Tagged Cost and Quality

March Madness Vasectomies Encourage Guys To Take One For The Team

Doctors say it all started eight years ago, when a urology clinic in Oregon ran an ad promoting the benefits of scheduling a vasectomy in March.

“You go in for a little snip, snip and come out with doctor’s orders to sit back and watch nonstop basketball,” the voice-over promised. “If you miss out on this, you’ll end up recovering during a weekend marathon of ‘Desperate Housewives’!”

Copycat ads followed. Now a sports radio show in Washington, D.C., has an annual Vasectomy Madness contest, where the prize is a free vasectomy.

Here’s how it works: Three guys come on the air to make their cases for getting snipped. The announcers ruthlessly roast them, and then listeners vote on their favorite.

“All right, let’s bring in our next contestant,” a host said. “I believe it’s Abe from Warrenton, Va. So tell us your story. Why are you here?”

Abe has three kids, ages 9, 6 and 3.

“Another one — surprise! Due in July,” Abe said. “I was shopping after the third for a vasectomy and, like a dope, dragged my feet.”

There’s Mike, also expecting his fourth child — also a surprise.

“My wife and I have had enough,” he pleaded. “We need help to stop the flow.”

And then there’s Charles.

“Four kids. Three different women,” Charles said, inspiring a roar of jeers from the hosts.

Procrastination can be so common with the “Big V” that it takes a panel of sports jocks offering a free procedure for some guys to finally let a doctor take a scalpel to their nether regions.

That may be one reason vasectomy rates are low: About 5 percent of women rely on their partner’s vasectomy for contraception, unchanged from a decade ago. The Centers for Disease Control and Prevention’s National Survey of Family Growth compares that to 20 percent of women who have had a sterilization procedure, even though women’s surgery is more invasive and more expensive.

“Men are culturally the providers. It’s hard for them to seek care,” said Dr. Paul Turek, a California urologist. “They don’t know how to be a patient.”

Turek has clinics in San Francisco and Beverly Hills. He sees an uptick in vasectomy visits during March Madness, and he’s also noticed more guys coming in together.

“One group came in from a tech company in a limousine,” he said.

Last year, five college buddies scheduled a group vasectomy in March. They live all over the U.S. now, and one of them had an idea to reunite in San Francisco and undergo the outpatient procedure together.

“I gave ’em a deal,” Turek said. “I closed the doors. We had sports TV on. They were having fun.”

As each guy returned to the waiting room, he was greeted with fist bumps and high-fives. Then the men hobbled back to their hotel to bet on the games and yell at the television together.

Turek made an interesting observation during that bro basketball weekend: The friends seemed to recover faster than his typical patients.

“They had no complaints,” he said. “They were back at work sooner. They took fewer pain pills. It was the best anesthesia, having their buddies with them.”

Turek gives all his vasectomy patients a certificate of honor for “uncommon bravery and meritorious performance.”

There is another theory about why vasectomies aren’t more popular: the cost. The Affordable Care Act requires insurers to cover contraceptives without charging out-of-pocket costs. But vasectomies weren’t included in the rule. The procedure costs about $500, but some doctors charge up to $1,000.

That’s why Charles subjected himself to the free vasectomy contest at the D.C. radio station. His insurance covers a portion of the procedure, “but I’d still have to pay my deductible, which is, like, a thousand bucks.”

Vasectomy was overlooked in Obamacare because, under the law, birth control was considered a women’s health service.

“Right now the policy says to a couple: Your insurance will cover birth control without any out-of-pocket costs on your end, as long as it’s the woman who’s using it,” says Adam Sonfield, senior policy manager at the Guttmacher Institute.

Last year, 12,000 people signed a petition asking regulators to cover vasectomy without cost sharing. Doctors’ groups even drafted language to this effect to add to the regulations.

But when the Trump administration took over, it told the groups to stop trying, according to Aaron Hamlin, executive director of the Male Contraception Initiative.

“The birth control benefit has been under pretty much continual political attack since the ACA was enacted,” said Sonfield.

So for now that leaves guys like Charles, Mike and Abe vying for a free March Madness vasectomy. The winner in the end?

Abe — one of the guys expecting his fourth child.

His prize came with a catch, though. He will have to let one of the sportscasters come to his appointment, to broadcast a “play-by-play.”

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

Categories: Cost and Quality, Health Industry, Public Health, The Health Law

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Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth

The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.

Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.

Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.

UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. “We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules,” he wrote in an email.

Burns also said that “litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong.”

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.

“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the “winners here are going to be American taxpayers.”

Burns also contends that the cases against UnitedHealth could potentially exceed $1 billion in damages, which would place them among the top two or three whistleblower-prompted cases on record.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.

On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.

“If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars,” Hanagami said.

David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is “deeply concerned by ongoing improper payments” to Medicare Advantage health plans.

These overpayments “undermine the finances of the overall Medicare program,” he said in an emailed statement. He said his group supports “more rigorous oversight” of payments made to the health plans.

The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.

The federal Centers for Medicare & Medicaid Services said in draft regulations issued in January 2014 that it would begin requiring that Medicare Advantage plans report any improper payment — either too much or too little.

These reviews “cannot be designed only to identify diagnoses that would trigger additional payments,” the proposal stated.

But CMS backed off the regulation’s reporting requirements in the face of opposition from the insurance industry. The agency didn’t say why it did so.

The Justice Department said in an April 2016 amicus brief in the Swoben case that the CMS decision not to move ahead with the reporting regulation “does not relieve defendants of the broad obligation to exercise due diligence in ensuring the accuracy” of claims submitted for payment.

The Justice Department concluded in the brief that the insurers “chose not to connect the dots,” even though they knew of both overpayments and underpayments. Instead, the insurers “acted in a deliberately ignorant or reckless manner in falsely certifying the accuracy, completeness and truthfulness of submitted data,” the 2016 brief states.

The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them.

Categories: Cost and Quality, Courts, Health Industry, Medicare

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Federal Government Takes In $22 Billion In Fines Paid By Health Companies Since 2010

Stat looked at data from 39 agencies to analyze which segments of the health care industry have settled with the government. It found that pharmaceutical companies paid the most, accounting for almost 80 percent of penalties.

Stat: Who Paid The Biggest Fines In Health Care?
When you think of business expenses in the health care industry, you probably don’t think about this mostly hidden cost: settlements made with government agencies. From 2010 to 2017, pharmaceutical companies, health care service providers, and producers of medical equipment and supplies paid the federal government more than $22 billion to settle legal cases. STAT analyzed data from 39 federal regulatory agencies that initiated legal actions against health care companies. In some instances, the companies settled cases without acknowledging any wrongdoing. (Bronshtein, 3/27)

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

‘Pre-Hospice’ Saves Money By Keeping People At Home Near The End Of Life

Gerald Chinchar isn’t quite at the end of life, but the end is not far away. The 77-year-old fell twice last year, shattering his hip and femur, and now gets around his San Diego home in a wheelchair. His medications fill a dresser drawer, and congestive heart failure puts him at high risk of emergency room visits and long hospital stays.

Chinchar, a Navy veteran who loves TV Westerns, said that’s the last thing he wants. He still likes to go watch his grandchildren’s sporting events and play blackjack at the casino. “If they told me I had six months to live or go to the hospital and last two years, I’d say leave me home,” Chinchar said. “That ain’t no trade for me.”

Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions.

Sharp HealthCare, the San Diego health system where Chinchar receives care, has devised a way to fulfill his wishes and reduce costs at the same time. It’s a pre-hospice program called Transitions, designed to give elderly patients the care they want at home and keep them out of the hospital.

Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans and teach them how to better manage their diseases. Physicians track their health and scrap unnecessary medications. Unlike hospice care, patients don’t need to have a prognosis of six months or less, and they can continue getting curative treatment for their illnesses, not just for symptoms.

Before the Transitions program started, the only option for many patients in a health crisis was to call 911 and be rushed to the emergency room. Now, they have round-the-clock access to nurses, one phone call away.

“Transitions is for just that point where people are starting to realize they can see the end of the road,” said San Diego physician Dan Hoefer, one of the creators of the program. “We are trying to help them through that process so it’s not filled with chaos.”

The importance of programs like Transitions is likely to grow in coming years as 10,000 baby boomers — many with multiple chronic diseases — turn 65 every day. Transitions was among the first of its kind, but several such programs, formally known as home-based palliative care, have since opened around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside hospital walls.

But a huge barrier stands in the way of pre-hospice programs: There is no clear way to pay for them. Health providers typically get paid for office visits and procedures, and hospitals still get reimbursed for patients in their beds. The services provided by home-based palliative care don’t fit that model.

In recent years, however, pressure has mounted to continue moving away from traditional payment systems. The Affordable Care Act has established new rules and pilot programs that reward the quality rather than the quantity of care. The health reform law, for example, set up “accountable care organizations” networks of doctors and hospitals that share responsibility for providing care to patients. They also share the savings when they rein in unnecessary spending by keeping people healthier. Those changes are helping to make home-based palliative care a more viable option.

In San Diego, Sharp’s palliative care program has a strong incentive to reduce the cost of caring for its patients, who are all in Medicare managed care. The nonprofit health organization receives a fixed amount of money per member each month, so it can pocket what it doesn’t spend on hospital stays and other costly medical interventions.

Gerald Chinchar’s medicine is packed in a kitchen drawer for a Sharp HealthCare Transitions program nurse to check. (Heidi de Marco/KHN)

‘Something That Works’

Palliative care focuses on relieving patients’ stress, pain and other symptoms as their health declines, and it helps them maintain their quality of life. It’s for people with serious illnesses, such as cancer, dementia and heart failure. The idea is for patients to get palliative care and then move into hospice care, but they don’t always make that transition.

The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. Many hospitals now have palliative care programs, delivered by teams of social workers, chaplains, doctors and nurses, for patients who aren’t yet ready for hospice. But until recently, few such efforts had opened beyond the confines of hospitals.

Kaiser Permanente set out to address this gap. Nearly 20 years ago, it created a home-based palliative care program, testing it in California and later in Hawaii and Colorado. Two studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

One of the studies, published in 2007, found that 36 percent of people receiving palliative care at home were hospitalized in their final months, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t.

“We thought, ‘Wow. We have something that works,’” said Susan Enguidanos, an associate professor at the University of Southern California’s Leonard Davis School of Gerontology, who worked on both studies. “Immediately we wanted to go and change the world.”

But Enguidanos knew that Kaiser Permanente was unlike most health organizations. It was responsible for both insuring and treating its patients, so it had a clear financial motivation to improve care and control costs. Enguidanos said she talked to medical providers around the nation about this type of palliative care, but the concept didn’t take off at the time. Providers kept asking the same question: How do you pay for it without charging patients or insurers?

“I liken it to paddling out too soon for the wave,” she said. “We were out there too soon. … But we didn’t have the right environment, the right incentive.”

A Bold Idea

Dan Hoefer’s medical office is in the city of El Cajon, which sits in a valley in eastern San Diego County. Hoefer, a former hospice and home health medical director and nursing home doctor, has spent years treating elderly patients. He learned an important lesson when seeing patients in his office: Despite the medical care they received, “they were far more likely to be admitted to the hospital than make it back to see me.”

When his patients were hospitalized, many would decline quickly. Even if their immediate symptoms were treated successfully, they would sometimes leave the hospital less able to take care of themselves. They would get infections or suffer from delirium. Some would fall.

His patients were like cars with 300,000 miles on them, he said. They had a lot of broken parts. “You can’t just fix one thing and think you have solved the problem,” he said.

And trying to do so can be very costly. About a quarter of all Medicare spending for beneficiaries 65 or older is to treat people in their last year of life, according to a report by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Hoefer’s colleague, Suzi Johnson, a nurse and administrator in Sharp’s hospice program, saw the opposite side of the equation. Patients admitted into hospice care would make surprising turnarounds once they started getting medical and social support at home and stopped going to the hospital. Some lived longer than doctors had expected.

In 2005, the pair hatched and honed a bold idea: What if they could design a home-based program for patients before they were eligible for hospice?

Thus, Transitions was born. They modeled their new program in part on the Kaiser experiment, then set out to persuade doctors, medical directors and financial officers to try it. But they met resistance from physicians and hospital administrators who were used to getting paid for seeing patients.

“We were doing something that was really revolutionary, that really went against the culture of health care at the time,” Johnson said. “We were inspired by the broken system and the opportunity we saw to fix something.”

Doctors, nurses and social workers gather in a small conference room for their bimonthly meeting to discuss patient cases for the Sharp HealthCare Transitions program in January. (Heidi de Marco/KHN)

Despite the concerns, Sharp’s foundation board gave the pair a $180,000 grant to test out Transitions. And in 2007, they started with heart failure patients and later expanded the program to those with advanced cancer, dementia, chronic obstructive pulmonary disease and other progressive illnesses. They started to win over some doctors who appreciated having additional eyes on their patients, but they still encountered “some skepticism about whether it was really going to do any good for our patients,” said Jeremy Hogan, a neurologist with Sharp. “It wasn’t really clear to the group … what the purpose of providing a service like this was.”

Nevertheless, Hogan referred some of his dementia patients to the program and quickly realized that the extra support for them and their families meant fewer panicked calls and emergency room trips.

Hoefer said doctors started realizing home-based care made sense for these patients — many of whom were too frail to get to a doctor’s office regularly. “At this point in the patient’s life, we should be bringing health care to the patient, not the other way around,” he said.

Across the country, more doctors, hospitals and insurers are starting to see the value of home-based palliative care and are figuring out how to pay for it, said Kathleen Kerr, a health care consultant who researches palliative care.

“It is picking up steam,” she said. “You know you are going to take better care of this population, and you are absolutely going to have lower health care costs.”

Providers are motivated in part by a growing body of research. A study published in January showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. Patients in the program also were more likely to go into hospice and to die at home, according to the study.

Two studies of Transitions in 2013 and 2016 reaffirmed that such programs save money. The second study, led by outside evaluators, showed it saved more than $4,200 per month on cancer patients and nearly $3,500 on those with heart failure.

The biggest differences occurred in the final two months of life, said one of the researchers, Brian Cassel, who is palliative care research director at the Virginia Commonwealth University School of Medicine in Richmond.

One reason for the success of these programs is that the teams really get to know patients, their hopes and aspirations, said Christine Ritchie, a professor at UC San Francisco’s medical school. “There is nothing like being in someone’s home, on their turf, to really understand what their life is like,” she said.

A Home Visit

Nurse Sheri Juan and social worker Mike Velasco, who both work for Sharp, walked up a wooden ramp to the Chinchars’ front door one recent January morning. Juan rolled a small suitcase behind her containing a blood pressure cuff, a stethoscope, books, a laptop computer and a printer.

Mary Jo Chinchar was already familiar with Transitions because her mother had been in the program before entering hospice and dying in 2015 at the age of 101. Late last year, Gerald Chinchar’s doctor recommended he enroll in it, explaining that his health was in a “tenuous position.”

Chinchar, who has nine grandchildren and four great-grandchildren, likes to tell stories about his time in the Navy, about traveling the country for jobs and living in San Francisco as a young man.

He has had breathing problems much of his life, suffering from asthma and chronic obstructive pulmonary disease — ailments he partly attributes to the four decades he spent painting and sandblasting fuel tanks for work. Chinchar also has diabetes, a disease that led to his mother’s death. He recently learned he had heart failure.

“I never knew I had any heart trouble,” he said. “That was the only good thing I had going for me.”

Now he’s trying to figure out how to keep it from getting worse: How much should he drink? What is he supposed to eat?

That’s where Juan comes in. Her job is to make sure the Chinchars understand Gerald’s disease so he doesn’t have a flare-up that could send him to the emergency room. She sat beside the couple in their living room, its bookshelves filled with titles on gardening and baseball. A basket of cough drops and a globe sat on a side table.

Any pain today? Juan asked. How is your breathing? Are you more fatigued than before? Is your weight the same? He replied that he had gained a few pounds recently but knew that was because he’d eaten too much bacon.

At this point in the patient’s life, we should be bringing health care to the patient, not the other way around.

Physician Dan Hoefer

Posted on the couple’s refrigerator was a notice advising them to call the nurse if Gerald had problems breathing, increased swelling or new chest pain.

Juan checked his blood pressure and examined his feet and legs for signs of more swelling. She looked through his medications and told him which ones the doctor wanted him to stop taking. “What we like to do as a palliative care program is streamline your medication list,” she said. “They may be doing more harm than good.”

Mary Jo Chinchar said she appreciates the visits, especially the advice about what Gerald should eat and drink. Her husband doesn’t always listen to her, she said. “It’s better to come from somebody else.”

A Nearly Impossible Decision

On a rainy January day, doctors, nurses and social workers gathered in a small conference room for their bimonthly meeting to discuss patient cases. Information about the patients — their hospitalizations, medications, diagnoses — was projected on the wall. Their task: to decide if new patients were appropriate for Transitions and if current patients should remain there.

It’s nearly impossible to predict how long someone will live. It’s an inexact algorithm based on the severity of their disease, depression, appetite, social support and other factors. Nevertheless, the team tries to do just that, and they may recommend hospice for patients expected to live less than six months.

That was the case with an 87-year-old woman suffering from Alzheimer’s disease. She had fallen many times, slept about 16 hours a day and no longer had much of an appetite. Those were all signs that the woman may be close to death, so she was referred to hospice.

Patients typically stay in Transitions about seven or eight months, but some last as long as two years before they stabilize and are discharged from the program. Others go directly to hospice, and still others die while they are still in Transitions.

The group turned its attention to an 89-year-old woman with dementia, who believed she was still a young Navy wife. She suffered from depression and kidney disease, and had been hospitalized twice last year.

“She’s a perfect patient for Transitions,” Hoefer told the team, adding that she could benefit from extra help. Another good candidate, Hoefer said later, was El Cajon resident Evelyn Matzen, who is 94 and has dementia. She had started to lose weight and was having more difficulty caring for herself. They took her in because “we were worried that it was going to start what I call the revolving door of hospitalization,” Hoefer said.

Evelyn Matzen, 94, has been a Sharp HealthCare Transitions patient for eight months. (Heidi de Marco/KHN)

About eight months after she joined the program, Matzen sat in Hoefer’s office as he checked her labs and listened to her chest. Her body was starting to slow down, but she was still doing well, he told her. “Whatever you are doing is working.”

Bill Matzen, who accompanied his mom to the appointment, said she had started to stabilize since going onto Transitions. “She is on less medication, she is in better condition, physically, mentally, the whole nine yards,” he said.

Hoefer explained that frail elderly patients have fewer reserves to tolerate medical treatment and especially hospitalization. Bill Matzen said his mother leaned that the hard way after a recent fall. Though the Transitions nurse had come to see her, the Matzens decided to go to the hospital because they were still concerned about a bruise on her head. While she was in the hospital, Evelyn Matzen started hallucinating and grew agitated.

Being in the hospital “kicks her back a notch or two,” her son said. “It takes her longer to recover than if she had been in a home environment.”

A Changed Climate

Outpatient palliative care programs are cropping up in various forms. Some new ones are run by insurers, others by health systems or hospice organizations. Others are for-profit, including Aspire Health, which was started by former senator Bill Frist in 2013.

Sutter Health operates a project called Advanced Illness Management to help patients manage symptoms and medications and plan for the future. The University of Southern California and Blue Shield of California recently received a $5 million grant to provide and study outpatient care.

“The climate has changed for palliative care,” said Enguidanos, the lead investigator on the USC-Blue Shield project.

Ritchie said she expects even more home-based programs in the years to come, especially if palliative care providers work alongside primary care doctors. “My expectation is that much of what is being done in the hospital won’t need to be done in the hospital anymore and it can be done in people’s homes,” she said.

Challenges remain, however. In addition to questions about reimbursement, not enough trained providers are available. And some doctors are unfamiliar with the approach, and patients may be reluctant, especially those who haven’t clearly been told they have a terminal diagnosis.

Now, some palliative care providers and researchers worry about the impact of President Donald Trump’s plans to repeal the Affordable Care Act and revamp Medicare.

“It would be horrible,” Kerr said. “Before, we had an inkling that this was helping a lot of folks. Now we know it is really helping.”

Gerald Chinchar, who grew up in Connecticut, said he never expected to live into old age. His father, a heavy drinker, died of cirrhosis of the liver at 47. In his family, Chinchar said, “you’re an old-timer if you make 60.”

Chinchar said he gave up drinking and is trying to eat less of his favorite foods — steak sandwiches and fish and chips. He just turned 77, a milestone he credits partly to the pre-hospice program.

“If I make 80, I figured I did pretty good,” he said. “And if I make 80, I’ll shoot for 85.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Categories: Aging, Cost and Quality

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Viewpoints: Support For Paid Leave; Immigrants Afraid Of Seeking Care

A collection of opinions on health care from around the country.

Arizona Republic: The Wrong Bill About Dying Went To Ducey’s Desk
Gov. Doug Ducey can stand up for individual rights and dignity. Or he can sign Senate Bill 1439 and buck a trend toward letting people control their lives and deaths. The bill is ostensibly about religious freedom. It is supported by the powerful Center for Arizona Policy, which supports conservative social policies and is headed by Ducey supporter Cathi Herrod. SB 1439 is supposed to protect health-care professionals and hospitals from discrimination if they refuse to help people die. (Linda Valdez, 3/22)

Louisville (Ky.) Courier-Journal: Savannah’s Funeral – ‘Tired Of Burying My Friends’
We should not feel comfortable raising children in a world where they learn how to order flowers for their friend’s funeral before they learn how to buy a house or start a retirement fund. I am a full-time student with a part-time job. I went to decent schools and stayed away from the neighborhoods my parents warned me about. I am not an anomaly, and neither is gun violence. I apologize if I seem insensitive towards the individual’s right to own a gun, but it is time we take a critical look at our society’s priorities. What good is a world full of guns if we must fill our days with this pain? How many of our children are we willing to lose to maintain our sense of entitlement? (Tara Ann Steiden, 3/23)

The New England Journal of Medicine: Chilling Effect? Post-Election Health Care Use By Undocumented And Mixed-Status Families
Navigating the health care system is particularly difficult for people with limited English proficiency and health literacy or without health insurance or a Social Security number. Many undocumented immigrants and their families therefore go without needed care, to their detriment and sometimes that of others, as in the case of a woman with syphilis who is pregnant with a future U.S. citizen. (Kathleen R. Page and Sarah Polk, 3/23)

The New England Journal of Medicine: Patient Inducements — High Graft Or High Value?
In May 2016, Uber announced a partnership with the Southeastern Pennsylvania Transportation Authority (SEPTA) to provide discounted ride-sharing services to “bridge the first and last mile gap” and encourage people to ride the regional rail system. It was a potential win for all — increased ridership for Uber and SEPTA, decreased traffic and pollution. The partnership was lauded for testing an innovative way to advance social goals. Contrast this partnership with one that might be arranged in health care. For instance, a partnership between a health system and a ride-sharing service to provide free rides for patients with transportation barriers might help elderly patients with disabilities or those with limited transportation options get needed care. However, it might be illegal. (Krisda H. Chaiyachati, David A. Asch and David T. Grande, 3/23)

The New England Journal of Medicine: Adopting Innovations In Care Delivery — The Case Of Shared Medical Appointments
Transformative innovations in care delivery often fail to spread. Consider shared medical appointments, in which patients receive one-on-one physician consultations in the presence of others with similar conditions. Shared appointments are used for routine care of chronic conditions, patient education, and even physical exams. Providers find that they can improve outcomes and patient satisfaction while dramatically reducing waiting times and costs. (Kamalini Ramdas and Ara Darzi, 3/23)

JAMA: The Rise Of Crowdfunding For Medical Care
The rise of medical crowdfunding carries the promise of more efficiently matching potential donors with unmet needs in ways that may increase overall giving, mirroring emerging technologies in other industries such as ride-hailing and retail services that aim to more efficiently match supply and demand. Despite its protean promises, however, medical crowdfunding raises a constellation of ethical and legal hurdles for patients, clinicians, institutions, and society. Understanding these issues will be of increasing importance as medical crowdfunding continues to grow in popularity. (Michael J. Young and Ethan Scheinberg, 3/23)

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

Essential Health Benefits Reviewed: ‘Galling’ Return To Bad Old Days; Lowering Premiums

Some opinion writers urge caution before jettisoning insurance guarantees, but premium costs appear to be at the heart of the argument to get rid of the health law’s essential health benefits.

Los Angeles Times: Remember When You Couldn’t Get Insurance With A Preexisting Condition? Those Days Are Probably Coming Back
Raise your hand if you want to go back to the days when you couldn’t get health insurance because you’d been sick or injured. That’s one of the galling possibilities raised by the evolving version of the American Health Care Act, the House GOP leadership’s plan to repeal and replace Obamacare. The blame lies with the changes that President Trump and House leaders reportedly pledged to make in the bill to win the support of members of a group of far-right House members, the Freedom Caucus. (Jon Healy, 3/23)

Forbes: Bring GOP Right-Wingers And Pragmatists Together On Obamacare — By Making Premiums Affordable
Thursday, March 23 was a wild day in Republicans’ quest to repeal and replace Obamacare, with vote cancellations, last-minute amendments, CBO analyses, and Presidential ultimatums. But the most surprising development of all was this: a way has emerged to get both hard-line and pragmatic conservatives to support the American Health Care Act. … The GOP’s right wing came to a surprisingly pragmatic realization. While refundable tax credits were not their favored approach to health reform, there were too many Republicans who believed otherwise; stubbornness on this point would jeopardize the success of any bill to replace Obamacare. So, congressional hard-liners reoriented their efforts toward repealing most, if not all, of Obamacare’s insurance regulations. (Avik Roy, 3/24)

The New York Times: Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy But Not Chemotherapy
Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don’t need to pay for benefits they won’t use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. … But there are two main problems with stripping away minimum benefit rules. One is that the meaning of “health insurance” can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it. (Margot Sanger-Katz, 3/23)

Huffington Post: Spicer Denies That Ending Maternity Care Guarantee Would Mean Women Pay More For Health Care He’s Wrong.
White House press secretary Sean Spicer on Thursday defended the idea of taking away guaranteed maternity coverage in health insurance, denying that it would mean women must pay relatively more for their health care. He’s wrong about that. Ending the guarantee could mean slightly lower premiums for individual men and much older women, but it would just as surely drive up premiums for women of child-bearing age and their families ― unless it left them paying the full cost of prenatal care and delivery, typically many thousands of dollars, out of their own pockets. (Jonathan Cohn, 3/23)

The New York Times: Yes, Senator, You Wouldn’t Want To Lose Your Mammograms — Or Women Voters
Republicans seem to have an evil genius for tone-deafness when it comes to women. On Thursday, a photograph that was widely circulated on Twitter showed a room packed with white men cutting a deal to eliminate maternity care and mammograms from the package of essential benefits that insurers are required to provide in the Republican bill to replace the Affordable Care Act. There were some women out of camera range, including Kellyanne Conway, the White House counselor. Earlier in the day, Senator Pat Roberts, Republican of Kansas, made an ill-judged quip that he quickly had to apologize for: “I wouldn’t want to lose my mammograms,” he said to a reporter from Talking Points Memo. (Susan Chira, 3/23)

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

Late Move To Dump ‘Essential’ Benefits Could Strand Chronically Ill

A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.

But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.

For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn’t buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.

What might be desirable for business would leave patients vulnerable.

“What you don’t want if you’re an insurer is only sick people buying whatever product you have,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. “So the way to get healthy people is to offer cheaper products designed for the healthy people.”

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The proposed change could give carriers wide room to do that by eliminating or shrinking “essential health benefits” including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don’t step in to fill the void, analysts said.

The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.

Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.

On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. “Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” Spicer told reporters.

Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. “Tomorrow we will show the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” said House Speaker Paul Ryan (R-Wis.). “And tomorrow we’re proceeding.” When asked if he had the votes, Ryan didn’t answer and walked briskly away from the press corps.

But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“They’re not going to offer benefits that attract people with chronic illness if they can help it,”said Claxton, whose collection of old insurance policies shows what the market looked like before.

One Aetna plan didn’t cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn’t cover any mental health treatment. A HealthNet plan didn’t cover outpatient rehabilitative services.

Before the ACA most individual plans didn’t include maternity coverage, either.

The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.

Before President Barack Obama’s health overhaul, insurers could reject sick applicants or charge them higher premiums.

Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn’t even bother to apply.

“You could see even worse holes in the insurance package” than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “If we’re going into a world where a carrier is going to have to accept all comers and they can’t charge them based on their health status, the benefit design becomes a much bigger deal” in how insurers keep the sick out of their plans, she said.

Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one “community” price would weaken coverage for chronically ill people.

“Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law,” he said. Republicans “are shooting themselves in the foot if they the offer this proposal.”

Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.

In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won’t, according to analysts.

“You’re going to have a lot of insurers in states trying to understand what existing laws they have in place,” Koller said. “It’s going to be really critical to see how quickly the states react. There are going to be some states that will not.”

Mary Agnes Carey and Phil Galewitz contributed to this story.

Categories: Cost and Quality, Insurance, Mental Health, Public Health, Repeal And Replace Watch, The Health Law

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Viewpoints: Ryan Says Vote Will Fulfill GOP Promise; Small Business Sees Relief; Vote No On ‘Skinflint’ Bill

A selection of opinions on the health care debate in Congress from around the country.

The Wall Street Journal: Keeping Our Promise To Repeal ObamaCare
The election of Donald Trump and a Republican Congress provides an opportunity: We can immediately halt the leftward drift of American social policy, while renewing prosperity through market-based, state-driven solutions that empower people instead of bureaucrats. This is the stuff of conservative dreams. But it will become reality only if Republicans keep the promises we have made. (House Speaker Paul Ryan, 3/22)

Los Angeles Times: A Healthcare Test We’re Hoping Republicans Will Flunk
On Thursday, House Republicans and President Trump face their first big test since the election that put the GOP in complete control of the federal government. The House will be voting on a bill to repeal much of the healthcare reform law Democrats pushed through Congress in 2010, replacing it with a skinflint alternative that’s projected to leave 24 million more people uninsured in a decade. It’s a horrible proposal, and the main hope for the country is that dissident Republicans will kill it because it’s not awful enough for them. (3/22)

Huffington Post: Mental Health, Maternity Care Guarantees In Jeopardy As GOP Wrangles For Votes
Someone with bipolar disease might have no way to pay for a psychiatrist to monitor his condition. A couple might have to fork over $15,000 to have a baby. These are just two of the possible consequences of a deal now under discussion in the U.S. House as Republican leaders working with the Trump administration try furiously to round up the votes they need to win approval for their bill to repeal the Affordable Care Act. (Jonathan Cohn, 3/23)

Los Angeles Times: Eliminating Essential Health Insurance Benefits Is A Stupid Idea That Won’t Save Money. Here’s Why.
David Anderson of Duke points us to a recent paper by Milliman, the preeminent cost-analysis firm in healthcare, about how much these essential benefits actually add to the cost of health insurance and the consequences of removing the mandates. The paper finds that eliminating the most vulnerable mandates, such as maternity care, will reduce average premiums somewhat but drive costs for people who need those services sky-high and transfer much of the cost to other public programs. The net gain for society is almost invisible. To put it another way, the savings are an illusion. In fact, eliminating the mandates might even cost the federal government more money. (Michael Hiltzik, 3/22)

USA Today: Vote ‘No’ On Ryancare: Our View
During the presidential campaign, Donald Trump repeatedly promised to repeal Obamacare and replace it with “something terrific.” There are many words for the House Republicans’ latest health care plan, embraced by Trump and scheduled for a vote on Thursday. “Terrific” is not among them. (3/22)

USA Today: Repair Damage From Obamacare: Opposing View
For decades, the National Federation of Independent Business (NFIB) has asked small business owners to rank the top challenges. For more than 30 years, their No. 1 problem has been the high cost of health care. Obamacare turned this concern into a crisis for small businesses. It fails to deliver on its main promise to make health care more affordable. For small business owners, the law has made insurance more complicated, more restrictive and more expensive. (Juanita Duggan, 3/22)

Los Angeles Times: The GOP Healthcare Bill Would Be Good For Small Business
The Affordable Care Act, or Obamacare, was perfectly misnamed. It failed entirely to make insurance affordable for small business owners and millions of other Americans. On the contrary, Obamacare has driven up costs for small business owners, who are hit with higher payroll taxes, taxes on health insurance products, the employer and individual mandate penalties, and the so-called Cadillac tax on expensive health insurance plans. (Tom Scott, 3/23)

Richmond Times-Dispatch: Obamacare Stinks. Small Businesses Need Something Better. 
Eight years ago, small-business owners were given many promises about the Affordable Care Act: that it would drive down costs; that small-business owners could take advantage of new tax credits; and that new exchanges would give owners and employees new options to purchase coverage. By the time President Obama signed the bill, it was abundantly clear that the law would do more to harm small businesses than help them. (Nicole Riley, 3/22)

The Washington Post: The GOP’s Health-Care Plan Goes In The Exact Wrong Direction
There’s a lot not to like about America’s fragmented, inefficient health-insurance system. If you had to identify its fundamental flaw, however, it would probably be this: People need medical care whether they have a job or not, yet the U.S. system is built on a linkage between health insurance and employment. (Charles Lane, 3/22)

Los Angeles Times: The GOP’s Tax Cut For Healthcare CEO Pay Is A Bigger Ripoff Of Taxpayers Than It First Seemed
As the House of Representatives prepares to vote Thursday to repeal the Affordable Care Act, there’s a new estimate of the cost of one of its hidden provisions, a rollback of rules designed to restrain executive pay at health insurance companies. Here’s the bottom line: Rolling back the provision will result in an even bigger ripoff of the American taxpayer than previously calculated. (Michael Hiltzik, 3/22)

Boston Globe: Health Bill Isn’t Reform; It’s A Tax Cut For The Wealthy 
Under Barack Obama, the Affordable Care Act adapted the Massachusetts model, and it now covers 22 million formerly uninsured Americans. But congressional Republicans are attacking national health reform and are seeking to destroy the ACA, not reform it. If they succeed, a moderate Republican governor and a liberal state legislature will soon face the choice of undoing coverage or once again leading the country on health reform. (Jon Kingsdale, 3/22)

Boston Globe: Romney’s Health Care Legacy Under Attack, Just Like Obama’s
Romneycare, as it came to be known, provided the conceptual foundation for Obamacare. And President Trump’s commitment to repealing President Obama’s signature accomplishment — the Affordable Care Act — also puts Romney’s signature accomplishment at great risk. Governor Charlie Baker is warning that the Republican plan to repeal the ACA would reduce federal funding to Massachusetts by as much as $1.1 billion to $1.9 billion. (Joan Vennochi, 3/22)

Forbes: In Amended Health Care Bill, GOP Doubles Down On Tax Breaks For The Rich, Reduced Medicaid Funding
Yesterday, the GOP released amendments to its health care bill, and in response to the shortcomings highlighted by the CBO report, the changes to the bill would add more tax breaks for the rich and further slash Medicaid funding. Yup, you read that right. But as counterintuitive as it may seem, there is a method to the GOP’s madness, as yesterday’s changes 1) make it more likely the bill will pass the House and potentially, the Senate, and 2) it brings within reach the bigger prize being sought by Republican leaders: tax reform. (Tony Nitti, 3/22)

The Washington Post: Health-Care Reform Is A Lot Harder Than Tax Cuts. So Why Are The Republicans Trying To Do It First?
Today, the House Republicans are voting on what I consider their awful health-care replacement plan for the Affordable Care Act. I’ve already explained my negativity about the highly regressive American Health Care Act. If you think the problem is that the wealthy don’t have enough after-tax income and the poor have too much health care, this is the plan for you. … Why are Republicans making their lives harder by starting with a complicated health-care replacement plan, one that itself conflates health policy with tax cuts? The answer, as tax analyst Chye Ching Huang points out in a new piece, is that “passing the health package first facilitates deeper tax cuts for the wealthy and corporations in subsequent tax legislation.” (Jared Bernstein, 3/22)

Bloomberg: Republicans Want To Repeal Medicaid, Too 
Under the AHCA, each state would instead be given a capped allowance, and that amount would rise each year with medical inflation. It would not account for any unforeseen expenses. Over time, as the rise in per-patient costs outstripped the rise in general medical inflation — as the Congressional Budget Office assumes they will — the federal share of funding would decline. Hundreds of billions in costs would be shifted from the federal government to the states. In response, states would need to either raise their own spending on Medicaid — or more likely, offer fewer services to fewer people. (3/22)

Seattle Times: Medicaid Is A Lifeline For Our Children
As discussions continue to swirl around the future of our nation’s health-care system and the American Health Care Act (AHCA), it’s vital we do not forget about the well-being of those who represent the future of our nation — our children. Medicaid is the most critical health care program for our country’s youth, and we at Seattle Children’s are deeply alarmed about the proposed changes to Medicaid that would disproportionately impact our children. (Jeff Sperring, 3/22)

The New York Times: Why Medicaid Work Requirements Won’t Work
Paul Ryan’s plan to replace Obamacare is headed to the House floor on Thursday for a vote that, even now, could go either way. That may sound surprising since Republicans have a sizable majority in the House. But if you’ve been following the debate over their replacement plan, the American Health Care Act, you know that, as harsh as it is, it’s not draconian enough for some members of Speaker Ryan’s party. In an attempt to win over those lawmakers, the Republican leadership has offered ideas to restrict coverage even further. One of the worst is a Medicaid work requirement. (Jared Bernstein and Ben Spielberg, 3/22)

Cincinnati Enquirer: America Needs A Clean Repeal Of Obamacare
There is no question that former President Barack Obama’s signature legislation – Obamacare – has been a massive failure with deadly consequences. The law, which requires Americans to buy insurance from private companies, also manages to increase premiums drastically. … Democrats have been stunningly comfortable playing politics with the life and death consequences of health insurance coverage. … Now is the chance to repeal Obamacare, and it is not a minute too soon. (Ken Blackwell, 3/22)

Cincinnati Enquirer: Insurance Has No Place In Medicine
No fiscal conservatives make health care policy or legislation. Nothing about today’s health care system is fiscally conservative. Insurance is a “needless markup” in the healthcare industry. The management and control of the medical/industrial/Congressional complex must be returned to physicians. Doctors receive only 10 percent of the monies that flow through this system, so they are not the cost problem. (James Baker, 3/22)

The Washington Post: Would The GOP Benefit If Its Obamacare Replacement Failed?
House Republicans plan to vote Thursday on an Obamacare replacement plan, called the American Health Care Act. On Tuesday, Post Opinions writer Jennifer Rubin and Alice Stewart, former spokeswoman for Sen. Ted Cruz’s 2016 presidential campaign, discussed how passage of the bill would affect the GOP’s political fortunes. The email discussion was moderated by Post Opinions digital editor James Downie and has been edited for style and clarity. (3/22)

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

Rural Georgia Hospitals To See Financial Benefit From New Tax Increase

In other state hospital news, executives for Beth Israel Deaconess Medical Center and Lahey Health tout the economic benefits of merging the two facilities. And a Philadelphia hospital brings in puppies and kittens to relieve the stress of its medical staff.

Georgia Health News: Recent Events Hearten Advocates Of Georgia’s Rural Hospitals 
Voters in Monroe and Jefferson counties Tuesday approved tax increases to help preserve their rural hospitals, which are in financial danger. And a proposed tax credit upgrade for donors to rural hospitals, an idea that had appeared dead in this year’s Georgia General Assembly session, is alive again less than two weeks before the legislators are expected to adjourn. (Miller, 3/22)

Boston Globe: Beth Israel, Lahey CEOs Say Merger Will Help Contain Health Care Costs
The chief executives of Beth Israel Deaconess Medical Center and Lahey Health on Wednesday pitched their proposed merger as an antidote to the state’s high health care costs, arguing that coming together would allow them to grab market share from pricier hospitals. In their first sit-down interviews with The Boston Globe since going public with their merger negotiations nearly two months ago, Dr. Howard R. Grant of Lahey and Dr. Kevin Tabb of Beth Israel Deaconess said the deal would also help them weather coming changes in the health care market, including shrinking reimbursements from insurers and the government, and changes to federal health care policy. (Dayal McCluskey, 3/23)

The Philadelphia Inquirer: RX For Hospital Stress: Hug A Puppy, Cuddle A Kitten
Wednesday’s event was Paws for Pennsy (P4P), a popular program that was started last year at the Philadelphia hospital. It was the creation of Care for the Care Provider, a hospital committee whose mission is to look at ways to address the stress and even sorrow that can come with being in the medical profession. Losing a longtime patient, experiencing the unexpected death of a patient or colleague, or other on-the-job losses can be so traumatic, the consequences have come to be known as “second-victim phenomenon.” (Giordano, 3/22)

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‘Right-To-Try’ Advocates Help Pass Laws In 33 States As Movement Gains National Foothold

Legislation to allow terminally ill patients access to experimental treatments not approved by the FDA also have momentum in the other 17 states. Today’s other public health stories report developments on a potential sepsis treatment, a devicemaker’s redesigned medical scope, a link between breast implants and a deadly cancer and the latest on the bird flu outbreak.

Stat: ‘Right To Try’ Is Becoming The Law Of The Land, State By State
Over the past three years, “right-to-try” advocates in 33 states have helped enact legislation to eliminate legal obstacles blocking terminally ill patients from treatments that aren’t yet approved by the Food and Drug Administration. Those advocates are showing considerable momentum in the remaining 17 states, potentially upending the established order for experimental drugs. The movement has been fueled in no small part by the anti-regulatory sentiment that propelled Donald Trump’s rise to the presidency and by the explicit support of Vice President Mike Pence. (Tedeschi, 3/23)

NPR: Doctor Turns Up Possible Treatment For Deadly Sepsis
It’s hard not to get excited about news of a potentially effective treatment for sepsis, a condition that leads to multiple organ failure and kills more people in the hospital than any other disease. But there have been so many false promises about this condition over the years, it’s also wise to treat announcements — like one published online by the journal, Chest — with caution. The study, from Eastern Virginia Medical School in Norfolk, Va., reported some remarkable success in treating patients who were at high risk of sudden death. (Harris, 3/23)

Los Angeles Times: Olympus’ Redesigned Scope Linked To Infection Outbreak
Doctors have tied a superbug outbreak at a foreign health facility to a medical scope that Olympus modified last year in an attempt to reduce its risk of spreading bacteria between patients. Five patients treated with the modified device tested positive for the same potentially deadly bacteria, according to a report filed with the Food and Drug Administration. (Petersen, 3/22)

NPR: Breast Implants Linked To Rare Blood Cancer In Small Proportion Of Women
The Food and Drug Administration says at least nine women have died of a rare blood cancer after receiving breast implants, and that the agency is officially acknowledging an association between the implants and the disease. On Tuesday, the agency announced that as of Feb. 1, it had received 359 breast implant-associated reports of a rare type of non-Hodgkin’s lymphoma called anaplastic large cell lymphoma, or ALCL. (Hersher, 3/22)

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Trump Budget Would Shake Medical Research And Health Training Programs

In related news, Mayo Clinic’s CEO says that he urged the Trump administration to maintain funding for research and to take foreign doctors into account in the administration’s immigration policy.

Arizona Republic: Funding For Medical Research, Health Training Takes Hit In Trump Budget
President Donald Trump’s budget outline would have widespread implications for health-care training and research in Arizona, including at the state’s universities. The budget would eliminate $403 million in training programs for nurses and health professionals. The budget would, however, maintain training programs that place practitioners in communities with a shortage of health professionals. (Alltucker and Ryman, 3/22)

The Star Tribune: Mayo CEO Tells Business Leaders He Advised Trump On Value Of Immigration, Research Funding 
Mayo Clinic’s chief executive told Minnesota business leaders Wednesday that he has pressed the Trump administration to maintain federal research funding and keep the nation’s borders open to patients needing care and doctors who seek training. … Immigration restrictions proposed by the Trump administration have presented potential obstacles for foreign doctors in certain nations to practice and train in the United States. (Olson, 3/23)

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How Millennials Win And Lose Under The GOP Health Bill

Designing skateboards is just one of Luke Franco’s gigs. On a recent afternoon, he had just enough time before his next shift to chat at a café in downtown Providence, R.I.

“I work at the YMCA Monday through Friday with kindergartners through fifth-graders. It’s split shift; 7 to 9, 2 to 6 daily,” he said. “With the rest of my day, I also work at a local pizza place. And in addition to that, I also own and operate a small skateboard company.”

But none of his jobs comes with an offer of health insurance. Does that worry him?

“Yes, especially being an avid skateboarder,” the 26-year-old said. “That’s constantly something in the back of my head now — before I try this trick, what happens if I get hurt?”

So he’s looking for a full-time job with benefits. Beyond that, Franco hasn’t fully explored his insurance options. He’s a member of the millennial generation. They represent more than a quarter of the nation’s population. These are people loosely defined as 18 to 34 years old, and they figure prominently in the health care debate. How they fare under the GOP health care bill going through Congress is complicated.

Franco doesn’t know whether he qualifies for Medicaid or a subsidy to buy coverage on the exchange set up under the Affordable Care Act, also called Obamacare.

“I’m assuming that paying full price for it [health care] would be completely unaffordable for me,” he said.

The GOP plan would offer Franco a tax credit of $2,000 a year — that’s the flat amount available to 26- to 29-year-olds to help them buy insurance. The amount goes up to $2,500 for those ages 30 to 39. But even if Franco could buy a plan for a few hundred dollars a month, he doesn’t want to. He would rather hold on to what little pocket money he has for dinner or drinks with friends.

Jen Mishory heads an organization called Young Invincibles, a tongue-in-cheek name for millennials who think they’re too healthy to need health insurance. But the organization is serious about advocating for young people. Mishory said the ACA helped this generation.

“You’re starting pre-ACA with an uninsurance rate of about 29 percent for young people. We see that uninsurance rate drop, over the course of the last five, six years to about 16 percent,” she said. That’s due to many factors, the expansion of Medicaid, for one, and children being able to stay on their parents’ insurance until age 26. That’s how Franco was insured until his last birthday.

But coverage on the exchange is still expensive for some millennials. Even with subsidies, they didn’t sign up for the ACA exchanges in the numbers insurers were hoping for.

Mishory points out the GOP proposal to roll back Medicaid expansion could hurt some young, single adults. The proposed tax credit might help others.

“For some young people, [the tax credit] may be more than what they received under the ACA,” she said. “But for a lot of the low-income young people, they could see reductions in that subsidy.”

What concerns Mishory most is the Republican provision that insurance companies could charge customers 30 percent more for a plan if their coverage lapses.

“Young people are the most likely to see gaps in coverage,” she said. That’s because young adults move and change jobs a lot. They also tend to have lower incomes [than their elders], so the penalty might discourage millennials, especially healthy ones, from enrolling in coverage again.

Molly Tracy, 25, is in a different category than Franco: She’ll buy insurance, penalty or not. But she worries the Republican model won’t be affordable.

“I’m not rich! I work in public education,” said Tracy, who works in a charter school. “So even if I do have coverage, having a $3,000 medical bill … that’s going to pose a significant challenge for me.”

Right now, Tracy is covered by her father’s health insurance. But her 26th birthday is coming soon, “so I’m trying to get a tonsillectomy before my insurance lapses. That’s one of the issues. The other issue is scheduling, having enough time to recover.”

When Tracy does get her own health insurance through work this fall, she wants to know what she will be getting. Will birth control remain affordable? Will mental health care be covered? A Congressional Budget Office analysis finds that people like Tracy might end up paying much more out-of-pocket for those benefits than they do now.

This story is part of a partnership that includes Rhode Island Public Radio, NPR and Kaiser Health News.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law, Uninsured

By Decade’s End, California Estimates It Would Lose $24 Billion Annually Under GOP Health Plan

California would lose $24.3 billion annually in federal funding by 2027 for low-income health coverage under the current Republican plan to replace the Affordable Care Act, according to a state analysis released Wednesday.

The bill, up for a vote in the House on Thursday, represents a “massive and significant fiscal shift” from the federal to state governments by setting caps on Medicaid spending, reducing the amount of money available for new enrollees and eliminating other funding for hospitals and Planned Parenthood, the analysis said.

“It’s really devastating,” said Mari Cantwell, state Medicaid director with the California Department of Health Care Services, who co-wrote the analysis. “It raises some serious questions about whether we can continue to operate the program the way we do today.”

Her boss, department director Jennifer Kent, went further:  “It’s challenging to see how it would not … jeopardize the entire program.”

The analysis, based on internal cost, utilization and enrollment data, was done by the health care services department and the Department of Finance and was shared with California’s congressional delegation.

In 2020 alone, the analysis estimated, the state would lose $6 billion; by 2027, the annual loss would reach $24.3 billion.

Kent said that when faced with shortfalls in the past, the state has made cuts to optional benefits such as adult dental care. The state also could set lower provider rates, or restrict who is eligible. “These are all decisions that California and other states would have to grapple with in the future if this were to be adopted as it is proposed today,” she said.

The impact would vary, of course, depending on the state’s fiscal health.

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The Republican bill, called the American Health Care Act, would dramatically change funding for the Medicaid program, known as Medi-Cal in California. Since its inception, Medicaid funding to states has been open-ended, based on need. Under the new bill, federal money would be capped either through block grants or fixed per-capita amounts.

The Affordable Care Act allowed states to expand their Medicaid programs in 2014 to low-income childless adults, and the federal government is paying nearly all the costs for those new beneficiaries. The new bill would scale the expansion back.

Sally Pipes, president of the San Francisco-based Pacific Research Institute, said the expansion of Medicaid was too costly and should have never been included in the ACA. “These programs are not sustainable, unless you are going to tremendously increase taxes on the middle class,” she said.

Pipes said Medicaid funding should be converted from entitlements into block grants and states should be left to decide how to structure their programs. “More and more people are thinking they are entitled to this and entitled to that and these programs are expensive and not efficient,” she said.

The cuts to Medi-Cal and the restructuring of the program will be better for the California economy, Pipes said.

Meanwhile, Gov. Jerry Brown, who was attending an anniversary celebration for the Affordable Care Act in Washington, D.C., had sharp words Wednesday for President Donald Trump and what he called his “fake health care bill.”

“In California, we’re not talking about a few thousand – we’re talking about millions of real people getting hurt – getting diseases that will not be cured – having heart attacks, not being able to go to a hospital or get a doctor,” the governor said in his prepared remarks.

California was among the most aggressive states in the nation in implementing the Affordable Care Act, and the majority of new enrollees came through Medi-Cal.

Medi-Cal now provides coverage to 13.5 million low-income residents, about half of California’s children and a third of the adults. About 3.7 million people of those became newly eligible for the publicly funded health coverage through the Medcaid expansion. That helped reduce the state’s uninsurance rate from 17 percent in 2013 to about 7 percent in 2016, according to the UC Berkeley Labor Center for Education and Research.

The Medicaid program is funded jointly by California and the federal government and provides health, dental, mental health, long-term care and other services.

The bill could put hospitals, clinics and other providers in a tenuous financial position by forcing them to live within the cost limits while at the same time seeing more uninsured patients, the analysis said.

The California Hospital Association did its own analysis and concluded that at least three million people would lose coverage under the GOP plan, and hospitals could see their bad debt and charity care increase by $3 billion per year.

“As more people lose coverage, they are still going to have health issues, and the hospital is the only place in the health care system required under federal law to provide care,” said Jan Emerson-Shea, vice president of external affairs for the association.

Health officials estimated that Medi-Cal costs would exceed per-capita caps by nearly $680 million in 2020, with the gap growing to $5.28 billion by 2027. That spending limit could have a “devastating and chilling effect” on any increases in provider payments or plan rates, according to the analysis.

The state also expects an additional $3.3 billion in costs in 2020, growing to $13 billion by 2027, because of a change that reduces federal funds for new enrollees and for people who have a break in coverage. The bill would require certain beneficiaries to renew coverage every six months rather than once a year, which state officials say will cause many to lose their coverage.

According to the analysis, the state would face additional losses from other federal cuts, including to a program that pays for in-home care for elderly and disabled residents. In addition, the proposed freeze on federal funding to organizations that provide abortions would make the state responsible for $400 million in payments to Planned Parenthood, which serves more than 600,000 people in Medi-Cal and a state family planning program.

A new study by UC Berkeley’s Labor Center released Wednesday also warned of dramatic cuts in federal Medi-Cal funding that would threaten coverage for low-income adults. The center estimated that the state would have to increase spending by $10 billion each year to maintain coverage for those who became eligible for coverage under the Affordable Care Act. Without that funding, the researchers wrote, 3.7 million people could lose coverage by 2027.

Ken Jacobs, chair of the center, said the Republican plan would also result in job losses because of reduced federal funding. Jacobs said both the center’s and the state’s calculations point to a significant financial impact on California if the GOP bill becomes law.

“It’s hard to see where else in the state budget this could be pulled from,” he said. “This would be a very big hit on the budget, the health system and the economy of California. … And the implications for people’s health are serious.”

 

This story was updated.

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

Categories: Cost and Quality, Repeal And Replace Watch, The Health Law

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Perspectives: FDA Nominee’s Laissez-Faire Regulatory Posture Bad For Public Health

Read recent commentaries about drug-cost issues.

Stat: Scott Gottlieb’s Fervor For Deregulation Could Harm Patients
The Senate will soon begin the process of considering President Trump’s nomination of Dr. Scott Gottlieb, who has close professional and financial ties with the pharmaceutical and biotechnology industries, for commissioner of the Food and Drug Administration. A trial that began in a federal courtroom in Boston in January is a timely reminder of how the laissez-faire regulatory posture that Gottlieb is expected to promote can harm the public’s health. (Renee M. Landers, 3/16)

The Hill: Trump’s Nominee To Lead FDA Could Make Drug Prices Low Again
President Trump is neither a fan of regulation nor high drug prices. So it is no surprise that his nominee to head the Food and Drug Administration, Scott Gottlieb, is a candidate sent straight from central casting. Gottlieb, who is himself a doctor, American Enterprise Institute scholar, and former deputy commissioner of the FDA under President George W. Bush, has long been on record as a critic of the FDA’s overly risk-averse approach to approving new drugs and generic forms of existing ones. (Mytheos Holt, 3/17)

Stat: My Child Is Fighting A Rare Disease. A ‘Streamlined’ FDA Won’t Help Her
My 4-year-old daughter, Elle, is in the fight of her life. Her older sister, Milla, lost her fight last November. Their opponent? Batten disease, a rare, fast-moving, and fatal condition that destroys the central nervous system’s ability to function. Elle has a chance to help manage, or maybe even beat, her disease that Milla didn’t have: a clinical trial in which an investigational protein is infused directly into Elle’s brain every 14 days. (Frazer Gieselmann, 3/17)

Stat: Here’s One Drug Safety Rule The FDA Should Enact — Quickly
Next month, the Food and Drug Administration is likely to miss another target date for implementing a rule to improve generic drug safety. If that happens, the American public will lose. The rule is important because it addresses a maddening quirk in the law. Right now, brand-name drug makers can change product labels after learning about potentially harmful side effects. But generic companies cannot do the same thing — unless such a change has already been made to the corresponding brand-name drug. (Ed Silverman, 3/20)

Bloomberg: There’s A Middle Ground In Amgen’s Drug-Price Battle
The February news that Amgen Inc.’s cholesterol-lowering drug Repatha helped prevent heart attacks was one of the most exciting biotech events of the year, renewing faith in the drug’s blockbuster potential. But the full trial results behind that headline, which Amgen released on Friday, disappointed investors, sinking the company’s shares more than 6 percent.  (Max Nisen, 3/20)

Bloomberg: PTC Sticks Its Face In A Drug-Pricing Wasps’ Nest
It’s generally considered good sense to give wasps’ nests a wide berth. But PTC Therapeutics Inc. just paid $140 million in cash and stock for the pleasure of sticking its face in one.  PTC on Thursday bought the Duchenne Muscular Dystrophy (DMD) drug Emflaza from Marathon Pharmaceuticals. The drug is an old steroid widely and cheaply available in other countries. Marathon got FDA approval for it last month and proceeded to price it at a hefty $89,000 per year. (Max Nisen, 3/16)

The Philadelphia Inquirer: A Toehold On The Confusing World Of Pharma Pricing
I’m about to violate my own HIPAA protections to illustrate the illogical nature of health-care costs. I have toenail fungus on one toe. Right foot, middle toe. Gross, I know. I never did anything about it until a routine visit to the dermatologist last year. When she saw that nasty dawg, she told me there were meds that could fix it. (Michael Smerconish, 3/19)

Bloomberg: Eli Lilly Wants You To Know Its Price Hikes Don’t Work
The drug-pricing debate focuses too much on President Donald Trump’s Twitter account, and too little on the fact that price hikes don’t work that well any more. According to a report it released Monday, Eli Lilly & Co. had a 50-percent-off sale on its drugs in the U.S. in 2016, giving half the list price of its medicines back to insurers and pharmacy benefit managers, on average. It raised list prices by 14 percent, but only received 2.4 percent of that increase. (Max Nisen, 3/20)

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Patient Groups Losing Faith In Pharma

News outlets report on stories related to pharmaceutical drug pricing.

Stat: Drug Makers Have A Bad Reputation Among Patient Groups
As far as many patient groups are concerned, the theme song for the pharmaceutical industry should be Joan Jett’s “Bad Reputation.” For all the criticism that drug makers have endured in recent years, a new survey finds that they are faring worse than ever. Just 38 percent of patient groups thought the pharmaceutical industry had an “excellent” or “good” reputation last year, down from almost 45 percent in 2015, according to PatientView, a research firm that canvassed more than 1,400 patient groups from 105 countries. (Silverman, 3/21)

Boston Globe: Biopharma Facing Stiffer Opposition 
Biopharma, a high-flying industry for most of the past decade, may be coming down to earth. The backlash against steep drug prices has become a rare subject of bipartisan agreement in Washington, D.C. Leading the charge is President Trump, who promised last week that his administration is “going to get drug prices so far lower than they are now your head will spin.” (Weisman, 3/19)

The Wall Street Journal: Sunlight Is The Best Medicine For Pharma
Scrutiny of high drug prices constitutes a major investment risk for big pharma. The industry’s transparency push can help. Eli Lilly released a report Monday that shows the growth of its gross and net prices across its U.S. drug portfolio. They are the third major drug company to release such data this year after Merck & Co. and Johnson & Johnson. The data show that Lilly has raised average gross prices by more than 11% in each of the past five calendar years. (Grant, 3/20)

Stat: Maryland Closer To Penalizing Generic Drug Makers On Prices
Abill that would allow the Maryland attorney general to take legal action against generic drug makers for price gouging cleared a significant hurdle on Monday night when the Maryland House of Delegates overwhelming voted to approve the measure. The legislation, which was approved by a vote of 137-to-4, now goes to the state Senate. Specifically, the bill would require the Maryland Medical Assistance Program to notify the attorney general when an “essential” generic drug rises in price by 50 percent or more within the preceding two-year period. (Silverman, 3/21)

Stat: Pricey Cholesterol Drug Cuts Cardiovascular Risk — But Will Insurers Pay?
Acholesterol-cutting drug from Amgen succeeded in lowering patients’ risk of cardiovascular trouble in a huge clinical trial — but the results, announced Friday, may not be good enough to prompt insurers to cover the expensive drug for millions of patients. Amgen’s treatment, called Repatha, met its goals in a two-year trial on more than 27,000 patients with heart disease who were already taking a maximum dose of statins like Lipitor and yet still had stubbornly high cholesterol. Those who got Amgen’s drug were 15 percent less likely to suffer a bad outcome, defined as heart attack, stroke, hospitalization for chest pain, placement of a stent, or death. (Garde, 3/17)

The Wall Street Journal: Two Cheers For Biogen’s Court Victory
Biogen scored another intellectual property win for its investors Tuesday, but growth concerns remain. The U.S. Patent Trial and Appeal Board upheld a key piece of intellectual property on Biogen’s multiple sclerosis drug Tecfidera, following a hedge fund’s challenge to its validity. Biogen shares rose Tuesday morning, even as most biotech stocks sold off sharply. (Grant, 3/21)

Kaiser Health News: Trump’s Promise To Rein In Drug Prices Could Open Dam To Importation Laws
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress. (Bluth, 3/22)

NPR: U.S. Could Drive Down Drug Prices By Exercising Patent Rights
Rising drug prices are one of the biggest challenges in health care in the United States. More people are using prescription drugs on a regular basis, and the costs of specialty drugs are rising faster than inflation. President Donald Trump has promised over and over again to drive down drug prices. … But Trump already has a weapon he could deploy to cut the prices of at least some expensive medications. (Kodjak, 3/16)

The Associated Press: How Do Insurers Decide What Medicines To Pay For?
How do insurance companies decide what medicines to pay for and when to pay for them? Insurers and other payers look first at how well the drug works — not its cost — when they decide whether to cover the latest treatments, according to the nation’s largest pharmacy benefits manager, Express Scripts. The price patients eventually pay gets determined later, when an insurance company or pharmacy benefits manager decides where a drug fits on a list of covered treatments called a formulary. (Murphy, 3/17)

Kaiser Health News: Prescription Drug Costs Are On The Rise; So Are The TV Ads Promoting Them
Laura Ries was moved to action when she saw a TV commercial that portrayed a woman enjoying time with her grandchildren after taking Lyrica, a prescription medication for diabetic nerve pain. Ries’ elderly mother suffered from just that problem. “The ad showed someone who was enjoying life again,” said Ries, president of a marketing strategy firm in Atlanta, who then researched the drug and spoke with her mother’s doctor. “This … was very relatable to what my mom was experiencing.” (Horovitz and Appleby, 3/20)

The Wall Street Journal: Sanofi’s Prescription For Growth: Drug Sales In The Middle Kingdom
Sanofi SA expects its drug sales in China to grow at least 10% this year, helped by its push outside cities and efforts to tailor medicines to suit local needs, senior executives said. Sales in China last year exceeded €2 billion ($2.15 billion), making it the French company’s third-largest market after the U.S. and France. Drugs accounted for €1.8 billion, with the rest from vaccines and consumer health products. (Rana, 3/21)

Kaiser Health News: Low-Income AIDS Patients Fear Coverage Gains May Slip Away
When Tami Haught was diagnosed with HIV, she was one day shy of her 25th birthday. The diagnosis did not come as a shock since doctors had determined her fiancé was dying of AIDS several weeks earlier. In the two decades since, Haught, 48, has turned to expensive prescription drugs to keep the deadly infection in check. In 2005, she began receiving help purchasing her medications through the AIDS Drug Assistance Program (ADAP), a federally funded network of programs in each state that assist low-income HIV and AIDS patients. Since the Affordable Care Act was implemented, ADAP instead has helped her buy an insurance policy to cover a wide assortment of her health care needs. (Heredia Rodriguez, 3/21)

Stat: Pharma Convinces FDA To Delay Rule On Off-Label Marketing
In response to anger from drug makers, the Food and Drug Administration delayed implementing a final rule until next year that would give the agency greater leeway to police off-label marketing. The move comes three weeks after the pharmaceutical industry filed a petition urging the agency to postpone the rule over concerns it would harm public health and chill “valuable scientific speech.” As we noted previously, the rule says drug makers must update product labeling if there is evidence indicating a company intended its medicine to be used off-label, or for an unapproved use. (Silverman, 3/17)

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State Highlights: Fla. House Committee OKs Hospice Measure; In Ariz., Bill Allowing Providers To Not Give End-Of-Life Instructions Gains Approval

Outlets report on news from Florida, Arizona, Georgia, Illinois, Missouri and California.

Health News Florida: House Panel Approves Hospice Care Expansion 
The House is advancing a measure making it easier for patients to access hospice care. Florida confines hospice services to the final six months of a person’s life.  But Rep. Gayle Harrell (R-Stuart) wants to ensure terminal patients can receive access to pain relief more quickly. (Evans, 3/21)

Georgia Health News: State Shows Improvement In Health System Scorecard
Georgia’s ranking on a health system scorecard has improved from 46th in the nation to 41st. The Commonwealth Fund’s 2017 scorecard ranked the 50 states and the District of Columbia on the most recent data available in five areas: health care access, quality, avoidable hospital use and costs, health outcomes, and health care equity. (Miller, 3/21)

Chicago Tribune: Advocate Children’s Hospital Takes On Rare Surgery To Help Baby Born With Four Legs 
Advocate Children’s Hospital surgeons have successfully operated on a baby from Africa born with two spines and an extra set of legs protruding from her neck. The Park Ridge hospital announced Tuesday that 10-month-old Dominique from Ivory Coast, or Cote d’Ivoire, in West Africa, is recovering well from the March 8 surgery. The baby already has started sitting up again, and doctors expect she’ll be able to live a normal, fully functional life. (Schencker, 3/21)

St. Louis Public Radio: More Farmers Claim That Monsanto’s Leading Weed Killer Product Caused Them Cancer 
Monsanto is facing more pressure to compensate farmers and farm workers who allege that its leading pesticide product caused them to develop cancer. A Los Angeles-based law firm on Friday filed 136 new cases against the company in St. Louis County Circuit Court. The lawsuits allege that exposure to glyphosate, the active ingredient in Roundup, caused the plaintiffs to develop non-Hodgkin’s lymphoma. (Chen, 3/21)

San Jose Mercury News: Walgreens’ “Disney” Animal Crackers Contain Cancerous Chemical, Group Says
“The Jungle Book” may be one of Disney’s most beloved animated movies, but a consumer health watchdog group is warning parents to lay-off feeding their kids Walgreens’ Disney Jungle Book whole grain animal crackers, featuring the storybook characters Mowgli and Baloo on the package. Turns out the bare necessities involved in making that version of the crackers requires higher baking temperatures, which produces excessive levels of a cancer-causing chemical called acrylamide, said Charles Margulis of the Oakland-based Center for Environmental Health. (Seipel, 3/21)

Tampa Bay Times: Senators Poised For First Major Medical Marijuana Hearing
Florida’s new medical marijuana market will start to take shape today as a panel of senators workshops five proposals to put the voter-approved constitutional amendment legalizing the drug into place. The Senate Health Policy committee, chaired by Tampa Republican Sen. Dana Young, will consider issues related to the five proposed bills and hear public comment, the first step toward passing legislation and the first time members of the public will hear what key senators think about how medical marijuana should be implemented. (Auslen, 3/22)

Health News Florida: Florida Legislature Starts To Tackle Medical Marijuana Bills 
Florida senators will begin hashing out possible medical marijuana laws this week. There are five competing bills just in the Florida Senate on how the state should implement a medical marijuana amendment. The Florida Senate’s Health Policy Committee under Senator Dana Young will start the medical marijuana debate. (Aboraya, 3/21)

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Hospital Bills Due To Gun Injuries Cost $6.6 Billion Over Last 8 Years

And that tally does not include expensive emergency room treatment. Today’s stories cover other public health news related to cancer and breast implants, Lewy body dementia, Alzheimer’s, Parkinson’s, smoking, “synthetic biology,” teen marijuana use, heart disease and more.

Los Angeles Times: Gun Injuries Cost Americans $730 Million A Year In Hospital Bills
Americans paid more than $6.6 billion over eight years to care for victims of gun violence, according to a new tally of hospital bills. And U.S. taxpayers picked up at least 41% of that tab. That’s just the tip of the iceberg, say the authors of a study published this week in the American Journal of Public Health. Their sum does not include the initial — and very costly — bill for gunshot victims’ care in emergency rooms. Nor does it include hospital readmissions to treat complications or provide follow-up care. The cost of rehabilitation, or of ongoing disability, is not included either. (Healy, 3/22)

The New York Times: 9 Deaths Are Linked To Rare Cancer From Breast Implants
A rare cancer first linked to breast implants in 2011 has now been associated with nine deaths, the Food and Drug Administration said Tuesday. As of Feb. 1, the agency had received a total of 359 reports of the cancer associated with the implants. The deaths were not caused by breast cancer, the agency said, but by a rare malignancy in the immune system, anaplastic large-cell lymphoma. (Grady, 3/21)

Denver Post: Englewood Doctor Studying Drugs Aimed At Fighting Lewy Body Dementia
[Dr. Rajeev] Kumar explained that Lewy body dementia is caused by the accumulation of the protein, alpha-synuclein, in the brain. The abnormally processed protein clumps together and impacts patients’ cognitive functions including the ability to plan and process information, ability to pay attention and ability to get rapid eye movement, or REM, sleep. Patients are known to physically act out their dreams, sometimes violently. The disorder is also linked to Parkinsonism — stiffness, tremors, slowness that come with the disease’s better-known related disorder, Parkinson’s disease. Behavior and mood problems including depression and anxiety and even hallucinations and delusions may develop. (Rubino, 3/21)

The Washington Post: FDA OKs New Drug As Add-On Treatment For Parkinson’s
U.S. regulators have approved the first new drug in a decade for Parkinson’s disease, a chronic neurological disorder that causes tremors and movement difficulties. The Food and Drug Administration said Tuesday that it has approved Xadago for use when a patient’s regular medicines aren’t working well. The pill was tested in two six-month studies that included about 1,200 patients taking a standard treatment, levodopa. (Johnson, 3/21)

WBUR: Harvard Scientists Call For Better Rules To Guide Research On ‘Embryoids’ 
How far should scientists be allowed to go in creating things that resemble primitive human brains, hearts, and even human embryos? That’s the question being asked by a group of Harvard scientists who are doing exactly that in their labs. They’re using stem cells, genetics and other new biological engineering techniques to create tissues, primitive organs and other living structures that mimic parts of the human body. Their concern is that they and others doing this type of “synthetic biology” research might be treading into disturbing territory. (Stein, 3/21)

The Washington Post: A Big Thing Marijuana Opponents Warned You About Is Definitely Not Happening
A state-run survey of 37,000 middle and high school students in Washington state finds that marijuana legalization there has had no effect on youngsters’ propensity to use the drug. The Washington State Healthy Youth Survey found that the 2016 rate of marijuana use was basically unchanged since 2012, when the state voted to legalize marijuana for recreational use. In the survey, researchers used the measure of “monthly use,” asking students across all grade levels whether they’d used the drug within the past month. (Ingraham, 3/21)

Orange County Register: What Lifestyle Prevents Heart Disease? California Cardiologist Looks To The Amazon For Answers
A Southern California cardiologist’s study of indigenous South Americans found that an extremely healthy lifestyle appears to prevent coronary artery disease, a leading cause of death in the U.S. Dr. Gregory Thomas, medical director of the Heart and Vascular Institute at Long Beach Memorial, helped lead the research project that was published Friday, March 17, in the British journal The Lancet. Researchers took CT scans of the hearts of 705 Tsimane adults who live in the Bolivian Amazon. (Perkes, 3/21)

Seattle Times: Rare, Often Fatal, Respiratory Disease Carried By Mice — Hantavirus — Confirmed In King County
Hantavirus Pulmonary Syndrome (HPS) is the severe respiratory disease in humans caused by infection with hantavirus. Anyone who comes into contact with rodents that carry hantavirus is at risk, according to the CDC. Rodent infestation in and around the home remains the primary risk for hantavirus exposure. There are no reported cases of hantavirus in the U.S. in which the disease was transmitted from one person to another, according to the CDC. (Young, 3/21)

Stat: For Insect Detectives, The Trickiest Cases Involve The Bugs That Aren’t There
Officially, as a scientist in the state Experiment Station’s insect inquiry office, Gale Ridge’s job is to help the public with many-legged creatures that actually exist. She has an “open-door policy”: Anyone can walk in, ring the service bell, and benefit from her expertise…But her most difficult cases haven’t involved spiders or bedbugs or chiggers or mites. Instead, the hardest bugs she has to deal with are the ones that aren’t really there. She labels these cases DP, short for delusional parasitosis. Some entomologists prefer Ekbom syndrome, because it carries less stigma. In the Diagnostic and Statistical Manual of Mental Disorders, which most psychiatrists use, the condition is listed as one kind of delusional disorder, defined as an unshakeable belief that you are being attacked by bugs or parasites even when there is no evidence of infestation. (Boodman, 3/22)

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A Young Man With Parkinson’s Frets Over The Affordability Of GOP Health Plan

Many millennials have their hands full as they launch into adulthood — jobs, homes and partners. But Ford Inbody, 33, already thinks about a time when he won’t be able to work. He has Parkinson’s disease.

Every night after work, he and his wife, Cortney, walk their two dogs through their Overland Park, Kan., neighborhood. For now, going out for an evening’s stroll is easy. But many of their evening conversations revolve around a time they know is coming — when these walks will prove difficult.

Inbody was diagnosed with young-onset Parkinson’s disease three years ago. When he was 25, he started noticing confusing health symptoms like joint stiffness, tremors and loss of smell. He said initially he was relieved to get a definitive diagnosis.

But, he said, “I then started doing more research about it; that’s when it became a little bit scary. There is no cure. There is no way to slow the progression of the disease. There’s nothing really except just symptom management.”

Since the diagnosis, the couple has had to dramatically rethink their future.

“We had to very much start considering life planning,” he said. “We had to make sure, you know, are we going to have enough income?”

They’re not planning to have kids and are bracing for a much more modest lifestyle than they once imagined. They live now with Ford’s grandmother, to save money for the day when the degenerative disease will eventually force him to stop working.

For now he gets health insurance through his job at a law firm, training attorneys on corporate policies. But Ford and Cortney worry about how his condition will progress and how they’ll pay for health care when he can no longer work.

Cortney works in the human resources department for a chocolatier. It is possible Ford could go on her insurance, but when they first ran the numbers, that was prohibitively expensive. So they thought Ford would get private insurance at a reasonable price despite his condition on the Affordable Care Act exchange; then he’d probably transition to Medicaid when his condition gets bad enough. That’s been his plan.

Ford, now 33, was diagnosed with young-onset Parkinson’s disease three years ago. He and Cortney savor his relatively good health today. But the disease is degenerative, which means they’ll likely need an individual health policy one day soon and will eventually turn to Medicaid. (Alex Smith/KCUR)

But ever since the election, he’s been preoccupied with the developments of repeal and replace.

It’s a constant concern, he said — “reading the news every day, checking out all the different stories that are going on.”

Inbody read every word of the original GOP replacement plan, released March 6. He was somewhat relieved to see that, at least so far, it includes the requirement that insurance companies cover preexisting conditions in every plan on the exchange.

“It’s not like a complete ‘all is lost’ situation,” he said. “And I certainly am not jumping from the roof and concerned that Republicans are trying to doom me to a life of no care.”

But he does have questions about how the overhaul of the health law will play out, in terms of his situation. Chris Sloan, a senior manager with the research and consulting firm Avalere Health, said it’s true Inbody would be able to get some sort of insurance policy, regardless. But there’s a big difference between how the new tax credits he’d get under the GOP plan would compare with the ACA subsidies to help pay for insurance costs.

“The changes to the tax credits and to the subsidies available could mean that he’s going to have to pay more,” Sloan said. “Depending on his finances, some of those changes could mean that he has to pay a lot more to get coverage on the individual market.”

Today, the annual ACA subsidies are based on income and the cost of coverage in each region. Under the GOP proposal, Inbody and his wife would, instead, get a flat $5,000 per year to help pay for health insurance coverage for them both. So when Inbody stops working and the couple’s income is much lower, they won’t get extra help in the GOP plan to pay for monthly health insurance premiums.

That’s not all. Sloan explains that, under the GOP plan, some extra help for out-of-pocket costs will disappear.

“With this new proposal, that just doesn’t exist anymore,” he said.

Sloan said there’s also nothing in the new plan to stop another problem — many exchange policies cover fewer medications than employer-based plans, and the networks of doctors and hospitals are getting narrower.

The bill also proposes drastic changes to Medicaid. Inbody could very well end up on Medicaid — it’s the insurance many people with disabilities rely on.

The Republican plan would limit how much money states get for each Medicaid recipient. And though that amount would go up each year, the increase would be based on overall inflation, not the increase in medical costs. So eventually, Sloan said, the federal government would be giving states a lot less money, relative to the cost of health care.

“Then the state has to make a decision. In Kansas’ case, they’ll have to say, ‘How do we make up that difference?’” Sloan said. “They can say, ‘You know what, we’re just going to reduce eligibility. Previously, we gave Medicaid to people up to this income. Now we’re going to take that — a little bit — because we need the money. So we’ll save money by not covering these people.’”

For example, consider Inbody’s case. Restricting eligibility for Medicaid, under the GOP plan, could mean it will be harder for Inbody to get that coverage, Sloan said. Then, “even if he gets Medicaid down the line, how generous are the benefits? Do they cover everything that he needs for his Parkinson’s condition?”

Inbody has hope that whatever legislation is ultimately passed will help him and others with their health problems. But the politics frustrates him.

“The Republicans, they want it their way,” Inbody said. “And the Democrats are going to do everything they can to refuse a Republican victory. And really, what that means in the end is something completely ineffectual that doesn’t really help anybody is going to get passed — and nobody’s really going to be happy about it.”

For now, Inbody said, he’s enjoying the health he has. He and Cortney headed out last weekend on a Colorado road trip.

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

Categories: Cost and Quality, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

Trump’s Promise To Rein In Drug Prices Could Open Dam To Importation Laws

With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.

Congress came close to allowing importation through the Medicare Modernization Act in 2003, but added one firm precondition that has proved a nonstarter. The secretary of Health and Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.

“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard — guaranteeing that no imported prescriptions posed a threat — has kept any secretary of HHS from condoning it.

In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan and Andrew von Eschenbach, who headed the FDA at various times between 2002 through 2016.

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The recent proposal, from Sen. Bernie Sanders (I-Vt.) and such Democrats as Cory Booker from New Jersey and Bob Casey from Pennsylvania, drops that requirement. Instead, it sets up a regulatory system where Canadian pharmacies who purchase their supply from manufacturers inspected by the Food and Drug Administration would be licensed to sell to customers across the border. The bill allows not only individuals but drug wholesalers and pharmacies to buy from Canada.

After two years, HHS could allow importation from other countries that meet standards comparable to those of the U.S.

(Another bill in Congress, proposed in January by John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.) focuses solely on allowing individuals to purchase from such pharmacies.)

Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with Elijah Cummings, Peter Welch (D-Vt.) and the head of Johns Hopkins Hospital, Redonda Miller, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cummings told reporters later that Trump said he supports Medicare price negotiation as well as the Sanders bill.

PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.

“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.

Surveys indicate that up to 8 percent of Americans have bought medicines outside the U.S. even though the practice is technically illegal and imported pills are subject to confiscation.

Around 45 million Americans — 18 percent of the adult population — said last year they did not fill a prescription due to cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of PharmacyChecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company comparing prices offered in Canada to those in New York, shows drugs are frequently three times or more as costly in the U.S. as over the border.

For example, a simple Proventil asthma inhaler costs $73.19 in the U.S. vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in the U.S. but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.

Many previous bills to allow importation or to allow Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77 percent of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.

To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A General Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings and regulatory expenses.

Allowing people to legally import medications wouldn’t totally solve the problem of high prescription drugs, advocates say, but would be a step in the right direction. Said Levitt: “The best way for Americans to afford their meds is to enact polices here to bring the prices down here.”

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

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GAO To Launch Investigation Of FDA’s Orphan Drug Program

Acting on a request from three influential U.S. senators, the government’s accountability arm confirmed that it will investigate potential abuses of the Orphan Drug Act.

The Government Accountability Office still must determine the full scope of what it will look into and the methodology to be used. Determining the scope will take some months, said Chuck Young, GAO’s managing director for public affairs.

Earlier this month, Sens. Orrin Hatch (R-Utah), Chuck Grassley (R-Iowa) and Tom Cotton (R-Ark.) sent a letter to the GAO and raised the possibility that regulatory or legislative changes might be needed “to preserve the intent of this vital law” that gives drugmakers lucrative incentives to develop drugs for rare diseases.

Grassley’s office said Tuesday they expected the GAO to begin its work in about nine months. The delay is typical as the agency has a queue of requests it is pursuing.

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The senators have asked the GAO to “investigate whether the ODA is still incentivizing product development for diseases with fewer than 200,000 affected individuals, as intended.”

Congress overwhelmingly passed the 1983 Orphan Drug Act to motivate pharmaceutical companies to develop drugs for people whose rare diseases had been ignored. Drugs approved as orphans are granted tax incentives and seven years of exclusive rights to market drugs that are needed by fewer than 200,000 patients in the U.S.

In recent months, reports of five- and six-figure annual price tags for orphan drugs have amplified long-simmering concerns about abuse of the law. The senators’ call for a GAO investigation reflects that sentiment.

“While few will argue against the importance of the development of these drugs, several recent press reports suggest that some pharmaceutical manufacturers might be taking advantage of the multiple designation allowance in the orphan drug approval process,” the letter states.

In January, Kaiser Health News published an investigation that found the orphan drug program is being manipulated by drugmakers to maximize profits and to protect niche markets for medicines being taken by millions.

That investigation, which also was published and aired by NPR, found that many drugs that now have orphan status aren’t entirely new. More than 70 were drugs first approved by the Food and Drug Administration for mass-market use. Those include cholesterol blockbuster Crestor, Abilify for psychiatric disorders and the rheumatoid arthritis drug Humira, the world’s best-selling drug.

Others are drugs that have received multiple exclusivity periods for two or more rare conditions.

The senators asked the GAO for a list of drugs approved or denied orphan status by the FDA. It also asked if resources at the FDA, which oversees the law, have “kept up with the number of requests” from drugmakers and whether there is consistency in the department’s reviews.

And they said it would be important to include patient experiences in the GAO review. The GAO does not provide updates on ongoing work but rather reports its findings once they complete an assignment.

The rare-disease drugs have become increasingly popular with pharmaceutical and biotech companies and are expected to comprise 21.4 percent of worldwide prescription sales by 2022, not including generics, according to consulting firm EvaluatePharma’s 2017 orphan drug report.

That’s in part because of the exorbitant prices that can be charged. Of the top 100 drugs in the U.S., the average cost per patient per year for an orphan drug was $140,443 in 2016, compared with $27,756 for a non-orphan, EvaluatePharma said.

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

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Trump Wants To Get Health Care Out Of The Way So He Can Move Onto Other Issues

The president, at a rally in Kentucky Monday night, spoke about what he wants to do once lawmakers keep their campaign promises to dismantle the Affordable Care Act.

Politico: Trump Sounds Done With Health Care Before He’s Really Started
On the precipice of the meatiest legislative fight of his young presidency, Donald Trump is increasingly talking about health care like the vegetables of his agenda — the thing he must begrudgingly finish in order to get to what he really wants: tax cuts, trade deals and infrastructure. (Goldmacher, 3/20)

The Associated Press: Trump Going Outside Washington For Support On Health Bill
Trump rallied supporters Monday night in Louisville, Kentucky, alongside Senate Majority Leader Mitch McConnell, R-Ky., after meetings and phone calls in Washington aimed at steadying the troubled legislation designed to erase President Barack Obama’s signature health care law. He planned to court House Republicans on Tuesday. (Thomas and Bykowicz, 3/20)

Fox News: Trump Tells Louisville Rally GOP Health Bill Is Chance To End ‘ObamaCare Catastrophe’
In a speech peppered with shout-outs to Kentucky’s congressional delegation — “Hey, Mitch,” Trump asked Senate Majority Leader Mitch McConnell at one point, “we gonna be OK? … That health care’s looking good?” — the president warned the crowd that if the health bill did not pass, “the alternative is what you have [and] what you have is nothing.” Trump also attempted conciliation toward Sen. Rand Paul, R-Ky., one of the bill’s most outspoken opponents, saying, “I look forward to working with him so we can get this bill passed — in some form.” (Chamberlain, 3/20)

Bloomberg: Trump Mounts Muted Defense Of Ryan’s Unpopular Health Bill
So far, Trump and his vice president, Mike Pence, have both taken a light touch promoting the House bill, suggesting the White House is more interested in maintaining some political distance in case it fails than in pushing it over the finish line. The Congressional Budget Office has estimated the legislation would lead to 24 million Americans dropping or losing their health insurance over 10 years, at a savings of $337 billion for the government. (Pettypiece, 3/20)

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I Do … Take You To Be My Lawfully Covered Health Care Dependent

“This is a first for me,” said Rabbi Andy Dubin, as he sat down on a collapsible chair opposite Ann Justi and Don Boyer.

The trio was in the compact living room of Boyer’s apartment in Yonkers, N.Y., standing between the sofa, TV and writing desk. Dubin was in his socks, having shed his snow-caked boots in the hallway.

Boyer and Justi were getting married. Never mind the blizzard-like conditions that kept one set of friends home, and a bad cold that waylaid another. They were determined to tie the knot that afternoon. So they recruited their landlord from downstairs and a public radio reporter to be witnesses.

Why the rush? Boyer and Justi had been listening to the news. They were planning to get married in the fall, but it occurred to them that there’s no knowing what could happen to health insurance if the Trump administration and congressional Republicans dismantle the Affordable Care Act.

Justi has several preexisting conditions — osteoporosis, asthma, allergies and vitamin B-12 malabsorption — and the insurance she carried over from her previous job will expire this summer. She had employer-based insurance for more than a decade but was laid off last year.

Justi and Boyer knew they could wait until the spring to get married, and she then could go on the health plan he receives as a concierge for a residential building — it’s a union job, and the health insurance is good. But Boyer worries about Republicans unspooling crucial Obamacare safeguards.

“There’s so much uncertainty as far as what’s going to be law tomorrow, what’s going to be law next month,” he said. “Nobody really knows, unfortunately.”

Much of the focus in the “repeal and replace” debate has been on the 20 million Americans who have received coverage via state and federal health insurance exchanges and Medicaid expansion. But most Americans still get coverage from employers, and their plans now have protections that could also be rolled back.

Under the Affordable Care Act, private insurers can no longer reject people with preexisting conditions, or charge them more for their insurance. As of now, the GOP plan moving through Congress also would require that people with preexisting conditions be able to get health insurance.

But there are other factors that could make that insurance much more expensive — such as the applicant’s age and the lack of a mandate, under the GOP plan, that everyone have health insurance. If you get rid of the mandate, many health care analysts say, it’s likely that the people buying that insurance would mostly be sick — further driving up the cost of the insurance, and driving out of the insurance pool the healthy, younger people who tend to bring down the cost of the insurance.

Justi’s current situation of having temporary insurance with an expiration date — instead of being on a stable health plan that can’t kick her off — takes her back to an earlier, uglier time in her life.

“Before the Affordable Care Act, I went from one employer to another, and the new employer’s insurance didn’t cover my preexisting conditions for a year, and that nearly bankrupted me,” she said.

So Justi and Boyer decided to get legally married as soon as possible, and have a more ceremonial, celebratory wedding in the fall. They found Rabbi Dubin online, on a list of licensed local wedding officiants. They warmed to his profile, even though neither is Jewish.

The service in their living room proved relaxed but formal. Dubin wore a suit, and both bride and groom were fashionably attired in black. Boyer sported a white rose boutonnière. Justi held a bouquet of white roses and calla lilies, their stems wrapped in silk. Dubin talked about marriage and commitment and faith. And he nodded to their need to protect themselves.

“Every marriage is important — but it’s also important because you are living in times, as we all are, when sometimes we have to take things into our own hands to make sure we come out all right on the other side,” he said.

For about 20 minutes, they discussed the journey behind the couple and the one ahead. Boyer and Justi read vows they’d written to each other, and then gave each other rings. Dubin declared, “By the authority vested in me by the state of New York, I now pronounce you, Don and Ann, husband and wife.”

They kissed, then signed some paperwork, raised a toast of sparkling water, took some smartphone pictures and embraced the rabbi.

They were beaming like newlyweds — albeit very practical newlyweds who were already planning next steps.

“As quickly as possible, I want to get you and this form down to the union headquarters tomorrow,” Boyer said.

And that was it. The landlord headed back downstairs. The rabbi and I headed out into the snow. And Justi and Boyer bundled up for a one-night honeymoon in a White Plains, N.Y., hotel. They said they’re prepared to face whatever comes next together — in sickness and in health.

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

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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GOP Bill’s Unheralded Changes In Rules Could Undermine Health Of Neediest

An under-the-radar provision in the Republican proposal to replace the Affordable Care Act would require the millions of Medicaid enrollees who signed up under the Obamacare expansion to renew their coverage every six months — twice as often as under current law.

That change would inevitably push many people out of coverage, at least temporarily, experts say, and help GOP leaders phase out Medicaid expansion — a key goal of the pending legislation.

“That’s designed to move people off those rolls as soon as possible,” said Ken Jacobs, chairman of the University of California, Berkeley, Center for Labor Research and Education.

The proposal to cut renewal time in half is among other changes that seem only procedural but could have a profound effect on Medicaid enrollees’ health, pocketbooks and ability to get — and keep — coverage.

Another proposal would eliminate the ability of new Medicaid enrollees to request retroactive coverage for up to three months before the month they apply, which they can do under the current law — assuming they were eligible during that previous period.

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Health care experts and advocates fear that could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers and raise costs throughout the health care system.

“These are changes to fundamental pieces of the Medicaid program,” said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California in Sacramento, which represents human services directors from the state’s 58 counties.

“They could result in people delaying their health care or having to pay out-of-pocket and not having any hope for reimbursement at all,” she said.

But Michael Cannon, director of Health Policy Studies at the libertarian Cato Institute, said some of these changes would prevent fraud and keep ineligible people from obtaining benefits, thus saving taxpayer money.

“It’s so hard to eliminate fraud in Medicaid, because someone always benefits from it,” he said. “They don’t want to give that up.”

The expansion of Medicaid — the federal-state health care program for people with low incomes, known as Medi-Cal in California — would be phased out under the Republicans’ plan starting in 2020.

The expansion, adopted by 31 states and the District of Columbia, added more than 11 million people to the rolls, including about 3.7 million in Medi-Cal. The federal government picks up a much higher proportion of the cost for this population than for traditional Medicaid enrollees.

In the GOP plan, people already covered under the expansion would continue to be funded by the federal government after Jan. 1, 2020, but if states opted to sign up new enrollees under the expansion criteria after that date, they wouldn’t receive the more generous federal funding for them.

And those who remained in the program after 2020 but later lost eligibility would not draw the more generous federal funding for expansion enrollees if they became eligible again and re-enrolled at a later date.

In California, the potential loss of federal dollars caused by the rollback of the expansion would be massive. The state Legislative Analyst’s Office estimated last month that the Golden State is slated to receive more than $17 billion from the federal government for the Medi-Cal expansion in 2017-18.

“We’re talking about a big shift in costs to the state of California and potentially a major loss in coverage,” said UC Berkeley’s Jacobs.

The GOP legislation, which is scheduled for a vote on the House floor on Thursday, would impose the new renewal requirement on expansion enrollees starting Oct. 1.

“They’re saying to states that do the expansion, ‘We’ll cover people who are continuously in the program, but we’ll make it really hard for people to be continuously in the program,’” Jacobs said.

Wolf Faulkins, a resident of Mariposa, Calif., who enrolled in Medi-Cal in 2014 as a result of the expansion, said the proposed rule change regarding renewal would add one more layer to Medi-Cal’s already considerable bureaucratic requirements, none of them logical or simple.

“If I were more of a senior citizen than I am now, I would be overwhelmed” by it, Faulkins, 61, said. “I would not be a happy camper.” But he would complete the extra paperwork, he added, because his Medi-Cal coverage keeps him alive: Among other things, he has a heart condition and high blood pressure as well as knee and hand ailments.

Senderling-McDonald said the new paperwork will lead some enrollees to drop out for two reasons: Either they’re no longer eligible, or they’re eligible but the new bureaucratic hurdle stops them.

Faulkins agreed. Even though he would jump through the necessary hoops to keep his coverage, some others probably wouldn’t, he guessed. “There are people who are just going to say, ‘It’s important, but it’s too overwhelming. There’s no one to advocate for me. There’s no one to help me figure this out, ” he said. “People are just going to get frustrated and say no.”

The new renewal time frame has a precedent in California, which adopted a semiannual reporting requirement in 2003 for some enrollees that lasted about a decade. Though it was less cumbersome than the regular annual renewals, it nonetheless resulted in people dropping from the rolls, Senderling-McDonald said.

But the Cato Institute’s Cannon believes six-month renewals are reasonable. “The savings from removing ineligible people would justify the paperwork involved,” he said.

The paperwork imposed by these changes could be the least of the headaches for Medicaid beneficiaries.

Retroactive benefits, for example, are extremely valuable for new Medicaid enrollees who face medical bills during a gap in coverage, and losing them could cause financial pain.

“If they have had health expenses, like having to pay for a prescription out-of-pocket or a doctor’s visit, or a woman goes into labor uninsured, they can say to the county, ‘I had medical bills. Can you see if I was eligible during that time?’” said Senderling-McDonald.

Pregnant women are among the most frequent beneficiaries because they often don’t know that they’re pregnant right away, she added.

The GOP bill would end this, and would allow coverage to begin only the month in which enrollees apply. This provision would affect all Medicaid applicants and, like the change in renewal time, would begin Oct. 1.

Some experts believe the proposed change would increase medical debt for consumers hit with massive bills, and for providers who ultimately won’t get paid for their services.

The three-month retroactive rule is “a big deal for hospitals as well as people, because it keeps them from being saddled with medical debt,” said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, D.C.

Senderling-McDonald warned that as more consumers racked up medical debt, the cost of it would shift to other people. “If someone has to declare bankruptcy when they are hit with bills they can’t pay, everybody else takes the hit for it,” she said. “They’re going to raise insurance rates or costs of care for everybody. People who have coverage through employers or the private market could see their rates go up.”

Cannon agreed that providers will get hit with more unpaid bills, but said that this provision would save the federal government money. “States have taxing authority and can fund these benefits themselves if they want to,” he said. “If they don’t, that should tell us something — that they don’t value these benefits that much.”

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

Categories: California Healthline, Cost and Quality, Health Industry, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

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‘It’s A Real Crisis’: Ohio’s Low Nursing Home Ratings Raise Care Concerns

The Cleveland Plan Dealer reports on its review of inspection reports, finding dozens of nursing home deaths involving patient care questions.

Cleveland Plain Dealer: Federal Rating System Is Flawed, Nursing Homes Say: A Critical Choice
The federal government’s Nursing Home Compare system is the only way to evaluate nursing homes nationally, but there’s a lively debate over whether it’s good enough for families to rely on. Critics, including administrators of some of the lowest-rated nursing homes in Northeast Ohio, say the system is flawed. They noted it penalizes homes for problems that may have occurred years ago, and say it punishes facilities that take in the most seriously ill residents. (Caniglia and Corrigan, 3/19)

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Medical Research, Cancer ‘Moonshot’ Would Be Hit Hard By Trump Budget Blueprint

From the FDA and NIH to Meals on Wheels, news outlets cover the impact that the proposed Trump administration budget cuts would have on a range of health care organizations and initiatives.

The Washington Post: Proposed Federal Budget Would Devastate Cancer Research, Advocates Say
Cancer researchers and advocacy groups are denouncing President Trump’s proposed budget, warning that its 19 percent cut for the National Institutes of Health could cripple or kill former vice president Joe Biden’s cancer “moonshot” initiative and other important biomedical efforts. “Forget about the moonshot. What about everything on the ground?” said George Demetri, an oncologist at Dana-Farber Cancer Institute in Boston. “Fundamentally, this is so extreme that all I can think is that it’s pushing two orders of magnitude off the grid so that when people come back to less extreme positions it looks normal.” (McGinley, 3/17)

The New York Times: Trump Plan Eliminates A Global Sentinel Against Disease, Experts Warn
Nobody in the United States has ever died from an intercontinental missile strike. Over the past 50 years, hundreds of billions of dollars have been spent on silos, submarines, bombers and satellites to ensure that does not happen. During the same period, nearly 2 million Americans have died from intercontinental virus strikes. The toll includes one American dead of Ebola, 2,000 dead of West Nile virus, 700,000 dead of AIDS, and 1.2 million dead of flu — a virus that returns from abroad each winter. (McNeil, 3/17)

CQ Roll Call: FDA And NIH Budget Proposals Startle Health Research Community
President Donald Trump’s budget proposal deeply rattled the nation’s biomedical research enterprise, which was not only dismayed by massive cuts to the National Institutes of Health but also caught off guard by major changes to the Food and Drug Administration’s budget. The administration did not specify a topline number for the FDA budget, which was around $4.7 billion in recent years. Normally $2.7 billion comes from discretionary appropriations and the rest from fees paid by regulated industries. The administration seems to want to flip that. The budget plan said it would “recalibrate” medical user fees and increase them by $1 billion in order to “replace the need for new budget authority.” (Siddons, 3/17)

Kaiser Health News: Researchers Call Trump’s Proposed NIH Cuts ‘Shocking’
An estimated $5.8 billion in cuts to the National Institutes of Health in President Donald Trump’s proposed budget has California’s top universities and medical institutions sounding the alarm. Trump’s spending plan — running into opposition from Republicans and Democrats alike — would cut about 20 percent of the roughly $30 billion budget of the nation’s medical research agency that supports research on cancer, Alzheimer’s disease, Zika and other conditions. Research institutions nationwide decried the cuts as potentially devastating to their work. (Korry, 3/17)

Cleveland Plain Dealer: Trump’s Budget Puts Local Public Health, Medical Research And Jobs At Risk
President Donald Trump’s proposed budget includes cuts in public health and medical research funding that would both eliminate jobs and essential services in Northeast Ohio, according to local health and policy experts. Combined with the proposed public health funding cuts in the Republican Obamacare replacement plan, the impact on Ohio state and local health department infrastructure and ability to deliver basic preventive health services would be enormous, said Cuyahoga County Health Commissioner Terry Allan. (Zeltner, 3/17)

Houston Chronicle: Houston Could Lose Big If Trump Cuts Medical Research Funding 
President Trump’s proposal to slash federal support of medical research would undercut Houston’s burgeoning health care and medical technology industries, which are becoming an increasingly important segment of the region’s economy. Health care employs more than 560,000 people in the Houston area, a steadily expanding sector that has added about 170,000 jobs over the past 10 years and helped stabilize the local economy during the recent oil bust. Those figures don’t include an emerging industry of biotechnology and medical device firms that are growing around Houston’s medical complex. (DePillis, 3/17)

Bloomberg: Trump’s Cuts To Meals On Wheels Could Hurt Veterans, Raise Health-Care Costs 
One of the casualties of President Donald Trump’s proposed budget may be Meals on Wheels, the familiar food delivery program for homebound Americans. The aim is to decrease federal spending, but cuts to the service could backfire by raising health-care costs, the program warned. The spending plan calls for reductions to two grants that Meals on Wheels relies on in some locations, as well as to federal departments that help fund the program, spokeswoman Jenny Bertolette said in a statement. “With a stated 17.9 percent cut to the U.S. Department of Health and Human Services budget,” Bertolette said, “it is difficult to imagine a scenario in which these critical services would not be significantly and negatively impacted if enacted into law.” (Mosendz, 3/17)

Public health officials also brace for the fallout of the administration’s visa policy and push to deregulate  —

The New York Times: Rural Areas Brace For A Shortage Of Doctors Due To Visa Policy
Small-town America relies on a steady flow of doctors from around the world to deliver babies, treat heart ailments and address its residents’ medical needs. But a recent, little-publicized decision by the government to alter the timetable for some visa applications is likely to delay the arrival of new foreign doctors, and is causing concern in the places that depend on them. (Jordan, 3/18)

KQED: Bay Area Lawmakers Outraged Over Trump’s Push To Eliminate Federal Refinery Regulator
Local leaders and health officials in Contra Costa County, home to four oil refineries, are blasting a part of President Trump’s budget that calls for cutting all money for the federal agency that investigates chemical accidents. Trump’s spending plan aims to eliminate funding for the U.S. Chemical Safety Board (CSB), which has conducted hundreds of probes, including one into the 2010 Deepwater Horizon oil spill. (Goldberg, 3/17)

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