Tag: Health Care Reform

A Lot of Thought, Little Action: Proposals About Mental Health Go Unheeded

Thousands of people struggle to access mental health services in Florida. The treatment system is disjointed and complex. Some residents bounce between providers and are prescribed different medications with clinicians unaware of what happened. Jails and prisons have become de facto homes for many who need care.

These problems and more were identified in a scathing report released earlier this year by the Commission on Mental Health and Substance Abuse, a 19-person panel that Florida lawmakers created in 2021 to push for reforms of the state’s patchwork of behavioral health services for uninsured people and low-income families.

What’s most troubling about the group’s findings? They aren’t new.

More than 20 years ago, the Florida Legislature set up a commission with the same name to examine the same issues and publish recommendations on how to improve mental health care in the publicly funded system.

The echoes between the two groups — over two decades apart — are unmistakable. And Florida isn’t the only state struggling with the criminalization of mental illness, a lack of coordination between providers, and insufficient access to treatment.

Last year, the national advocacy group Mental Health America said Florida ranked 46th among the 50 states and the District of Columbia for access to such care. Arizona, Kansas, Georgia, Alabama, and Texas were worse off, according to the nonprofit, which based its rankings on access to insurance, treatment, and special education, along with the cost and quality of insurance and the number of mental health providers.

Conversations about mental health are at the forefront nationwide amid the proliferation of mass shootings, pandemic-related stress, rising suicide rates, and shifting viewpoints on the role of police in handling 911 calls.

“It comes down to how much investment, financially, legislators are willing to put into building a system that works,” said Caren Howard, director of policy and advocacy at Mental Health America, a nonprofit just outside Washington, D.C.

In Florida, the 1999 Commission on Mental Health and Substance Abuse was launched when Jeb Bush was governor. In a 74-page report released in 2001, the group called the state’s treatment system “complex, fragmented, uncoordinated and often ineffective.”

The commission found that jails and prisons were Florida’s “largest mental hospitals” after “deinstitutionalization” began — the 20th-century movement to shutter state psychiatric facilities and treat people instead through community services.

The report also blasted Florida agencies for not sharing patient data with one another and being unable to track whether those with severe mental illnesses like schizophrenia were truly getting needed help.

“A lot of the things that we’re finding now, they found back then,” said Charlotte County Sheriff Bill Prummell, a member of the latest commission who served as the chairperson for about 18 months.

The similarities raise questions for the group about whether its work will also end up on a shelf, collecting dust, as Florida lawmakers continue to wrestle with the same challenges again and again.

“Are they really going to take us seriously?” Prummell asked.

A man reaching for an item in a bookshelf filled with old books and reports.
A copy of the 2001 report released by Florida’s 1999 Commission on Mental Health and Substance Abuse rests on a shelf in David Shern’s home office.(Ivy Ceballo / Tampa Bay Times)

Dropping the Ball

After hosting public meetings across Florida, the 1999 commission urged a slate of reforms, including expanding jail diversion programs like mental health courts.

But the group’s key recommendation was to set up a “coordinating council” in the governor’s office to lead the system and develop a strategy for care.

That never happened.

David Shern, chairperson of the 1999 group and former dean of the University of South Florida’s Louis de la Parte Florida Mental Health Institute, said he thinks Bush’s office dropped the ball.

The Republican governor, known for his spending cuts, didn’t want to add staff to his office, so the coordinating council was never created, said Shern.

That’s “where the plan really fell apart,” he said.

Instead, lawmakers established a work group in the Department of Children and Families to review how Florida could improve its behavioral health system and submit a report to Bush, among other leaders.

The work group disbanded in 2003. That same year, the legislature created a not-for-profit corporation to oversee the system, but it was dissolved in 2011, according to state business records. When the Tampa Bay Times recently asked for the work group’s report, Laura Walthall, a spokesperson for the Department of Children and Families, said it couldn’t be found. Bush didn’t respond to emailed questions.

Former state Rep. Sandra Murman, however, said that what happened is just a reality of bureaucracy.

“It’s the same with all commissions,” said Murman, a Tampa Republican who was part of the 1999 group. “The life cycle of any big report that comes out is probably about five years.”

Lawmakers leave Tallahassee because of term limits. Agency heads step down. New officials get elected. Priorities shift.

“They come in with their agenda, and you won’t see social services ever at the top,” she said of Florida legislative leaders.

A close-up photo of the Florida mental health commission report released in 2001.
David Shern holds a copy of the report his mental health commission released in 2001. A recent report by a new state commission reached similar conclusions.(Ivy Ceballo / Tampa Bay Times)

But some state lawmakers focused on mental illness in the wake of the 2018 shooting that left 17 students and staff members dead at Marjory Stoneman Douglas High School in Parkland. Amid mounting public demand for more drastic gun control measures, such as an assault weapons ban, the Republican-controlled legislature instead approved more limited restrictions, like Florida’s “red flag” law, along with steps unrelated to gun control, allocating about $400 million for mental health and school safety initiatives.

Before the massacre, Parkland shooter Nikolas Cruz received mental health services through several public and private providers, splitting the future gunman’s medical history, according to a 2019 report from the Marjory Stoneman Douglas High School Public Safety Commission.

“No single health professional or entity had the entire ‘story’ regarding Cruz’s mental health and family issues, due, in part, to an absence of communication between providers and a lack of disclosure by the Cruz family,” the report said.

The vast majority of people with a mental illness are not violent, according to the nonprofit National Council for Mental Wellbeing in Washington, D.C. And they are more likely to be victims of violent crime than perpetrators.

In 2020, a grand jury investigating school safety issues related to the shooting called Florida’s mental health care system “a mess.”

“Deficiencies in funding, leadership and services,” the grand jury said, “tend to turn up everywhere like bad pennies.”

The panel said it didn’t have enough time to conduct a full review of the system and urged state lawmakers to set up a commission to do so.

The latest commission reported that the system remains splintered and suffers from “enormous gaps in treatment.” And there’s still no centralized database on patients.

The group, just like its predecessor over two decades ago, has suggested that Florida create more jail diversion programs and that state agencies share patient data. The commission has pitched new ideas, too, like a pilot program in which one agency manages all public behavioral health funding in a geographic area, including state money and local dollars, so providers can focus more on care and less on complicated billing processes.

“This isn’t going away, and if we don’t address it, it’s going to get worse,” Prummell told a House subcommittee last month.

Solutions to Florida’s problems are not headline grabbers, which makes it tough to generate political support, said Holly Bullard, chief strategy and development officer at the Florida Policy Institute, an Orlando nonprofit.

“Building good government, it can get technical,” she said, “and sometimes it’s hard to communicate the importance of it.”

Will Anything Change?

A photo of a man putting a copy of a report away on his bookshelf.
David Shern with a copy of the report his mental health commission released in 2001.(Ivy Ceballo / Tampa Bay Times)

There’s been some progress in Florida’s mental health care system since 2001, said Jay Reeve, the new chairperson of the latest commission and CEO of Apalachee Center, a behavioral health provider in Tallahassee.

The system is more responsive to regional issues, partly because of state contracts with seven “managing entities” — nonprofits that oversee safety-net services for the uninsured, he said.

There’s also been an increase in initiatives like mobile response teams, which help people in mental health emergencies, and crisis intervention training for police officers, in which they get trained on de-escalation techniques and psychiatric diagnoses so they know when to get residents into treatment instead of arresting them, Reeve said.

The Department of Children and Families used to spend about $500 million a year on community-based behavioral health services such as outpatient treatment, case management, and crisis stabilization units, the 1999 commission reported. Now, its budget for such care is $1.1 billion.

Pockets of innovation exist at the local level, too, as in Palm Beach County, where an initiative called BeWellPBC aims to boost the area’s mental health care workforce, among other things, said Shern, senior associate in the department of mental health at the Johns Hopkins Bloomberg School of Public Health.

But challenges remain.

Nearly 3 million Florida adults have a mental illness, according to Mental Health America. That’s about 17% of the state’s population of those 18 and up. An estimated 225,000 youths experienced at least one major depressive episode in the past year, the nonprofit reported in October.

In 2020, Florida ranked last among states for per capita mental health care funding, the Parkland grand jury said. In 2021, the Miami-Dade County jail system was the largest psychiatric institution in the state, according to the 11th Judicial Circuit.

“As long as you keep things siloed, accountability is easier to dodge,” said Ann Berner, a member of the 2021 commission and CEO of Southeast Florida Behavioral Health Network, a managing entity.

Political will is needed to enact major reforms, Shern said. So is follow-up on the commission’s work, said Murman, who works at Shumaker Advisors Florida, a lobbying firm.

“In this case, it probably is something that has to be revived every five years to really make an impact,” she said.

Rep. Christine Hunschofsky, a Parkland Democrat on the 2021 commission, said there’s bipartisan support to improve the system.

But during the current legislative session, the Tampa Bay Times on March 13 could find only one House bill and a matching Senate bill based on the commission’s 35-page interim report: a proposal to study Medicaid expansion for some young adults age 26 and under. (Republican leaders in Florida have refused to expand the federal-state health care program under the Affordable Care Act, which became law in 2010.)

Hunschofsky said she thinks the legislature will take more action once the commission releases its final report, which is due by Sept. 1.

Republican Gov. Ron DeSantis’ office referred questions to the Department of Children and Families, where officials didn’t answer them.

Senate President Kathleen Passidomo didn’t respond to a voicemail and interview requests made through a spokesperson. Nor could House Speaker Paul Renner be reached for comment.

After more than 20 years, Shern is frustrated.

“It’s time to move on these issues,” he said. “We’ve spent literally decades thinking about them, talking about them.”

A photo of a man posing for a portrait in his office.
David Shern in his home office.(Ivy Ceballo / Tampa Bay Times)

This article was produced in partnership with the Tampa Bay Times.

Listen to ‘Tradeoffs’: Medical Debt Delivers ‘A Shocking Amount of Misery’

The numbers that tell the story of medical debt in the U.S. are staggering: Around 100 million Americans have health care debt, and together they owe at least $140 billion. And research suggests this debt can have striking consequences on people’s financial, physical, and mental health.

In this episode of the “Tradeoffs” podcast, Dan Gorenstein talks about the pain and possible solutions to medical debt with KHN senior correspondent Noam N. Levey and UCLA researcher Wes Yin.

“About a third of people who have medical debt owe less than $1,000,” Levey said. “But a quarter of people owe, I think, more than $5,000. More than half say they’ve had to make a difficult sacrifice, like using up all their savings, moving in with friends and family, or losing their homes. So I don’t think it’s hyperbole to say that there’s a shocking amount of misery out there.”

New CDC Opioid Guidelines: Too Little, Too Late for Chronic Pain Patients?

Jessica Layman estimates she has called more than 150 doctors in the past few years in her search for someone to prescribe opioids for her chronic pain.

“A lot of them are straight-up insulting,” said the 40-year-old, who lives in Dallas. “They say things like ‘We don’t treat drug addicts.’”

Layman has tried a host of non-opioid treatments to help with the intense daily pain caused by double scoliosis, a collapsed spinal disc, and facet joint arthritis. But she said nothing worked as well as methadone, an opioid she has taken since 2013.

The latest phone calls came late last year, after her previous doctor shuttered his pain medicine practice, she said. She hopes her current doctor won’t do the same. “If something should happen to him, there’s nowhere for me to go,” she said.

Layman is one of the millions in the U.S. living with chronic pain. Many have struggled to get opioid prescriptions written and filled since 2016 guidelines from the Centers for Disease Control and Prevention inspired laws cracking down on doctor and pharmacy practices. The CDC recently updated those recommendations to try to ease their impact, but doctors, patients, researchers, and advocates say the damage is done.

“We had a massive opioid problem that needed to be rectified,” said Antonio Ciaccia, president of 3 Axis Advisors, a consulting firm that analyzes prescription drug pricing. “But the federal crackdowns and guidelines have created collateral damage: patients left high and dry.”

Born of an effort to fight the nation’s overdose crisis, the guidance led to legal restrictions on doctors’ ability to prescribe painkillers. The recommendations left many patients grappling with the mental and physical health consequences of rapid dose tapering or abruptly stopping medication they’d been taking for years, which carries risks of withdrawal, depression, anxiety, and even suicide.

In November, the agency released new guidelines, encouraging physicians to focus on the individual needs of patients. While the guidelines still say opioids should not be the go-to option for pain, they ease recommendations about dose limits, which were widely viewed as hard rules in the CDC’s 2016 guidance. The new standards also warn doctors about risks associated with rapid dose changes after long-term use.

But some doctors worry the new recommendations will take a long time to make a meaningful change — and may be too little, too late for some patients. The reasons include a lack of coordination from other federal agencies, fear of legal consequences among providers, state policymakers hesitant to tweak laws, and widespread stigma surrounding opioid medication.

The 2016 guidelines for prescribing opioids to people with chronic pain filled a vacuum for state officials searching for solutions to the overdose crisis, said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.

The dozens of laws that states passed limiting how providers prescribe or dispense those medications, she said, had an effect: a decline in opioid prescriptions even as overdoses continued to climb.

The first CDC guidelines “put everybody on notice,’’ said Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force. Physicians reduced the number of opioid pills they prescribe after surgeries, he said. The 2022 revisions are “a dramatic change,” he said.

The human toll of the opioid crisis is hard to overstate. Opioid overdose deaths have risen steadily in the U.S. in the past two decades, with a spike early in the covid-19 pandemic. The CDC says illicit fentanyl has fueled a recent surge in overdose deaths.

Taking into account the perspective of chronic pain patients, the latest recommendations try to scale back some of the harms to people who had benefited from opioids but were cut off, said Dr. Jeanmarie Perrone, director of the Penn Medicine Center for Addiction Medicine and Policy.

“I hope we just continue to spread caution without spreading too much fear about never using opioids,” said Perrone, who helped craft the CDC’s latest recommendations.

Christopher Jones, director of the CDC’s National Center for Injury Prevention and Control, said the updated recommendations are not a regulatory mandate but only a tool to help doctors “make informed, person-centered decisions related to pain care.”

Multiple studies question whether opioids are the most effective way to treat chronic pain in the long term. But drug tapering is associated with deaths from overdose and suicide, with risk increasing the longer a person had been taking opioids, according to research by Dr. Stefan Kertesz, a professor of medicine at the University of Alabama-Birmingham.

He said the new CDC guidance reflects “an extraordinary amount of input” from chronic pain patients and their doctors but doubts it will have much of an impact if the FDA and the Drug Enforcement Administration don’t change how they enforce federal laws.

The FDA approves new drugs and their reformulations, but the guidance it provides for how to start or wean patients could urge clinicians to do so with caution, Kertesz said. The DEA, which investigates physicians suspected of illegally prescribing opioids, declined to comment.

Smith has experienced pain in her left leg since a nerve was cut during surgery years ago. But in December her pharmacy stopped filling her prescriptions for painkillers.(Andy Miller / KHN)

The DEA’s pursuit of doctors put Danny Elliott of Warner Robins, Georgia, in a horrible predicament, said his brother, Jim.

In 1991, Danny, a pharmaceutical company rep, suffered an electric shock. He took pain medicine for the resulting brain injury for years until his doctor faced federal charges of illegally dispensing prescription opioids, Jim said.

Danny turned to doctors out of state — first in Texas and then in California. But Danny’s latest physician had his license suspended by the DEA last year, and he couldn’t find a new doctor who would prescribe those medications, Jim said.

Danny, 61, and his wife, Gretchen, 59, died by suicide in November. “I’m really frustrated and angry about pain patients being cut off,” Jim said.

Danny became an advocate against forced drug tapering before he died. Chronic pain patients who spoke with KHN pointed to his plight in calling for more access to opioid medications.

Even for people with prescriptions, it’s not always easy to get the drugs they need.

Pharmacy chains and drug wholesalers have settled lawsuits for billions of dollars over their alleged role in the opioid crisis. Some pharmacies have seen their opioid allocations limited or cut off, noted Ciaccia, with 3 Axis Advisors.

Rheba Smith, 61, of Atlanta, said that in December her pharmacy stopped filling her prescriptions for Percocet and MS Contin. She had taken those opioid medications for years to manage chronic pain after her iliac nerve was mistakenly cut during surgery, she said.

Smith said she visited nearly two dozen pharmacies in early January but could not find one that would fill her prescriptions. She finally found a local mail-order pharmacy that filled a one-month supply of Percocet. But now that drug and MS Contin are not available, the pharmacy told her.

“It has been a horrible three months. I have been in terrible pain,” Smith said.

Many patients fear a future of constant pain. Layman thinks about the lengths she’d go to in order to get medication.

“Would you be willing to buy drugs off the street? Would you be willing to go to an addiction clinic and try to get pain treatment there? What are you willing to do to stay alive?” she said. “That is what it comes down to.”

Why Does Insulin Cost So Much? Big Pharma Isn’t the Only Player Driving Prices

Eli Lilly & Co.’s announcement that it is slashing prices for its major insulin products could make life easier for some diabetes patients while easing pressure on Big Pharma.

It also casts light on the profiteering methods of the drug industry’s price mediators — the pharmacy benefit managers, or PBMs — at a time when Congress has shifted its focus to them.

Insulin has come to embody the perversity of the U.S. health care system as list prices for the century-old drug, which 8.4 million Americans depend on for survival, quintupled over two decades to more than $300 for a single vial. Just because Lilly — which sells about a third of the insulin in the United States — lowers its price doesn’t mean all patients will pay less, even in the long run.

Lilly capped the out-of-pocket costs of its most popular insulins at $35 effective immediately, and said that later this year the list price of its “authorized generic” Lispro — which is identical to Humalog, its bestselling brand-name insulin — would fall to $25 a vial. This followed President Joe Biden’s State of the Union address, and speeches since, in which he has blamed “Big Pharma” and its “record profits” for the incredible expense of insulin.

David Ricks, Lilly CEO, in interviews March 1 called for other manufacturers to join his company in “taking away the affordability challenges” of diabetes.

Even as Lilly promotes its altruism, this move may actually save it money, said health care analyst Sean Dickson. A federal rule taking effect next year penalizes companies that charge Medicaid high prices, especially for older, branded drugs. Lowering the list price of Humalog would allow Lilly to pay significantly less in rebates to government Medicaid programs that buy the drug.

Drugmakers have long ceased to be the only, or even primary, villain of the insulin price scandal. The three companies that produce nearly all the insulin in this country — Lilly, Sanofi, and Novo Nordisk — posted stagnant or declining revenue from their versions of the drug in recent years despite the steadily climbing list prices they charged. They’ve even advised investors that they don’t see insulin sales as a high-profit area anymore.

But while Lilly is cutting the “wholesale acquisition price,” or list price, of its big-selling insulin drugs, “will other ‘parties at play’ cause this price to increase before it hits my pharmacy counter?” asked Rebecca Kelly of Richmond, Kentucky, who has Type 1 diabetes and is an activist for lower drug prices.

Those parties include gigantic pharmacy benefit managers — owned by CVS Health and insurance giants UnitedHealthcare and Cigna — that have aggressively played the insulin makers off one another in a way that mainly fattened their own accounts, as was revealed in a scathing 2021 Senate Finance Committee report.

In theory, when pharmacy benefit managers negotiate contracts with drug manufacturers on behalf of insurers, they pass along savings to patients. In practice, while the hard-nosed bargaining may benefit the well-insured, it can hurt patients on fixed incomes and others less able to afford their insulin.

To compete for access to insured patients, according to the report, the three insulin makers in the 2010s steadily increased rebates and fees paid to the powerful PBMs, which are owned by or allied with major insurers. This spurred drugmakers to keep raising their list prices, because the more they paid in rebates — calculated as a percentage of list price — the better their placement on insurance formularies, the complex lists of drugs insurers cover for patients.

In other words, the more the insulin makers compete, the more consumers — the unlucky ones, anyway — may pay.

“Insulin is a commodity, so formulary position is everything,” said David Kliff, who edits the website Diabetic Investor. “It’s like location in real estate.”

In 2018, Novo Nordisk, amid public rancor over rising insulin prices, considered a 50% cut, according to the report. But the company’s board decided against it, noting that “many in the supply chain will be negatively affected ($) and may retaliate.” The company also feared that irate insurers might retaliate against Novo’s blockbuster diabetes and weight-loss drugs like Ozempic, which compete against Lilly’s Mounjaro.

Sanofi and Novo Nordisk did not directly respond to Lilly’s price-dropping move but noted, in statements, that their discount programs already provide cheap insulin for those who need them. Millions of Americans have used these coupons, but patients like Kelly say they come with red tape and can be unreliable.

Lilly declined to respond to a question about how its cut in list price might affect negotiations with insurers, which have come to expect big rebates on drugs with competitively high list prices.

For example, Sanofi paid rebates worth 2% to 4% of its insulin list price in 2013, but 56% in 2018, according to the Senate report. Over that period, Sanofi tripled the price of its Lantus insulin to about $275 per vial. A 2018 study estimated it costs roughly $2 to $4 to produce a vial of analog insulin, the type used by most patients.

Most of the insulin list price increases have gone to PBMs, the go-between companies. For example, Lilly earned about $25 for each Humalog injection pen from 2013 to 2018, while the list price increased from $57 to $106. Net prices have remained stable the past few years and insulin revenues actually declined last year, according to recent Sanofi and Lilly financial reports.

Trade secrecy makes it hard to see which portions of the kickbacks end up as profit or savings for pharmacy benefit managers, insurers, pharmacies, or patients. But patients who are uninsured, are underinsured, or pay high deductibles can end up with whopping insulin bills, because their copayments are tied to the drug’s list price.

“The system transfers financial resources from sick patients to healthy, premium-paying beneficiaries, the opposite of what insurance is supposed to do,” Erin Trish, co-director of the University of Southern California Schaeffer Center for Health Policy & Economics, told a Senate Commerce Committee hearing Feb. 16.

Medicare beneficiaries, for example, paid a collective $1 billion out-of-pocket for their insulin in 2020, more than four times what they paid in 2007, according to a KFF study. So did many others.

Kelly, a 48-year-old personal trainer, got insulin through her husband’s insurance but had to pay out-of-pocket until she met a $5,000 deductible each year. So in 2019, the Kellys dropped the policy and decided to risk the open market. They ended up driving to Canada, where Kelly told KHN she spent $256 on eight vials of insulin that would have cost $2,616 at her local pharmacy. During the pandemic, she used Lilly coupons that enabled her to buy Humalog for $35 per vial, enough for about two weeks.

Despite coupon programs, surveys conducted since 2017 showed that up to a quarter of U.S. patients reported skimping on insulin because of its cost. Some patients have died while trying to ration the drug.

The contrast with other developed countries is stark. Germans with diabetes pay around $5 for a month’s worth of insulin. In the United Kingdom, patients pay nothing.

Federal legislation signed into law last year capped out-of-pocket insulin costs at $35 per month for Medicare recipients. At least 22 states and the District of Columbia have set caps on private plans as well.

The three big insulin makers have fought off competition that could lower prices across the board. They’ve done this, for example, by introducing their own, slightly less expensive “authorized generics,” which discourage other companies from entering the insulin market. It wasn’t until 2021 that a competitor brought a long-acting “biosimilar” insulin — essentially a generic version of Lantus — to the market, and it has barely made a dent. The company, Viatris, which since sold its product to Biocon Biologics, did win entry to one formulary by creating an essentially identical product, tripling its list price and offering PBMs a big rebate.

These kinds of behaviors have increasingly drawn congressional attention, and drug manufacturing attack ad campaigns.

“Imagine a world where a cheaper product, yet equally effective, has a harder time selling,” Sen. Chuck Grassley (R-Iowa) said at the Feb. 16 Commerce Committee hearing. “That’s the prescription drug industry.”

Still, Lilly’s announcement may be a harbinger of better news for the most economically vulnerable people with diabetes.

California has funded a plan to make and distribute its own insulin. Separately, Civica, a nonprofit drug manufacturer, hopes by the end of 2024 to sell insulin produced in India. Civica will bypass benefit managers and provide the drug to any pharmacy that promises to sell it for no more than $30 per vial, said Allan Coukell, its senior vice president for public policy.

Civica plans to produce enough insulin for a third of all U.S. patients, he said.

El tema del aborto ayuda a los demócratas a minimizar pérdidas en estas elecciones

Es probable que los republicanos tomen el control de una o ambas cámaras del Congreso cuando todos los votos estén contados. Pero los demócratas están celebrando el hecho de que su partido desafió las pérdidas pronosticadas para estas elecciones de medio término.

La reacción a la decisión de la Corte Suprema en junio pasado de anular 49 años de derecho al aborto aparentemente fue una de las principales razones.

Como mostraron consistentemente las encuestas pre electorales, la inflación y la economía fueron los temas de votación más importantes, citados por el 51% de los votantes en las encuestas a boca de urna realizadas por Associated Press y analizadas por encuestadores de KFF.

Pero el aborto fue el tema más importante para una cuarta parte de todos los votantes y para una tercera parte de las mujeres menores de 50 años. Las encuestas a boca de urna de NBC News indicaron que la inflación fue el principal tema para votar para un 32%, y en segundo lugar el aborto, 27%.

La pronosticada “ola roja” de republicanos derrocando a los demócratas en la Cámara y el Senado no sucedió, aunque a partir del miércoles por la mañana parecía probable que los republicanos obtuvieran el puñado de escaños que necesitaban para lograr la mayoría de la Cámara.

En el Senado, donde los republicanos solo necesitaban un asiento para tomar el control, ningún titular había perdido oficialmente, aunque los demócratas capturaron el escaño de Pennsylvania que dejó vacante el senador republicano Pat Toomey.

Aún no se habían convocado varias otras contiendas reñidas, y el control de la cámara bien podría descansar en una posible segunda vuelta en diciembre en Georgia entre el actual senador demócrata Raphael Warnock y el republicano Herschel Walker.

Entre otros problemas que enfrentaron los votantes el martes, los residentes de Dakota del Sur aprobaron una expansión de Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Se convirtió así en el séptimo estado en expandir el programa a pesar de las objeciones de su gobernador republicano y/o la legislatura estatal.

Antes, medidas similares fueron aprobadas en Idaho, Maine, Missouri, Nebraska, Oklahoma y Utah. La aprobación de Dakota del Sur reducirá a 11 el número de estados que no han ampliado el programa a personas con ingresos de hasta el 138 % de la línea de pobreza, entre ellos Texas, Florida y Georgia.

Sobre el tema del derecho al aborto, los votantes de media docena de estados de todo el espectro político mostraron su apoyo directo a través de iniciativas electorales. En la más observada de esas medidas, los votantes de Michigan aprobaron una enmienda constitucional que garantiza la libertad reproductiva, evitando así que entre en vigencia una prohibición de 1931.

Los votantes de Kentucky rechazaron por poco margen una enmienda que habría declarado en su constitución que no había derecho al aborto. Eso lo convirtió en el primer estado del sur en expresar su apoyo directo al derecho al aborto.

Se aprobaron otras preguntas sobre el derecho al aborto en Vermont y California. La medida de California, que fue aprobada con el 65% de los votos, consolidó el derecho al aborto y a la  anticoncepción.

En Montana, una medida electoral para exigir que los bebés nacidos vivos después de un intento de aborto reciban atención médica estaba perdiendo con el 80% de los votos. Este requisito ya existe en la ley federal.

Además, en varios estados clave donde la legalidad del aborto está en juego, los gobernadores y candidatos a favor del derecho al aborto derrotaron a los opositores al aborto, incluidos Pennsylvania, Wisconsin y Michigan.

El aborto también fue un tema en las elecciones de la Corte Suprema en al menos seis estados, donde los desafíos a las leyes del aborto o las interpretaciones constitucionales podrían decidir si sigue o no siendo legal.

En Kentucky, la jueza Michelle Keller estaba liderando sobre Joe Fischer, un legislador estatal republicano que patrocinó la ley de activación del aborto de Kentucky. La jueza titular de Montana, Ingrid Gustafson, derrotó a su rival, James Brown, un republicano respaldado por el gobernador republicano del estado y los líderes del partido que buscaban revertir un fallo judicial de 1999 de que la constitución estatal protege el derecho al aborto.

Pero el aborto no fue el único problema de salud en las papeletas estatales del martes.

En Arizona, una pregunta electoral para limitar el interés de la deuda médica estaba ganando fácilmente con el 60% de los votos contados. En Oregon, sin embargo, una cuestión en su mayoría inaplicable que declaraba un “derecho a la atención médica” en la constitución estatal estaba perdiendo por poco con el 64% de los votos escrutados.

En medidas más específicas, los votantes de California aprobaron la prohibición de los productos de tabaco con sabor, mientras que los votantes de Massachusetts apoyaron a los dentistas sobre las compañías de seguros al aprobar el requisito de que al menos el 83% de las primas del seguro dental se gasten en atención dental directa. Massachusetts no es el primer estado en imponer tal requisito.

En Iowa, los defensores del derecho a portar armas lograron una victoria con la fácil aprobación de una enmienda constitucional que declara que los habitantes del estado tienen “un derecho individual fundamental” a poseer y portar armas, y que cualquier restricción sobre las armas debe pasar por un “escrutinio estricto” en los tribunales. Para el miércoles por la mañana, con 97 de 99 condados reportando boletas, la enmienda tenía el respaldo del 65% de los votantes de Iowa.

Abortion Issue Helps Limit Democrats’ Losses in Midterms

Republicans are likely to take control of one or both houses of Congress when all the votes are counted, but Democrats on Wednesday were celebrating after their party defied expectations of substantial losses in the midterm election. The backlash over the Supreme Court’s decision in June to overturn 49 years of abortion rights was apparently a big reason.

Inflation and the economy proved the most important voting issue, cited as the motivation of 51% of voters in exit polls conducted by the Associated Press and analyzed by KFF pollsters. But abortion was the single-most important issue for a quarter of all voters, and for a third of women under age 50. Exit polls by NBC News placed the importance of abortion even higher, with 32% of voters saying inflation was their top voting issue and abortion ranking second at 27%.

The predicted “red wave” of Republicans toppling Democrats in the House and Senate did not happen, although as of Wednesday afternoon, it seemed likely that Republicans would gain the handful of seats they needed to take over the House majority.

In the Senate, where Republicans needed just one pickup to take control, no incumbent had officially lost, and Democrats captured the Pennsylvania seat being vacated by Republican Sen. Pat Toomey. Several other close races had yet to be called, and control of the chamber may well rest on a December runoff in Georgia between Democratic incumbent Sen. Raphael Warnock and Republican Herschel Walker. In recent decades, the party that controls the White House has generally suffered serious setbacks in congressional power in the midterms.

Among other issues facing voters Tuesday, residents of South Dakota approved an expansion of Medicaid under the Affordable Care Act. That made it the seventh state to expand the program over the objections of a Republican governor and/or state legislature. Previous successful initiatives passed in Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah. South Dakota’s approval will reduce to 11 the number of states that have not expanded the program to people with incomes up to 138% of the federal poverty level, although included in that list are the heavily populated states of Texas, Florida, and Georgia.

On the issue of abortion rights, voters in five states across the political spectrum showed direct support through ballot initiatives. In the most closely watched of those measures, Michigan voters approved a constitutional amendment guaranteeing reproductive freedom, thus preventing a ban from 1931 from taking effect.

Kentucky voters narrowly rejected an amendment that would have declared in its constitution that there was no right to abortion. That made it the first Southern state to express direct support for abortion rights.

Other abortion rights ballot questions were approved in Vermont and California. The California measure, which passed with 65% of the vote, enshrined the rights to both abortion and contraception.

In Montana, a ballot measure to require that infants born alive after attempted abortions be given medical care was losing with 80% of the votes in. Such a requirement already exists in federal law.

In addition, in several key states where the legality of abortion hangs in the balance, governors and candidates who favor abortion rights defeated anti-abortion challengers, including Pennsylvania, Wisconsin, and Michigan.

Abortion was also an issue in contested Supreme Court elections in at least six states, where challenges to abortion laws or constitutional interpretations could decide whether the procedure remains legal. One state saw party control of its high court flip: North Carolina, where a Republican challenger defeated a Democratic incumbent to give the GOP a 4-3 majority. Democratic judicial majorities appeared to be holding in Illinois and in Michigan, which holds nonpartisan judicial elections after the candidates are nominated by political parties. In Ohio, Republicans kept their majority on the high court.

In Kentucky, Justice Michelle Keller defeated challenger Joe Fischer, a Republican state legislator who sponsored Kentucky’s abortion trigger law. Montana incumbent Justice Ingrid Gustafson defeated her challenger, James Brown, a Republican endorsed by the state’s GOP governor and party leaders seeking to reverse a 1999 court ruling that the state constitution protects the right to an abortion.

Abortion was not the only health issue on state ballots Tuesday.

In Arizona, a ballot question to limit interest on medical debt won easily with 66% of the vote counted. In Oregon, however, a mostly unenforceable question declaring a “right to health care” in the state constitution was losing narrowly with 64% of the votes in.

California voters approved a ban on the sale of most flavored tobacco products while voters in Massachusetts supported dentists over insurance companies in approving a requirement that at least 83% of dental insurance premiums be spent on direct dental care. Massachusetts is the first state to impose such a requirement.

In Iowa, gun rights advocates scored a victory with easy passage of a constitutional amendment declaring that Iowans have “a fundamental individual right” to keep and bear arms, and that any restrictions on guns must stand up to “strict scrutiny” in court.

KHN’s ‘What the Health?’: ACA Open Enrollment Without the Drama

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

It’s open enrollment time for Affordable Care Act health coverage. And for the first time, people are enrolling with comparatively little controversy, as most Republicans have moved on from trying to repeal the law.

On the campaign trail, meanwhile, Democrats are charging that if Republicans win majorities in the U.S. House or Senate, they will try to cut Social Security and Medicare.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Tami Luhby of CNN, and Julie Appleby of KHN.

Among the takeaways from this week’s episode:

  • There are some big changes to the ACA from years past. The Biden administration used its authority to close the “family glitch” that had prevented many families of low- and moderate-income workers from getting subsidies to purchase insurance on healthcare.gov or state marketplaces.
  • Also new this year, states are required to offer “standardized” plans with the same benefits so consumers can better compare them.
  • Another important change: For the first time, people with low incomes (under 150 percent of the federal poverty level) can enroll in ACA plans anytime, instead of only during open enrollment. This could become particularly important in 2023, as many people are likely to lose their Medicaid coverage when the Biden administration ends the covid-related public health emergency.
  • Health overall has not been as big a campaign issue as usual. With a few exceptions, most Republicans on the campaign trail seem to have moved on from vows to repeal the Affordable Care Act.
  • Abortion was expected to be the top voter concern in this year’s elections, but it seems to have been trumped in most cases by inflation and the state of the economy. At least one Democratic candidate, Michigan Gov. Gretchen Whitmer, is trying to combine the issues. She is claiming that if voters in her state approve a constitutional amendment protecting the right to abortion, businesses in states with abortion bans will be more likely to move there. It’s unclear whether this will happen, though.
  • The Justice Department this week had its first-ever win in a criminal case alleging that labor antitrust rules had been violated. A Nevada staffing agency that supplies school nurses had an agreement with a similar agency in an adjacent county not to hire nurses across the county line, in an effort to prevent the nurses from seeking higher wages.  

Also this week, Rovner interviews KHN’s Arthur Allen, who wrote the latest KNH-NPR Bill of the Month, about an old but still very expensive cancer drug. Do you have an exorbitant or baffling medical bill you’d like to share with us? You can do that here.

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

Julie Rovner: Modern Healthcare’s “Elon Musk Bought Twitter. Should Healthcare Professionals Be Worried?” by Caroline Hudson

Joanne Kenen: Mountain State Spotlight’s “Stigmatize, Blame, Then Restrict: How This West Virginia City Responded to the Opioid Epidemic,” by Ellie Heffernan

Tami Luhby: The Washington Post’s “A Psychiatry Wait List Had 880 patients; a Hospital Couldn’t Keep Up,” by Rachel Zimmerman

Julie Appleby: KHN’s “‘Fourth Trimester’ Focus Is Pushed to Prevent Maternal Deaths,” by April Dembosky

Also mentioned in this week’s episode:

Politico’s “Michigan Democrats’ Pitch to Voters: Abortion Bans Are Bad for Business,” by Alice Miranda Ollstein

Bloomberg Law’s “DOJ Notches First No-Poach Win With Staffing Firm’s Sentencing,” by Dan Papscun

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

“Cuarto trimestre”: período clave para prevenir las muertes maternas

Durante varias semanas al año, el trabajo de la enfermera-comadrona Karen Sheffield-Abdullah es detectivesco. Con un equipo de investigadores médicos del Departamento de Salud Pública de Carolina del Norte examina los registros hospitalarios y los informes forenses de las madres que murieron después de dar a luz.

Estos comités de revisión de la mortalidad materna buscan pistas sobre lo que ha contribuido a estas muertes —recetas que nunca se recogieron, faltar a citas médicas postnatales, señales de alerta que los médicos pasaron por alto—, para averiguar cuántas podrían haberse evitado y cómo.

Los comités trabajan en 36 estados, y en la última y mayor recopilación de datos de este tipo, publicada en septiembre por los Centros para el Control y Prevención de Enfermedades (CDC), un sorprendente 84% de las muertes relacionadas con el embarazo se consideraron prevenibles.

Lo que resulta aún más alarmante para enfermeras-detectives como Sheffield-Abdullah es que el 53% de las muertes se produjeron mucho después de que las mujeres fueran dadas de alta del hospital, entre siete días y un año después del parto.

“Estamos muy centrados en el bebé”, afirma. “Una vez que el bebé está aquí, es casi como si la madre fuera descartada… Y en lo que realmente tenemos que pensar es en ese cuarto trimestre, ese tiempo después del nacimiento del bebé”.

Las condiciones de salud mental fueron la principal causa subyacente de muertes maternas entre 2017 y 2019. Las blancas no hispanas y las hispanas fueron las más propensas a morir por suicidio o sobredosis de drogas, mientras que los problemas cardíacos fueron la principal causa de muerte para las mujeres negras no hispanas.

Ambas circunstancias ocurren desproporcionadamente más tarde en el período posparto, según el informe de los CDC.

Los datos revelan múltiples deficiencias en el sistema de atención a las nuevas madres, desde los obstetras que no están adiestrados (o bien pagados) para buscar signos de problemas mentales o de adicción, hasta las pólizas que despojan a las mujeres de la cobertura médica poco después de dar a luz.

El principal problema es que el típico control postnatal de seis semanas es demasiado tarde, según Sheffield-Abdullah. En los datos de Carolina del Norte, las nuevas madres que murieron más tarde no acudieron a esta cita porque tenían que volver al trabajo o tenían otros niños pequeños, agregó.

“Tenemos que estar realmente en contacto mientras están en el hospital”, dijo Sheffield-Abdullah, y luego asegurarnos de que las pacientes reciban la atención de seguimiento adecuada “una o dos semanas después del parto”.

Otra de las recomendaciones de los CDC es más pruebas de detección de depresión y ansiedad posparto, durante todo el año posterior al parto, así como una mejor coordinación de la atención entre los servicios médicos y sociales, según David Goodman, que dirige el equipo de prevención de mortalidad materna de la División de Salud Reproductiva de los CDC, que publicó el informe.

Una crisis frecuente es que la adicción de uno de los padres se agrava tanto que los servicios de protección infantil se llevan al bebé, lo que precipita una sobredosis accidental o intencionada de la madre. Tener acceso al tratamiento y asegurarse de que las visitas a los niños se produzcan con regularidad podría ser la clave para prevenir estas muertes, apuntó Goodman.

El cambio político más importante ha sido la ampliación de la cobertura sanitaria gratuita a través de Medicaid, indicó. Hasta hace poco, la cobertura de Medicaid relacionada con el embarazo solía expirar dos meses después del parto, lo que obligaba a las mujeres a dejar de tomar medicamentos o de acudir a un terapeuta o a un médico porque no podían pagar el costo sin seguro médico.

Ahora, 36 estados han ampliado o tienen previsto ampliar la cobertura de Medicaid hasta un año completo después del parto, en parte como respuesta a los primeros trabajos de los comités de revisión de la mortalidad materna.

“Si esto no es una llamada a la acción, no sé qué es”, señaló Adrienne Griffen, directora ejecutiva de la Maternal Mental Health Leadership Alliance, una organización sin fines de lucro centrada en la política nacional. “Hace tiempo que sabemos que los problemas de salud mental son la complicación más común del embarazo y el parto. Solo que no hemos tenido la voluntad de hacer algo al respecto”.

El último estudio de los CDC de septiembre analizó 1,018 muertes en 36 estados, casi el doble de los 14 estados que participaron en el informe anterior. Los CDC están dando aún más fondos para las revisiones de la mortalidad materna, dijo Goodman, con la esperanza de captar datos más completos de más estados en el futuro.

El aumento de la concientización y la atención sobre la mortalidad materna les ha dado esperanza a activistas y médicos, especialmente por los esfuerzos para corregir las disparidades raciales: las mujeres negras tienen tres veces más probabilidades de morir por complicaciones relacionadas con el embarazo que las blancas.

Pero muchos de estos mismos partidarios de una mejor atención materna dicen estar consternados por la reciente decisión del Tribunal Supremo de Estados Unidos de erradicar el derecho federal al aborto; las restricciones en torno a la atención de la salud reproductiva, dicen, erosionarán los avances.

Desde que estados como Texas empezaron a prohibir los abortos en etapas tempranas del embarazo y a hacer menos excepciones para aquellos casos en los que la salud de la embarazada está en peligro, a algunas mujeres les resulta más difícil recibir atención de urgencia por un aborto espontáneo.

Los estados también están prohibiendo los abortos —incluso en casos de violación o incesto— en chicas jóvenes, que afrontan un riesgo mucho mayor de complicaciones o muerte por llevar un embarazo a término.

“Cada vez más el mensaje es que ‘no eres dueña de tu cuerpo’”, dijo Jameta Nicole Barlow, profesora adjunta de redacción, política y gestión sanitaria en la Universidad George Washington.

Según Barlow, esto no hará más que agravar los problemas de salud mental que experimentan las mujeres en torno al embarazo, especialmente las mujeres negras, que también se enfrentan a la larga historia intergeneracional de la esclavitud y el embarazo forzado. Sospecha que las cifras de mortalidad materna empeorarán antes de mejorar, debido a la interrelación entre la política y la psicología.

“Hasta que no abordemos lo que está ocurriendo políticamente”, dijo, “no vamos a poder ayudar a lo que está ocurriendo psicológicamente”.

Esta historia es parte de una alianza que incluye a KQEDNPR, y KHN.

Readers and Tweeters Take Positions on Sleep Apnea Treatment

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

On a ‘Woke’ Journalist’s Journey

I found Jay Hancock’s piece rather intriguing (“Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” Oct. 3). While I agree that positional therapy is often overlooked as a first-line treatment for obstructive sleep apnea, one has to look at this serious, life-threatening health issue in a bit more detail. First, Mr. Hancock’s diagnosis was central sleep apnea, which suggests either a neurologic and/or breathing control etiology. Sleeping on the side may prevent airway obstruction, but the underlying cause has likely not been addressed. Second, the danger here is that — a bit like hypertension, with which there are little or no perceived symptoms — a catastrophic event might occur with little or no warning. Third, it sounds as if the positional therapy in this case alleviated the condition — but as one gets older, the condition will likely worsen.

Bottom line: Why does this particular patient have this condition and what can be done to address the root cause instead of taking a symptomatic approach? My fear is that, left untreated, the patients fall asleep with a false sense of security to never wake up the next morning.

— Dr. Dave Singh, an adjunct professor in sleep medicine at Stanford University, Oakland, California

— Liz Beaulieu, Yarmouth, Maine

Finally! Jay Hancock exposed the sleep apnea medical racket. I have another treatment option: During covid, many inpatients were intubated in the prone position. I was curious about that and did some Googling. Not only does sleeping on your stomach increase lung capacity, the gravity on the throat is a natural treatment for sleep apnea. While difficult to adapt to, it’s better than a CPAP. Again, doctors don’t mention it. No money in a simple gravity solution.

— Peg Keohane, Syracuse, New York

— Stanley Morrical, San Francisco

I want to thank you for this very timely article. I have suspected there was more to the question of apnea than was being reported. As stated, it is a big industry that perpetuates the idea that everyone is affected.

The reporter’s discovery that side-sleeping is the answer is absolutely valid, as I determined long ago. The article should be widely disseminated as it is of extreme importance to millions who are falling for the hype!

— Lawrence Dee, Chino Valley, Arizona

— Robert Roy Britt, Phoenix

My mouth dropped open when I read Jay Hancock’s piece about sleep apnea. You are the harbinger of a tidal wave, my friend. The party is just getting started.

Empowered Sleep Apnea is a project we created to protect individual patients from the “conveyer belt” of the American health care system, as it’s poised to deal with tens of millions of new diagnoses of sleep apnea, which will soon be made in primary care and dental offices all over our great land, using automated, wearable technology. That time is coming within 18 months.

You suffered because there was inadequate coaching for a terribly complicated disease. Simple as that. All those who will be subjected to a cloudburst of automated diagnostics will have the same journey to make. Out of necessity, your solution was to slog through your own research to get yourself some sane direction. You empowered yourself. Good on you.

My solution was to take my life’s work as a patient-centered sleep medicine physician and turn it into something beautiful to behold, so that everyone can benefit from sane coaching. Our project hinges on patient empowerment. Our website is a nice introduction. Our podcast is also a blast that I think your readers would find very interesting.

— Dr. David E. McCarty, owner and CEO of Empowered Sleep Apnea, Boulder, Colorado

— Dr. Art Sedrakyan, New York City

As president of the American Academy of Sleep Medicine (AASM), I write to address several concerns about the recent article “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution” (Oct. 3). While I commend the author for seeking medical help for his daytime drowsiness and snoring, I fear his article may mislead readers in a way that could jeopardize not only their own health and safety but that of others as well.

The author is clearly dissatisfied with the care he received; however, using this to suggest that nearly everyone diagnosed with sleep apnea should simply treat it on their own “for free” is dangerous. Sleep apnea is a common and chronic medical condition that increases the risks for numerous physical and mental health consequences, diminished quality of life, motor vehicle crashes, and premature death.

Positional therapy (which typically requires the use of a device to maintain a side-sleeping position), though useful for some patients with sleep apnea, is not the best treatment for most patients, especially those with moderate to severe sleep apnea. Positive airway pressure (PAP) therapy is the best-supported, evidence-based treatment for sleep apnea. The most recent systematic review and meta-analysis included 80 randomized controlled trials investigating the use of PAP therapy to improve outcomes. Millions of patients with sleep apnea can attest to the life-changing — and even lifesaving — impact of PAP therapy. Treatment selection is an important decision that should be made together by a patient and their treating provider.

Furthermore, it is inappropriate for the author to use his experience as justification to malign our entire organization and our 12,000 members. AASM strongly refutes the implication that support from industry biases our clinical practice guidelines and policies. Our guidelines are based on a review of the latest research by a task force of experts who determine the strength of evidence for a given treatment. The AASM also ensures conflicts of interest are mitigated through a stringent clinical practice guideline development process. While the author claims our organization “finances its operations” with industry support, this is simply untrue. Industry support represents roughly 1% of our annual revenue and is guided by a clear policy that helps ensure transparent interactions to prevent undue influence and support public health. Likewise, the implication that our members are prescribing PAP therapy as part of a revenue-generating scheme is fallacious. The vast majority of PAP devices are sold by durable medical equipment suppliers, not by sleep centers or sleep doctors.

I hope that readers struggling to get a good night’s sleep will seek information from credible sources and talk with a trusted health care professional to determine which treatment best addresses their specific situations.

— Jennifer L. Martin, president of the American Academy of Sleep Medicine, Darien, Illinois

— Timothy Noah, Washington, D.C.

I just saw Jay Hancock’s article on my Google feed and read it, as I suffer from serious sleep apnea as well. I’ve received tailor-made mouthguards, so to speak, which appear to work rather well.

But I’ve also been reading books on breathing, starting with “Breath, the New Science of a Lost Art” by James Nestor, and then on to “The Oxygen Advantage” by Patrick McKeown. I realized I was a mouth breather and that that contributes to the apnea problem as well and have since been trying to learn to breathe through my nose at all times — thus far with mixed results, but the subject is very interesting as it pertains to a lot more than just how to get a good night’s sleep.

— Dimitri F. Frank, Málaga, Spain

— James Hughes, Savannah, Georgia

Treating Trauma — Followed by Billing Trauma

I’m an emergency physician who also works at urgent care. While I appreciate patients trying to be fiscally responsible with their choices, the urgent care did precisely the right thing in this case (Bill of the Month: “Turned Away From Urgent Care — And Toward a Big ER Bill,” Sept. 29). Urgent care can typically manage fender benders or other minor accidents, but someone whose airbags deployed and whose car rolled three times and wound up “crushed” up into a tree should always go to the emergency room. The mechanism of such accidents is very concerning and typically justifies a trauma activation and CT scans to evaluate for internal injuries. Urgent care is not equipped to handle patients if they develop life-threatening complications from a severe injury.

— Dr. William Weber, Harvard Medical School / Beth Israel Deaconess, Boston

— James Conner, Kalispell, Montana

This article is missing the perspective of a medical provider. I am a retired board-certified emergency physician with 33 years in the emergency department and more than five years in urgent care and feel the need to address the medical care differences between the ED and urgent care.

I agree with the facts of your article and don’t dispute the financial issues, problems, inequities of the broken system. But there is more to the story.

The knowledge, ability, skill, and experience of the provider are key. The location of care predisposes to the abilities of the provider but doesn’t guarantee them. You may receive excellent to below-average care depending on the provider. I have seen people die from auto accidents that were sent home from urgent care after receiving an evaluation by a general practitioner not trained in trauma. Some ED physicians miss things, but the odds are better that the ED doctor will not miss critical cases.

Conversely, you might get care from an experienced ED physician at an urgent care.

Then there are the personnel and resources provided. If it is a simple “urgent” problem, no significant difference in outcome is likely to result.

There is the dilemma. What is an emergency? This has been argued in Congress: to err on the side of not missing serious problems for which a “prudent layperson” could observe symptoms. So an emergency is what a “prudent layperson” believes it is.

Some of the urgent care centers I worked in turned away “third-party” cases but most didn’t — even within the same hospital-owned urgent care chain. An option would be to offer to pay cash, asking for the cash-upfront price. Difficult to be accurate in predicting the cost ahead of time, but an estimate is not unreasonable. Instead of a low four-figure bill, the family might have turned out to have a low three-figure bill if not referred to the hospital after the urgent care evaluation.

In my experience, I’ve never seen a patient sent from urgent care (owned by or affiliated with a hospital) to the hospital for the sole reason of the hospital billing a second charge. Many patients are sent because they need a higher level of care that isn’t available, such as hospitalization, injectable medications, specialty care, imaging, and “stat” lab work not available.

Sure, the hospital uses the urgent care as a feeder site, but the patient (or the paramedic) gets to choose which hospital to go to, if they have a preference.

Please remember that not all hospitals or urgent cares are the same. Many smaller hospitals do not have some/many specialists required to back up the emergency department. Some urgent cares use primarily general practitioners, while others use only board-certified emergency physicians, nurse practitioners, or physician assistants.

Yes, the system is broken. Per a recent webinar by the California Medical Association: In the past 50 years, the increase in the number of physicians was 2%. Administrative health care personnel increased more than 3,000%. (That includes both the provider and the payer side.)

— Dr. Mickey Kolodny, Palos Verdes Peninsula, California

— Donald Farmer, Woodinville, Washington

After 40 years as a board-certified emergency medicine physician, I believe the article by Sam Whitehead is very misleading. First of all, the patient should never have gone to an urgent care. Had she called 911 as she should have, just because of the mechanism of the crash, she would have been brought to an emergency room. The ER obviously believed two CT scans were needed, which the urgent care would not have been able to provide. The reporter did not dig into the details of the acute trauma care this patient needed — other than understating her post-accident situation, which was self-defined. The author writes as if it is strictly an insurance issue or a way for the urgent care/hospital system to gain patients.

There is no indication of this happening given that the patient needed, by protocol, Advanced Trauma and Life Support (ATLS). By EMS protocol and by malpractice case law, this patient needed a visit to a trauma center emergency room. And the bill is a totally different issue. In other words, the author totally missed the medical issues to overstate and sensationalize billing issues.

— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin

— Kendra Lee, Woodbridge, Virginia

I listened to your story as retold on NPR about a young woman who had a high bill for an ER visit after a car accident. I felt that the story was editorially biased, as it mentioned nothing about the requirements for care for traumatically injured patients. It seemed to recommend visiting urgent care centers instead of emergency rooms. Although less expensive, such facilities generally should not care for patients with serious injuries. Most hospitals require board-certified emergency medicine physicians and have extensive resources whereas an urgent care doctor may not have completed a residency. The “physician expert” in the story clearly had no experience in the care of traumatically injured patients. Having such insight would lend depth to what I saw as a superficial look at a nuanced issue. Clearly the public should be better informed about cost-effective care, but an evaluation after a serious car crash is inappropriate to be sent to an urgent care.

— Dr. Christopher Goltz, Flint, Michigan

A Wealth of WISDOM

Nice article (“Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients,” Sept. 21). With breast cancer awareness month upon us, I would also point out the existence of the WISDOM study funded by the National Institutes of Health, which is looking at different approaches to using genetic testing to screen women for breast cancer. Check it out at www.thewisdomstudy.org.

— Dr. Daniel Halevy, New York City

— Dr. Cee A. Davis, Winchester, Virginia

On the Birth of Obstetrics Emergency Departments

I was disappointed by your article “Baby, That Bill Is High: Private Equity ‘Gambit’ Squeezes Excessive ER Charges From Routine Births” (Oct. 13). While I recognize that medical billing is often confusing and at times even alarming to patients, I would like to share a few points that I feel were downplayed or omitted:

  • The article gives the impression that the obstetrics emergency department, or OBED, is created simply by rebranding an existing process within hospitals. The author neglects to mention that before the OBED, most hospitals did not have OB-GYN hospitalists stationed in-house 24/7 to address emergencies. Prior to the implementation of the OBED, many expectant mothers, concerned that something might be wrong, were not able to see a physician when they visited a hospital emergency room. Instead, they were transferred to the labor and delivery department to be evaluated by a nurse taking instructions over the phone from a physician. If the patient and her baby were in serious distress, it became a waiting game, with the risk escalating every minute she waited for medical attention from her doctor — or any doctor. Hundreds of thousands of life-threatening emergencies are managed each year by OB-GYN hospitalists who staff obstetrics emergency departments.
  • Reporter Rae Ellen Bichell seems to have a beef with the practice of hospitals charging for an emergency evaluation when unscheduled pregnant patients arrive at the hospital with medical complaints. Whether we like it or not, that is simply the way that health care works in America. If you show up unexpectedly at a hospital for evaluation of a health concern, you will be treated as an emergency — and you will likely receive a large bill corresponding to the unscheduled care you received.
  • The author works hard to establish or imply a causal relationship between the private equity backing of medical staffing companies and the fact that hospitals are billing patients for emergency medical services. However, hospital service providers and vendors have absolutely no control over a hospital’s billing practices. This bit about private equity seems to serve no logical purpose in this article except to make the story appear as a “whodunit,” casting private equity firms in the role of immoral shadow bosses turning a profit at the expense of unwitting expectant mothers, when in fact they play no role in establishing the billing policies that Ms. Bichell incorrectly and perhaps unfairly characterizes as “moneymaking ‘emergency’ events.”

I have dedicated my career to the development and implementation of obstetrics emergency departments in hundreds of hospitals across the U.S., but I am unaware of any hospital turning routine births into moneymaking emergency events as claimed in the title and misleading argument of this article. I stand by my statement — and my sincere belief — that having trained doctors available 24/7 on the labor-and-delivery floor has significantly enhanced the quality of care available to expectant mothers at some of the most challenging and medically consequential hours of their lives.

Thank you for considering my point of view.

— Dr. Christopher C. Swain, Charleston, South Carolina

— Adam W. Gaffney, Boston

Shooting Craps?

Online stock brokerage houses have made all cellphones into “gambling devices” years ago (“Addiction Experts Fear the Fallout if California Legalizes Sports Betting,” Oct. 5). What a load of crap that California gaming would suddenly create new cases of addiction. Stop the crap reports.

— Matt McLaughlin, Carpinteria, California

— Kristina Bas Hamilton, Sacramento, California

Measuring Fat: A Gut Check

Julie Appleby provided useful information on how modern medicine misclassifies patients’ health status through the use of the body mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12). She included comments advocating the use of waist circumference (WC, by tape measure in the standing position) rather than body weight to indicate more specifically where the metabolic problems can be found. She’s on the right track, but her article might have gone further to explore alternative, more focused indicators of excess adiposity.

Anatomically, more than 90% of human body fat can be classified into three main depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, abdominal subcutaneous adipose tissue, and visceral (inside the abdomen) adipose tissue. Of these three, only the visceral fat is clearly associated with cardiac and metabolic disorders. Increased gluteo-femoral subcutaneous fat has been shown repeatedly to be associated with improved health outcomes. Abdominal subcutaneous fat tends to have neutral, benign effects for most individuals.

What we need is a simple adiposity indicator that can estimate the burden of visceral fat. Three decades of research suggests that a simple measure of the supine sagittal abdominal diameter (SAD, sometimes called the “abdominal height”) predicts poor health better than the standing WC. When persons are in the supine position, their benign, abdominal subcutaneous fat falls to the sides of the midline. For this reason, variation in the SAD, rather than in the WC, is more strongly associated with the variation in visceral fat volume. The SAD/height ratio (SADHtR) is arguably even better than SAD alone. The SADHtR has been shown in the federal National Health and Nutrition Examination Survey (NHANES) to be significantly better than BMI for identifying major cardio-metabolic risk factors, i.e., insulin resistance or serum triglycerides.

There is a simple tool that researchers or clinicians can use to measure the SAD: a low-cost, portable, sliding-beam caliper. Various calipers are available, all of which are less expensive than a high-quality scale. And the calipers are easier to calibrate, too.

Choosing between the adiposity indicators SAD or WC could depend on the method’s simplicity and replicability. Especially among persons with large bellies, the reliability of the standing WC is challenged by conflicts between minimizing tension on the measuring tape and the tape’s tendency to droop unpredictably below the horizontal plane. For the SAD, both the examinee and the examiner can relax as the upper arm of the sliding-beam caliper descends just to the point where it touches the abdomen. No further judgment is required.

— Dr. Henry S. Kahn, Atlanta

— Morgan Harlan, Washington, D.C.

Revisiting the Homelessness Conundrum

To me, there is only one solution to helping our homeless get off the streets and into an environment that is safe, that will provide them with food, medical attention, and security, as well as provide them a means to regain the loss of self-esteem of so many of the homeless (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21). Our military bases could provide all the above, of course, with the permission of the Department of Defense and base commanders. I see so many efforts at trying to utilize hotels, apartment buildings, and the like, that are costing our cities, states, and federal government so much money that really is just a waste of time. We need to show our homeless that our government and all of us really care about them. We need to offer them the opportunity to settle in on a military base. They have the human resources and financial resources to really do something, and in a short period of time. These homeless could even be offered up some tasks to do on the bases. Please support this effort. Thank you for your efforts, too. I think every heart cries when we see this tragic situation on our street, and leaves us feeling helpless and hopeless for them.

— Mike Stalsby, La Jolla, California

— Arielle Kane, Washington, D.C.

KHN’s ‘What the Health?’: Looking Ahead to the Lame-Duck Session

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When the lame-duck Congress returns to Washington after Election Day, it will face a long list of health items needing attention before the end of the year, including setting overall spending for health programs and averting a series of Medicare payment cuts to health care providers.

Meanwhile, in California, Democratic Gov. Gavin Newsom has signed a first-in-the-nation bill aimed at curbing covid-19 misinformation and disinformation by doctors.

This week’s panelists are Julie Rovner of KHN; Sandhya Raman of CQ Roll Call; Jessie Hellmann, also of CQ Roll Call; and Mary Agnes Carey of KHN.

Among the takeaways from this week’s episode:

  • When congressional lawmakers left town last week for a month of campaigning before the midterm elections, they agreed to fund the government — but only until mid-December. The election results may impact whether they reach agreements on funding for the full fiscal year when they come back.
  • Key Democratic members of the House have pledged to jettison the so-called Hyde Amendment from any spending bills, but clearly those efforts don’t have enough support to get through the Senate. The Hyde Amendment, named for Rep. Henry Hyde (R-Ill.), who died in 2007, bans federal funds from being used for most abortions.
  • Among the funding issues still to be settled by lawmakers is whether they will continue certain programs begun during the pandemic, such as allowing Medicare to cover telehealth services and whether enhanced Medicaid will continue for U.S. territories.
  • Also still awaiting a decision by Congress is a bipartisan effort to improve mental health services.
  • In response to some of the unusual treatments and theories that emerged surrounding covid, California has enacted a law that could bring more discipline for doctors who knowingly spread disinformation directly to patients. They can be reprimanded by the state medical board.
  • The issue of abortion is heating up in campaigns around the country, especially among Democrats running for Congress, governor, or attorney general. Republicans, on the other hand, are playing down the issue while they try to emphasize economic and immigration issues.
  • A new report from Ohio officials points to the surprisingly high number of girls and young teens seeking abortions. The state health department reported that among 538 children age 17 and younger who got abortions in Ohio last year, 57 were under 15.

Also this week, Rovner interviews KHN’s Sam Whitehead, who reported and wrote the latest KHN-NPR “Bill of the Month” episode about a family who tried to use urgent care to save money but ended up with a big emergency room bill, anyway. If you have an outrageous or enormous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: NPR’s “The Ice Bucket Challenge Wasn’t Just for Social Media. It Helped Fund a New ALS Drug,” by Wynne Davis

Sandhya Raman: Mountain State Spotlight’s “As WV Officials Tout Small Reductions in Drug Overdose Deaths, Epidemic Remains at Crisis Levels,” by Allen Siegler

Jessie Hellmann: KHN’s “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” by Jay Hancock

Mary Agnes Carey: The Washington Post’s “Seniors Are Stuck Home Alone as Health Aides Flee for Higher-Paying Jobs,” by Christopher Rowland

Also mentioned in this week’s episode:

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