan, Explained By Somebody Who’s Thought About It for 20 Years,” by Dylan Scott

The New York Times’ “The Best Health Care System in the World: Which One Would You Pick?” By Aaron E. Carroll and Austin Frakt

The Nation’s “Medicare-for-All Isn’t the Solution for Universal Health Care,” by Joshua Holland

The New York Times’ “’Don’t Get Too Excited’ About Medicare for All,” by Elisabeth Rosenthal and Shefali Luthra

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too.

Julie Rovner: Yahoo News’ “What Trump Got Wrong About ‘Right to Try,’” by Kadia Tubman

Joanne Kenen: STAT News’ “The Modern Tragedy of Fake Cancer Cures,” by Matthew Herper

Rebecca Adams: The Texas Tribune’s “Thousands of Texans Were Shocked By Surprise Medical Bills. Their Requests for Help Overwhelmed the State,” by Jay Root and Shannon Najmabadi

Paige Winfield Cunningham: STAT News’ “The ‘Big Pharma’ Candidate? As He Runs for President, Cory Booker Looks to Shake His Reputation for Drug Industry Coziness,” by Lev Facher

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Two Crises In One: As Drug Use Rises, So Does Syphilis

Public health officials grappling with record-high syphilis rates around the nation have pinpointed what appears to be a major risk factor: drug use.

“Two major public health issues are colliding,” said Dr. Sarah Kidd, a medical officer at the Centers for Disease Control and Prevention and lead author of a new report issued Thursday on the link between drugs and syphilis.

The report shows a large intersection between drug use and syphilis among women and heterosexual men. In those groups, reported use of methamphetamine, heroin and other injection drugs more than doubled from 2013 to 2017.

The data did not reveal the same increases in drug use among gay men with syphilis, the group with the highest rates of the disease.

Researchers said the results suggest that drug use — and the risky sexual behaviors associated with it — may be driving some of the increase in syphilis transmission among heterosexuals.

People who use drugs are more likely to engage in unsafe sexual behaviors, which put them at higher risk for sexually transmitted diseases, experts said. The CDC also saw increases in syphilis among heterosexuals during the crack cocaine epidemic of the 1980s and 1990s, and use of the drug was associated with higher syphilis transmission.

“The addiction takes over,” said Patricia Kissinger, an epidemiology professor at Tulane University School of Public Health and Tropical Medicine.

For example, people using drugs may avoid condoms, have multiple sex partners or exchange sex for drugs or money — all significant risk factors for sexually transmitted diseases, said Dr. Sara Kennedy, medical director of Planned Parenthood Northern California.

“I think it’s impossible to eradicate syphilis and congenital syphilis unless we are simultaneously addressing the meth-use and IV-use epidemic,” Kennedy said.

Syphilis rates are setting records nationally. They jumped by 73 percent overall and 156 percent for women from 2013 to 2017. The highest rates were reported in Nevada, California and Louisiana.

Syphilis — which had been nearly eradicated before its resurgence in recent years — is treatable with antibiotics, but if left untreated it can lead to organ damage and even death. Congenital syphilis, which occurs when a mother passes the disease to her unborn baby, can lead to premature birth and newborn deaths.

The study’s authors analyzed syphilis cases from 2013 to 2017 and determined which patients had also reported using drugs. They discovered methamphetamine was the biggest problem: More than one-third of women and one-quarter of heterosexual men with syphilis reported using methamphetamine within the previous year.

Substance use among both populations was highest in 13 Western states and lowest in the Northeast. In California, methamphetamine use by people with syphilis nearly doubled for women and heterosexual men from 2013 to 2017, according to the California Department of Public Health.

The intersecting epidemics of sexually transmitted infections and substance abuse make it harder to identify and treat people with syphilis because drug use makes people less likely to go to the doctor and to report their sexual partners, Kidd said.

Pregnant women also may be reluctant to seek prenatal care and get syphilis testing and treatment because of concerns their doctor will report the drug use.

To stem the transmission of syphilis, the CDC urges more collaboration between programs that address STDs and programs that treat substances abuse.

Drug use is an “incredibly huge contributing factor” to somebody getting an STD and transmitting it, said Jennifer Howell, sexual health program coordinator for the health district in Washoe County, Nev.

“Everybody needs to see that we are dealing with a lot of the same clients,” she said.

Fresno County has the highest rate of congenital syphilis in California. Its health department analyzed 25 cases of congenital syphilis in 2017 and determined that more than two-thirds of the mothers were using drugs, said Joe Prado, the county’s community health division manager.

The county has started offering STD testing for people entering inpatient drug treatment facilities, Prado said. “That’s our opportunity to get them screened,” he said.

Those who return for the results are offered incentives such as gift cards. The county also gives people in drug treatment a care package that contains condoms and education materials about sexually transmitted infections, Prado said.

The city of Long Beach sends a mobile clinic to drug treatment facilities, where it provides HIV testing, said Dr. Anissa Davis, the city’s health officer. She said Long Beach hopes to expand services to include screening for other sexually transmitted infections.

Although increased collaboration between drug treatment providers and STD clinics is essential, it’s not always easy because they traditionally have not worked together, said Kissinger of Tulane.

“The STI people are hyperfocused on STIs and the substance abuse people are focused on substance abuse,” she said. It is an “opportunity lost” if people in drug treatment aren’t screened for syphilis and other sexually transmitted infections, she added.

Fighting the rising rates of syphilis will also require more resources, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

“The STD workforce has almost entirely disappeared,” he said. “While policies could be put in place that require syphilis testing, those policies also have to come with resources.”

Two Crises In One: As Drug Use Rises, So Does Syphilis

Public health officials grappling with record-high syphilis rates around the nation have pinpointed what appears to be a major risk factor: drug use.

“Two major public health issues are colliding,” said Dr. Sarah Kidd, a medical officer at the Centers for Disease Control and Prevention and lead author of a new report issued Thursday on the link between drugs and syphilis.

The report shows a large intersection between drug use and syphilis among women and heterosexual men. In those groups, reported use of methamphetamine, heroin and other injection drugs more than doubled from 2013 to 2017.

The data did not reveal the same increases in drug use among gay men with syphilis, the group with the highest rates of the disease.

Researchers said the results suggest that drug use — and the risky sexual behaviors associated with it — may be driving some of the increase in syphilis transmission among heterosexuals.

People who use drugs are more likely to engage in unsafe sexual behaviors, which put them at higher risk for sexually transmitted diseases, experts said. The CDC also saw increases in syphilis among heterosexuals during the crack cocaine epidemic of the 1980s and 1990s, and use of the drug was associated with higher syphilis transmission.

“The addiction takes over,” said Patricia Kissinger, an epidemiology professor at Tulane University School of Public Health and Tropical Medicine.

For example, people using drugs may avoid condoms, have multiple sex partners or exchange sex for drugs or money — all significant risk factors for sexually transmitted diseases, said Dr. Sara Kennedy, medical director of Planned Parenthood Northern California.

“I think it’s impossible to eradicate syphilis and congenital syphilis unless we are simultaneously addressing the meth-use and IV-use epidemic,” Kennedy said.

Syphilis rates are setting records nationally. They jumped by 73 percent overall and 156 percent for women from 2013 to 2017. The highest rates were reported in Nevada, California and Louisiana.

Syphilis — which had been nearly eradicated before its resurgence in recent years — is treatable with antibiotics, but if left untreated it can lead to organ damage and even death. Congenital syphilis, which occurs when a mother passes the disease to her unborn baby, can lead to premature birth and newborn deaths.

The study’s authors analyzed syphilis cases from 2013 to 2017 and determined which patients had also reported using drugs. They discovered methamphetamine was the biggest problem: More than one-third of women and one-quarter of heterosexual men with syphilis reported using methamphetamine within the previous year.

Substance use among both populations was highest in 13 Western states and lowest in the Northeast. In California, methamphetamine use by people with syphilis nearly doubled for women and heterosexual men from 2013 to 2017, according to the California Department of Public Health.

The intersecting epidemics of sexually transmitted infections and substance abuse make it harder to identify and treat people with syphilis because drug use makes people less likely to go to the doctor and to report their sexual partners, Kidd said.

Pregnant women also may be reluctant to seek prenatal care and get syphilis testing and treatment because of concerns their doctor will report the drug use.

To stem the transmission of syphilis, the CDC urges more collaboration between programs that address STDs and programs that treat substances abuse.

Drug use is an “incredibly huge contributing factor” to somebody getting an STD and transmitting it, said Jennifer Howell, sexual health program coordinator for the health district in Washoe County, Nev.

“Everybody needs to see that we are dealing with a lot of the same clients,” she said.

Fresno County has the highest rate of congenital syphilis in California. Its health department analyzed 25 cases of congenital syphilis in 2017 and determined that more than two-thirds of the mothers were using drugs, said Joe Prado, the county’s community health division manager.

The county has started offering STD testing for people entering inpatient drug treatment facilities, Prado said. “That’s our opportunity to get them screened,” he said.

Those who return for the results are offered incentives such as gift cards. The county also gives people in drug treatment a care package that contains condoms and education materials about sexually transmitted infections, Prado said.

The city of Long Beach sends a mobile clinic to drug treatment facilities, where it provides HIV testing, said Dr. Anissa Davis, the city’s health officer. She said Long Beach hopes to expand services to include screening for other sexually transmitted infections.

Although increased collaboration between drug treatment providers and STD clinics is essential, it’s not always easy because they traditionally have not worked together, said Kissinger of Tulane.

“The STI people are hyperfocused on STIs and the substance abuse people are focused on substance abuse,” she said. It is an “opportunity lost” if people in drug treatment aren’t screened for syphilis and other sexually transmitted infections, she added.

Fighting the rising rates of syphilis will also require more resources, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

“The STD workforce has almost entirely disappeared,” he said. “While policies could be put in place that require syphilis testing, those policies also have to come with resources.”