Tagged opioids

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As you all know, when I come across an outrageous medical mystery story I like to drag you all down with me because horrified misery loves company. This week’s offering: A man in Kentucky went into his doctor complaining of eye irritation. And what did his doctor pull out of his eyeball? That’s right! A tick. (You’re welcome.)

Quickly moving on! Here’s what you might have missed during this very hot week.

The tensions in the Democratic presidential field that have been brewing for a while erupted into verbal sparring between Sen. Bernie Sanders (I-Vt.) and former Vice President Joe Biden. The mini-war seems to be more than just your typical political posturing — both men have deep personal stakes in the issue (which, if you haven’t noticed, voters care a lot about right now). Sanders’ “Medicare for All” plan is nearly synonymous with the man himself, while Biden experienced firsthand the blood, sweat and tears it took to actually get the health law passed.

Earlier in the week, Biden dropped his own health plan, which could be summed up as the Affordable Care Act on steroids. And his promise that went along with the reveal — “If you like your plan … you can keep it” — was a blast-from-the-past that highlights all the advantages (the health law is quite popular at the moment) and pitfalls (that promise when President Barack Obama made it was ranked PolitiFact’s “Lie of the Year”) of taking this particular path.

It also nudged Biden and Sanders into a collision over their philosophical differences that played out in public at various events this week. Neither candidate pulled punches, but Sanders, in particular, had some tough words for his rival. “Unfortunately, he is sounding like Donald Trump,” he said. “He is sounding like the health care industry, in that regard.”

On that note, Sanders called on the Democratic candidates to join his pledge not to take donations from the health industry or pharma. Though he didn’t name names, it seemed to many like another jab at Biden.

Biden also took shots of his own, calling Medicare for All costly and complicated, and insinuating that those looking to get rid of the health law are no better than Republicans.

Whatever the outcome of this particular scuffle, it highlights that, in a crowded field, candidates are looking for things to set them apart. And in this particular election cycle, looks like it’s health care.

CNN: Biden Proposes Massive New Obamacare Subsidies, Public Option in Health Care Plan

The New York Times: Sanders and Biden Fight Over Health Care, and It’s Personal

Politico: Sanders Calls on Democratic Rivals to Reject Drug, Insurance Industry Donations

The New York Times: Anxious Democratic Governors Urge 2020 Field Not to Veer Too Far Left

Meanwhile, the health law faced off against an unlikely foe this week: Democrats. Lawmakers in the House delivered what is in all intents and purposes a death blow to the “Cadillac tax,” a cost-containing provision that at one point in time was looked at as crucial to the law’s success. (The Senate hasn’t voted on it yet, but Republicans are not exactly fans of the tax, so its fate seems decided.)

But as hell has not frozen over, it’s not as if the Democrats are suddenly jumping on the GOP bandwagon to dismantle the law. The tax was disliked by unions (a key constituency) and some liberal-leaning economists. Rep. Joe Courtney (D-Conn.), the author of the repeal bill, even (subtly) called it, the “Middle Class Health Benefits Tax Repeal Act.”

The New York Times: House Votes to Repeal Obamacare Tax Once Seen As Key to Health Law

As a side note, you should be following Noam Levey’s great series on the ways Americans are hurting in the wake of the high-deductible revolution.

Los Angeles Times: Rising Health Insurance Deductibles Fuel Middle-Class Anger and Resentment

The Democratic field’s fireworks over candidates’ philosophical differences weren’t the only ones on display this week. Dr. Leana Wen was ousted from her position as head of Planned Parenthood after only eight months in the role. Although there have been reports about managerial styles, Wen has hinted that the friction comes from her desire to view the organization through a public health prism. During a time when the abortion wars grow only more intense, Wen’s strategy to emphasize abortion as part of a larger part of improving women’s health felt out of step to some.

The New York Times: A Messy Exit Leaves Planned Parenthood at a Philosophical Crossroads

As if underscoring that very tension, the ousting came as the Trump administration announced that the changes to family planing funding, often called a “gag rule” by critics, would be enforced immediately, now that it has the court’s go-ahead.

The Associated Press: Trump Abortion Restrictions Effective Immediately

After a yearlong legal battle, The Washington Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, obtained information from a Drug Enforcement Administration database that shows how 76 billion oxycodone and hydrocodone pain pills saturated the country as the opioid epidemic was gaining steam. Just six companies distributed 75% of the pills from 2006 to 2012, sending millions of pills into tiny rural towns with only a few thousand residents. The numbers reveal a trail of bright, screaming red flags that were overlooked as the country barreled toward a crisis point.

The Washington Post: Largest U.S. Drug Companies Flooded Country With 76 Billion Opioid Pills, DEA Data Shows

PBS NewsHour: The Opioid Industry Fought Hard to Keep This Database Hidden. Here’s What It Shows

There was some rare good news on the opioid front this week: For the first time since 1990, fatal drug overdoses actually fell. There are (of course!) caveats, though: Experts still see worrying trends when it comes to synthetic drugs such as fentanyl.

The Washington Post: Drug Overdoses Fell Significantly in 2018 for First Time in Decades, Provisional CDC Data Show

Everyone in Congress and the administration is really, very, extremely angry about high drug prices … and yet pharma is still racking up the wins on Capitol Hill. Stat has a great read on exactly what’s going on with the industry’s influence, and looks at a new strategy from drugmakers, who seem to be targeting a pair of vulnerable Republicans to get their way.

Stat: How Pharma, Under Attack From All Sides, Keeps Winning in Washington

In a landscape where everyone is jonesing to cut costs, why is it so breathtakingly easy to scam insurers? Some investigators estimate that fraud eats up 10% of all health care spending. Consumers’ gut reaction is that insurers would, of course, be stepping in to police these bad actors. But they don’t seem to have any desire — or, at least, not enough — to actually act. Maybe that’s because consumers are the ones getting stuck with the losses.

ProPublica: Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You.

Speaking of, a former VA employee who was supposed to help veterans navigate insurance for their kids who had spina bifida used the position to collect millions in kickbacks, prosecutors allege.

The Daily Beast: Feds Say Former VA Employee Used Vets’ Ailing Kids to Scam Millions

A lot of very cool (or at least interesting) news came out of the Alzheimer’s Association International Conference this week. A look at highlights:

Los Angeles Times: Blood Test for Alzheimer’s Disease Moves Closer to Becoming a Reality

CNN: Lifestyle Can Still Lower Dementia Risk Even If You Have High Genetic Risk, Study Suggests

The Washington Post: Women Who Work for a Salary See Slower Memory Decline in Old Age, Reducing Their Risk of Dementia, a New Study Suggests

And in the miscellaneous file:

• What’s it like to be a Border Patrol agent? Because access to them can be tightly controlled, it’s rare to hear about their experiences. This story contains a chilling, yet fitting musing: “Somewhere down the line people just accepted what’s going on as normal.”

ProPublica: A Border Patrol Agent Reveals What It’s Really Like to Guard Migrant Children

• It’s one of health care’s biggest challenges: weaning people off the habit of going to the ER instead of a primary care doctor. Well, New York City is going to invest $100 million a year to try to do just that.

The Wall Street Journal: New York City Hopes to Ease Strain on Its Emergency Rooms

• More than 200,000 kids in Tennessee were either cut or slated to be cut from insurance because the state’s unwieldy system heavily relied on hard-copy forms.

The Tennessean: At Least 220,000 Tennessee Kids Faced Loss of Health Insurance Due to Lacking Paperwork

• Do service dogs actually help veterans with PTSD? Although there are plenty of heart-warming anecdotal stories about the benefits, doctors in the VA are hesitant to recommend them over treatment that has been shown to work because there’s little hard science on their benefits. The thing is, the VA is supposed to be doing research on it. Yet, for some reason, it’s been lagging, despite the burgeoning mental health crisis among veterans.

The New York Times: Do Service Dogs Help Treat PTSD? After Years of Research, the V.A. Still Doesn’t Know

• A look at law enforcement in Alaska, where violence against women is gaining national attention, shows that dozens of convicted criminals have been hired as cops for these communities. In one small village, every single policeman on the force, including the chief, has a criminal record of domestic violence.

ProPublica/Anchorage Daily News: The Village Where Every Cop Has Been Convicted of Domestic Violence

That’s it from me! Try to stay cool and make sure to hydrate this weekend!

KHN’s ‘What The Health?’: Biden Doubles Down On Obamacare

Can’t see the audio player? Click here to listen on SoundCloud.

Former Vice President Joe Biden has said if he’s elected president he would build on the Affordable Care Act rather than move to a whole new health care system, such as the “Medicare for All” plan supported by some of his primary opponents for the Democratic nomination. But his campaign’s new health plan would include many things Congress tried and failed to pass as part of the health law, including a government-run “public option” plan that would be widely available.

Meanwhile, the U.S. House voted to repeal one of the ACA’s key financing mechanisms, voting overwhelmingly to cancel the so-called “Cadillac tax,” which was set to take effect in 2022. It is a 40% excise tax on the most generous employer-provided health plans.

And it was not a good week for Planned Parenthood. The women’s health provider parted ways with its president of less than a year, Leana Wen. And the Trump administration announced it would begin enforcement of new rules for the federal family planning program that Planned Parenthood said will force it to stop participating.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of the Washington Examiner and Margo Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Biden’s health proposal seeks to lower out-of-pocket costs for many people in several ways. For example, it would make federal premium help available to all who buy their own insurance, not just those with low and middle incomes. It would also change how federal premium subsidies are determined. It would base the assistance on the cost of a gold plan, rather than the current practice of using the second lowest priced silver plan. Since gold plans are more generous, using that standard could lower the amount of deductibles and copayments people getting subsidies have to pay.
  • The ACA’s Cadillac tax has been strongly endorsed by health economists, who view it as a way to cut the amount of unnecessary care some people with generous plans seek. But many employers, consumers and labor unions don’t want to tinker with the current tax system of job-based insurance.
  • The administration’s decision to go forward with its new rules for the Title X family planning program — while critics are challenging those regulations in the courts — will have a significant effect on Planned Parenthood’s finances. But the group gets even more government money through the Medicaid program.
  • Despite two setbacks last week in the administration’s efforts to reduce drug prices, President Donald Trump is continuing to hint that he wants to go forward with a plan to tie some Medicare drug prices to what people in other countries pay for the medications.
  • Federal officials have announced that opioid deaths have declined, but it is not clear that opioid overdoses or addiction has declined.

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

Julie Rovner: The New York Times’s “Where Roe v Wade Matters Most,” by Quoctrung Bui, Claire Cain Miller and Margot Sanger-Katz.

Joanne Kenen:  Scientific American’s “Why Doctors Are Drowning in Medical School Debt,” by Daniel Barron.

Margot Sanger-Katz: Bloomberg News’ “Deadly Disease Is Treatable, But Newborn Screening Patchwork Leaves Many Vulnerable,” by Michelle Cortez.

Kimberly Leonard: The Washingtonian’s “DC Types Have Been Flocking to Shrinks Ever Since Trump Won. And a Lot of the Therapists Are Miserable,” by Britt Peterson.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

KHN Investigation On Opioid Prescribers Pains Some Readers And Tweeters

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.

In Defense Of Opioid Prescribers

Articles such as this one are leaving elderly patients with debilitating pain and also hospice patients struggling to get adequate pain control (“Surgeons’ Opioid-Prescribing Habits Are Hard To Kick,” June 21). After seeing my father in agony in hospice care this year, I am upset by this opioid-induced fear of prescribing. Also, leaving post-surgical patients in pain by not prescribing enough pain medication is a shame in this day and age. The anti-opioid movement pendulum has swung way too far to the opposite side. I watched my dad suffer needlessly in hospice care because the nurse practitioner (who, by the way, never once visited my father) would balk anytime we begged for them to relieve my father’s uncontrolled pain. I am angry. I am sorry. But things need to change in the health care field. Medical practitioners are more scared of getting in trouble than they are helping patients in pain.

David Colegrove, Powell, Ohio

— Dr. Scott Gottlieb, Washington, D.C., former commissioner of the Food and Drug Administration

You are engaging in the worst kind of public shaming with this investigation of opioid prescribers (“Opioid Operators: How Surgeons Ply Patients With Painkillers,” June 20). I remember when my dad had bypass surgery and he was in a lot of pain. I look at these numbers and wonder how many patients didn’t have someone to get the prescription filled. We are attacking the wrong people. The overdoses are caused by illegal heroin and fentanyl. I have been on these medications a long time for intractable pain. I have never taken more than prescribed and nearly all patients like me do the same. If I have been taking the same dose for six years, I would say the odds of an overdose are slim to none. Learn the difference between physical dependence and addiction.

— Dennis Ewing, San Antonio

— Dr. Edward Chory, Lancaster, Pa.

Your project entitled “Opioid Operators” is ridiculously inflammatory. I hope you get sued by the same doctors you are “exposing.” You have no idea what each individual patient needs because you aren’t there.

In addition to being wracked with the pain of complex regional pain syndrome (CRPS) 24/7, I am also the caregiver to my husband, who has end-stage renal disease. Taking away pain medication when 99% of the pain patients who use it never abuse it is a crime. It will have no effect on addiction. It will just kill people who are already frail from having to combat pain from incurable disorders.

— Bijoux Faraj, Concord, Calif.

— Madi Alexander, Arlington, Va.

Why do groups constantly put “information” out to the public that fits their narrative? This story about opioids is nothing more than a reason to bash doctors who prescribe pain medication to people in pain. Why not investigate why doctors prescribe this medication to patients? I have had chronic pain for 25 years. These stories have caused my medication to be all but taken away. How about running a “rebuttal” to that story and let the “other side” speak?

— Dennis Shivers, Lake Ronkonkoma, N.Y.

— Peter Grinspoon, Boston

Boggled By Mind Games In ACA Court Battle

I want to congratulate Julie Appleby (“DOJ Lawyers Try New Tricks To Undo Obamacare. Will It Work?” July 12) for distilling what I consider to be one of the worst oral presentations by the Department of Justice I have ever seen or heard (I listened to the entire audio of the oral arguments). I say this as a health care attorney of some 46 years who was also brought to D.C. to counsel members of Congress on the Affordable Care Act as it was being developed.

The positions taken by DOJ counsel floored me — viz a viz, that the outcome of the case should apply to only the plaintiff states and not the rest of the country; or that the entire act is inseverable from the mandate provision, but since the act is “complicated” (really? of course it is), it would have to be worked out which provisions could remain in effect — for only the plaintiffs? for the entire country?

Scholars on both sides of the ACA agree the decision of the lower court was anathema to sound judicial foundation and precedent. The critical fact is that the 2017 Congress — not the one that passed the ACA in 2010 —eliminated the tax/penalty to zero and kept the rest of the act in place. Judges do not eliminate laws unless there are clear expressions from the legislature in its legislation to do so, or the language of the act is so ambiguous as to require judicial interpretation of the words used. With the ACA, there was no expression of inseverability related to zeroing out the individual mandate … despite the DOJ telling the appeals panel there was.

Finally, Judge Kurt Engelhardt, a member of the panel hearing the case and a Donald Trump appointee, questioned why the House could not pass another bill that kept the worthy features of the ACA in the event the current law remains unconstitutional. The role of appeals jurists is to probe the strengths and weaknesses of all sides during oral argument, not ask foolish questions, considering Mitch McConnell controls the Senate, the majority of the House is blue and, of course, Trump presently remains president. As I have written for over a decade before it was in vogue to do so, health care is a right for all Americans, and the ACA is the embodiment of this philosophy ingrained within the fabric of our country. To even posture a new health care bill given the current political environment is glaring fool’s gold.

— Miles J. Zaremski, Highland Park, Ill.

Caring For Survivors Of Sexual Assault

I just read Michelle Andrew’s story about the staggering, and often re-traumatizing, hospital bills that survivors of sexual assault frequently receive after getting a forensic exam in a hospital setting (“Despite Federal Protections, Rape Victims Still Get Billed For Forensic Exams,” July 12). At The SAFE Alliance in Austin, Texas, we operate a community-based sexual assault clinic called Eloise House, where survivors can receive a private exam and evidence collection as well as free medical care after experiencing an assault.

We’ve found that this free, trauma-informed model eliminates many barriers for people who’ve experienced an extremely traumatizing situation by eliminating emergency room wait times and creating an environment that feels more like a home than a hospital. Our advocates work alongside our forensic nurses to offer emotional support, explain the steps of the exam process, answer questions about what the reporting process may look like if the survivor chooses to report, assist with safety planning and much more. Since we opened the clinic in 2015, we’ve served over 2,000 survivors of sexual assault in Central Texas.

I hope that one day every community has access to a clinic like Eloise House, to make the healing process even a little easier for survivors of sexual assault. Thank you for reporting on this little-known issue.

Emma Rogers, Austin, Texas

 As Rural Areas Lose Hospitals, Misplaced Priorities?

I’m getting more discouraged as people exclaim how well our economy is doing when there are losses in our communities such as the closing of rural hospitals (“Have Cancer, Must Travel: Patients Left In Lurch After Hospital Closes,” July 1). Similar reductions and losses are occurring in education, infrastructure and environmental protection, to name a few. This contrast must be reported so citizens can better understand these upside-down priorities are hurting all of us — except for the ultra-rich. This downward spiral will ultimately catch up with them, too, as they will then end up paying for the resultant problems this “ignore-ance” will create.

— Victoria Mosse, Joseph, Ore.

— Mark Fleury, Washington, D.C.

Hospitals in rural areas are closing. Americans are not being treated with human dignity and care. And ignorant people of this country have the audacity to care about immigrants? I have no respect for the immigrants coming here for all the freebies of medical care and housing while Americans are being treated like second-class citizens.

— Debra Schaal, Hobe Sound, Fla.

— Jim Tananbaum, San Francisco

Preventing Falls For A New Generation

Your piece “More Seniors Are Dying In Falls. Doctors Could Do More To Reduce The Risk” (June 27) addresses an important yet rarely discussed epidemic that has become increasingly deadly over the past decade. According to the Centers for Disease Control and Prevention, fall deaths among seniors increased by 31% from 2007 to 2016 — a trend slated to worsen over the next few years as more baby boomers enter retirement. Falls are now the No. 1 cause of injury for older Americans, resulting in 800,000 hospitalizations every year and $50 billion in health care spending.

As a physical therapist (PT), I’ve seen the effectiveness of some of the treatment strategies mentioned in this article. But, while fall risk assessments and personalized patient plans are important preventive tactics, one important factor that wasn’t mentioned in the article is the value of telehealth in reducing seniors’ risk of falling.

Telehealth appointments and virtual fall risk assessments can be incredibly beneficial, particularly for patients with age-related disabilities and limited mobility. Telehealth services provide valuable opportunities for seniors to receive professional PT in the comfort and privacy of their own homes. In turn, this reduces access barriers — particularly for patients in rural and underserved areas — and helps seniors who struggle with transportation issues get the care they need. In fact, one of the initiatives mentioned in your article included a strong telehealth component, which improved compliance with and the effectiveness of PT-prescribed fall prevention exercise regimens. Because falling once doubles the chances of falling again, it is critical to empower America’s seniors with care that makes them stronger, steadier and more flexible.

With an increasingly graying U.S. population, this problem demands a novel and comprehensive response. Having helped countless patients reduce their fall risk, I believe that telehealth PT, together with other solutions mentioned in your article, will play an important role in addressing this epidemic. By embracing evidence-based practices such as telehealth PT, we can seize the opportunity to prevent falls, reduce Medicare spending and, ultimately, save lives.

— Nikesh Patel, PT, DPT, physical therapist and executive director of the Alliance for Physical Therapy Quality and Innovation, Washington, D.C.

— Dr. Judy Stone, Cumberland, Md.

— Wendl Kornfeld, New York City

While Fact-Checking Debates, Check The Moderator’s Attitude

KHN reader Ira Dember demonstrates outside U.S. Sen. John Cornyn’s office in Houston in January. (Courtesy of FairNow.org)

While the facts were somewhat interesting, the elephant in the room was the rigged, wildly biased phrasing of host Lester Holt’s “Medicare for All” question: “Who here would abolish their private health insurance in favor of a government-run plan? Just a show of hands …” On this point, I’m surprised and disappointed KHN didn’t deconstruct that framework (“PolitiFact & KHN HealthCheck: ‘Medicare For All’ Emerges As Early Divide In First Democratic Debate,” June 27).

Last week, the latest voter poll from The Washington Post and ABC News included a Medicare for All question so carefully crafted it could serve as the gold standard for questions that strive to eliminate respondent bias on emotionally charged issues. It asked: [Would you support or oppose M4A] “if there was no private insurance option available?” This phrasing removes the actor: No one is abolishing or taking away anything. It’s the passive voice put to exquisitely good use to avoid bias: “… if there was no private insurance option available.”

Also, notice pollsters’ use of the word “option.” It implicitly frames private insurance as something expendable. It’s an option. Not a requirement, not written in stone. I give big kudos to the pollsters for this careful, and truthful, framing.

And while we’re on the subject of wording: The day before the first debate, an NPR commentator prospectively boiled it down to a struggle between “pragmatists” and “progressives.” Obviously, progressives advocate for substantive change such as Medicare for All — which by implicit definition is not “pragmatic.”

Current public policies that leave us with upward of 500,000 medical-related bankruptcies a year and 36,000 annual deaths attributed strictly to lack of health care coverage are somehow blandly acceptable as “pragmatic.” Needless to say (but I’ll say it anyway), this is an affront to both logic and morality.

— Ira Dember, Houston, founder of FairNow.org

Ensuring The Robust Right To Appeal

On behalf of the California Association of Health Plans, which represents 46 public and private health plans that collectively provide health care coverage to over 26 million Californians, we would contend that the “Asking Never Hurts” column “Did Your Health Plan Deny You Care? Fight Back” (July 15) mistakenly implies that California’s long-standing system for handling grievances, complaints and medical reviews is somehow confrontational, contentious and unknown. The fact is that California has had a robust framework of consumer protections for decades — long before the Affordable Care Act created similar consumer rights at the national level. Our system of resolving disputes balances maintaining a functional and affordable health care system while giving enrollees and providers an opportunity to appeal.

If a patient’s claim is denied by their health plan, the patient has the right to appeal with their health plan, and the right to an independent medical review by the state regulator if they disagree with the health plan’s decision. Independent medical reviews are conducted by a team of providers that have no affiliation with the health plan, and the decision of the independent medical review is binding.

Health plans ensure enrollees are aware of their existing consumer protections under California law, and we provide a comprehensive list of covered services when they are medically necessary. This happens millions and millions of times without dispute. When there is a difference of opinion, health plans want to get it right.

Every Californian deserves to have the peace of mind that they have access to an independent appeals process should they need it. California’s health plans work hard to provide consumers with that peace of mind as we continuously strive to improve outcomes for patients and provide accessible, high-quality, affordable care for all Californians.

— Charles Bacchi, president and CEO of California Association of Health Plans, Sacramento

A Handy Takeaway From Your Podcast

I heard the “An Arm and a Leg” podcast recently (“Forget The Shakedown. To Get Paid, Hospitals Get Creative,” June 12). Great stuff!

Then I dislocated a bone in my foot and went to see an orthopedist at SportsMED Orthopedic Surgery & Spine Center in Huntsville, Ala. Doc ordered an Aircast AirSelect brace. The brace shop said my insurance covered it 100%. That was good, so I had them fit it. My foot felt better right away, more stable. Then, as I’m ready to leave, I’m told I have to sign a digital pad with only a signature space. “What is it you want me to sign?” I asked.

Turns out it was a form stating I agreed to pay all costs that may be later billed and not covered by insurance (which they could not tell me what that would be). Long story short — forget about my insurance covering it 100%. After checking with Blue Cross Blue Shield, I learned my out-of-pocket cost could have been $378.

If I had come in with no insurance, it would only be $110, and a variety of other permutations of random pricing all “the fault of my insurer, not their pricing,” per their insurance supervisor. Having heard your podcast, I checked Amazon — an identical Aircast was $78 with free shipping. So, I limped out and ordered it on Amazon. At least I knew how much I would pay. The person before me left with a knee brace for his son for a $415 insurance copay.

— Lisa Moore, Huntsville, Ala.

Out In The Open About Well-Thought-Out Exit Strategies


This is a topic (“In Secret, Seniors Discuss ‘Rational Suicide,’” June 25) that should be public, not sequestered in private. My 87-year-old father and I have had this conversation, and it’s not taboo in our family. Thank you for talking about it.

It’s sad that as a society we can’t face the fact that people want to have choice, especially on the quality of their life and remaining years — whether or not they have a terminal diagnosis. Just because medicine could possibly prolong our lives doesn’t mean we want it to do so.

— Laura Palmer, Denver

— Homa S. Woodrum, Carson City, Nev.

I think a point missed may be that many seniors are becoming increasingly distraught with the state of the world — not so much from depression, but from the pervasive hostility, anger, loss of traditional values, ignorance, lack of caring, political bickering and general “meanness” that is the world nowadays.

Together with my physical limitations that further limit my ability to find continued meaning in life, I am glad to say that I have an exit strategy in place that I can activate when the time is right. I think if the right to choose were available and supported, there would be (and likely will be, if current trends continue) more interest in having this option more easily available.

— Dr. Bill Saunders, Snohomish County, Wash.

— Rich Meyer, Naples, Fla.

— Duane Blackwell, Alexandria, La.

No More Band-Aid Solutions On Surprise Medical Bills

An approach to solving this problem is to set standard costs for all procedures (“Bill Of The Month: A Year After Spinal Surgery, A $94,031 Bill Feels Like A Back-Breaker,” June 17). Using Medicare reimbursement as a benchmark, set national reimbursement rates adjusted for regional cost of living. Set the rates as Medicare plus a percentage and require all providers to accept those rates. This would do away with the need for networks.

Standardize insurance plans using the Medicare Part B concept. There can be a variety of plans, but each insurer must offer the exact same coverage for a specific plan. Then the purchaser can make an informed comparison among plans. If the goal is to lower medical costs, standardization, along with best practices is probably the best approach.

We need to drive out the unnecessary costs and eliminate the annual 160,000 unnecessary deaths and estimated 100 million medication errors in the U.S. hospital system. The unnecessary annual death total is greater than annual opioid deaths, gun violence deaths and automobile accident deaths combined.

This will be a long struggle because of the entrenched financial interests, but we need to draw a line in the sand.

— Michael Hausig, San Antonio

— Kerri Barber, Chicago

Not Anti-Vaccine, Just Against This Legislation

I oppose Senate Bill 276 in California (“A Proposal To Make It Harder For Kids To Skip Vaccines Gives Powerful Voices Pause,” June 14). I have a child who nearly died from seizures after being administered the DTaP vaccine [to guard against diphtheria, tetanus, and whooping cough, or pertussis]. That reaction is a CDC-acknowledged adverse event. Stop calling everyone who opposes this bill “anti-vaccine activists.” While some people might characterize themselves as “anti-vaccine,” most people are simply parents who did vaccinate their child until they were seriously harmed. To call us “anti-vaccine” activists and ignore that fact is extremely deceptive.

We are activists now, that part is true. We had to become activists, because these organizations you mention in your article (such as the American Academy of Pediatrics) have done nothing to help our children. The AAP is a lobbying organization that receives funds from vaccine manufacturers. It lobbied against AB-2832 (Assemblyman Travis Allen), which was a one-sentence bill that would have put a link on the California Department of Health website to two “.gov” websites: the Vaccine Adverse Event Reporting Systems (VAERS), the database for serious adverse events after vaccination, and the National Vaccine Injury Compensation Program. The purpose was to help parents find this information when they need it. That the AAP lobbied against it says everything you need to know about their priorities when it comes to vaccines. They are not doing what is in the best interest of families. Clearly, their pharmaceutical company funding influences their lobbying.

In your story, Dr. Michelle Bholat’s concern about who would qualify for a medical exemption is exactly the same concern that parents opposed to this bill have. There is a good chance my child would not qualify for a medical exemption to the vaccine that nearly killed him, and he definitely would not qualify for an exemption to any others. If I had another child, I would not be able to get a medical exemption to the vaccine that nearly killed my son for that new baby. This bill puts our kids at serious risk for irreparable harm or even death.

Kara Morales, San Diego

— Dr. Amesh Adalja, Pittsburgh

Something In The Water? Drink To Your Health!

A recently published article (“A Million Californians Don’t Have Clean Drinking Water. Where Do They Live?” June 28) cast some doubts concerning the safety of drinking water available out of the tap for Alpine County residents and visitors.

First, some background. There were 1,175 persons counted in the 2010 census in Alpine County. There are several hundred private wells in Alpine County, which are initially permitted by the county, but then managed by the owner. The Environmental Health Program staff of the Alpine County Public Health Department regulates about 40 small public water systems, including the Markleeville Water Co., Woodfords Mutual Water Co., Diamond Valley Elementary School and numerous campgrounds. Two large water systems are regulated by the California State Water Resources Control Board: Kirkwood Meadows Public Utilities District and Lake Alpine Water Co., along with the Grover Hot Springs State Park. The definition of a “large” water system is one with more than 200 connections.

The greatest risk to the public’s health from drinking water is bacterial contamination, which is controlled by disinfection. The surface water used by the large water systems is disinfected with chlorine. Byproducts of the disinfection process include trihalomethanes (TTHM) and haloacetic acids (HAA5). Managers work to achieve the ideal balance between enough chlorine to provide water free of bacterial contamination, and at the same time keeping levels of byproducts lower than the maximum contaminant level (MCL) as required by the State Water Resources Control Board.

Conclusions in the article were drawn from a review of state compliance data dating prior to 2018 and refer only to the Lake Alpine Water Co.

The facts:

  1. The data source stated that the Lake Alpine Water Co. serves a population of 625. This includes 125 residents and 500 transients (skiers, visitors at the Bear Valley Lodge, and condos); thus, the original statement “more than half of residents” was incorrect. The data source states that Lake Alpine Water Co. serves 487 service connections. This includes 294 single-family residences, 179 multiple-dwelling units (lodge, condos), 12 commercial, and two irrigation systems. So, essentially correct, but includes water provided to visitors.
  2. The data shows that the Lake Alpine Water Co. was out of compliance with levels of total haloacetic acid exceeding the MCL, the latest violation on 12/31/17. However, what it does not show is that corrective action was promptly performed, with compliance obtained in January 2018. Quarterly testing during the past 18 months has shown continued compliance, and an official Return to Compliance (RTC) status will be achieved in the near future. There have not been any other violations or enforcement actions taken.
  3. The Water Board has never issued an order that “residents can’t drink water flowing from their taps,” as the article stated— anywhere in the county.
  4. In the past 25 years of records and memories, water systems in Alpine County have not exceeded MCLs for either nitrates or arsenic — anywhere in the county.

My conclusion: Drink up (water)!

— Dr. Richard O. Johnson, health officer for Alpine County, Calif.

(Editor’s note: Thank you for your salient points. The article has been revised to reflect your concerns.)

Listen: Opioid Trial In Oklahoma Wraps Up

Did drugmaker Johnson & Johnson create a “public nuisance” that led to the opioid epidemic? That’s the question a state judge in Oklahoma is weighing after the country’s first trial against opioid manufacturers wrapped up Monday. The state is asking for $17 billion in damages. Jackie Fortier of StateImpact Oklahoma has covered the trial from start to finish for NPR and Kaiser Health News. This account of the seven-week trial’s closing arguments aired on NPR’s “Morning Edition” on Tuesday.

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

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! If you want a smile after this long week, be sure to check out today’s Google Doodle. I feel like this is the right crowd to appreciate it.

Now on to what you may have missed!

The courtroom was where much of the action took place this week, from Title X funding to drug prices to opioids. But the biggest spotlight of all was on the fate of the Affordable Care Act.

The latest challenge to the health law was a long-shot case, with legal experts writing off its chances of prevailing at the start. The suit can be perfectly summed up by a question from Judge Jennifer Walker Elrod, one of the three judges who heard oral arguments on the case in New Orleans: “If you no longer have the tax, why isn’t it unconstitutional?”

Judge Kurt Engelhardt also asked why the Senate hadn’t sent a lawyer along with the House counsel to convey that the congressional intent had been to keep most of the law. “They’re sort of the 800-pound gorilla that’s not in the room,” he said.

Despite some blunt questioning, though, it’s not clear where the judges will land on the final decision. The case could end up in front of the Supreme Court right in the heart of the 2020 election cycle. Considering that the “we’re the side protecting all those popular health law provisions” argument was at least partly credited for Democrats’ blue wave in the midterms, the timing of the case could have deep political ramifications for Republicans.

The Washington Post: Appeals Judges Question Whether the ACA Can Stand Without Insurance Penalty

Politico: Long-Shot Legal Challenge Could End Obamacare During the 2020 Campaign

If the law is overturned, the far-reaching ripple effects would go far beyond politics. It’s not just that 21 million people could lose health insurance, or that the protections for people with preexisting conditions would go away or that insurers would no longer have to cover young adults on their parents’ plans. So many of the Affordable Care Act’s directives have become ingrained in daily life that it’s as if many people forget they’re tied to that hot-button “Obamacare” topic.

On that list? Calorie counts on menus, lactation rooms at work, transparency for gifts from pharma companies to doctors, YMCA courses that teach diabetes maintenance, etc., etc.

The New York Times: So You Want to Overturn Obamacare. Here Are Some Things That Would Be Headaches.

Also on that list? A wonky provision that grants HHS “innovation” authority. The reason it’s important? President Donald Trump is using that very authority (that’s part of the law he’s trying to get overturned) to make big promises on revolutionizing the kidney care marketplace.

The New York Times: Trump’s Assault on Obamacare Could Undermine His Own Health Initiatives

(Pardon my detour from the courts for a minute, but that’s an impossible-not-to-utilize segue for the other big news of the week, and I’m going to jump on it.)

Trump announced an extremely ambitious plan this week to upend the kidney care world. Currently, the marketplace relies heavily on patients getting care at large dialysis clinics, even though at-home options are both safe and cost-effective. But those big chains can pull in $24 billion a year in revenue, so I somehow doubt that they’re going to go gently into that good night. Another part of the plan would incentivize kidney donations with reimbursements for lost wages and child care to try to address the country’s shortages. (And a special shoutout to Politico for the scoop on the plan.)

The New York Times: Trump Proposes Ways to Improve Care for Kidney Disease and Increase Transplants

Politico: Trump Aims to Shake Up Kidney Care Market

And now back to our court news: Trump’s strategy to curb drug prices sustained the first of two significant blows this week when a federal judge ruled that the administration can’t force companies to put prices in their TV ads. Judge Amit Mehta dodged the tricky First Amendment debate and instead focused on HHS’ authority (or lack thereof, really) to enforce such a rule. His ruling was, essentially: Hey, high drug prices are the pits and this might be an effective tool. But HHS can’t do more than Congress has authorized.

The New York Times: Judge Blocks Trump Rule Requiring Drug Companies to List Prices in TV Ads

The second punch came Friday when the administration pulled the plug on a signature proposal to eliminate drug rebates for pharmacy benefit managers (the target du jour for ire over high prices). Policy experts had worried the rule would lead to higher premiums for Medicare beneficiaries. Insurers and PBMs were popping the champagne over the announcement, while the general consensus is that pharma companies should now be braced for (an even bigger) storm headed their way.

Stat: After Trump Pulled the Plug on Rebates, His Options to Reduce Drug Prices Narrow. And He May Need Congress

The 2020 Democratic candidates were busy bees this week:

— Sen. Elizabeth Warren (D-Mass.) announced an immigration plan that would include the creation of a DOJ task force to investigate complaints of abuse and neglect from detainees.

Politico: Elizabeth Warren Takes on Trump With Immigration Overhaul

— Sen. Kamala Harris (D-Calif.) wants to take on the epidemic of outrageous rape kit backlogs. The kits can sometimes sit in police departments, which are strained for resources, for years. Harris has some bona fide experience to back up her plan. When she was California’s attorney general, her Rapid DNA Service team said it cleared all 1,300 untested rape kits in the state’s backlog in one year and earned national recognition and grants for its efforts.

USA Today: Kamala Harris: Rape Kit Backlog Can Be Cleared at Cost of Trump Golf Trips

— Sen. Amy Klobuchar (D-Minn.) released a proposal to tackle a wide range of problems that affect Americans’ seniors, from high drug costs to Alzheimer’s research to long-term care issues.

Politico: How Amy Klobuchar Would Improve Care for Seniors

— And Sen. Bernie Sanders (I-Vt.) is hopping on a bus to Canada with a group of Americans in search of cheaper insulin. This isn’t his first time embarking on such a trip. Twenty years ago, he went north with a group of breast cancer patients with a similar goal. (That two-decade gap between the trips speaks volumes, doesn’t it?)

CNN: Bernie Sanders to Join People With Type 1 Diabetes on Canada Trip for Cheaper Insulin

As we’ve seen in recent weeks, nearly all the Democratic candidates support the idea of providing health care to people who are in the country illegally. But what exactly would that entail? For one, it would place the U.S. even further left of progressive countries who already have universal health care. Most of them have at least some restrictions in place. But experts say that not only in the long run could providing care for them save money — immigrants in the country without legal permission tend to be young and relatively healthy and underuse available care.

The New York Times: What Would Giving Health Care to Undocumented Immigrants Mean?

Meanwhile, California is charging forward to become the first state in the country to offer Medicaid coverage to residents below the age of 26, regardless of their immigration status.

The Associated Press: California OKs Benefits to Immigrants In Country Illegally

Speaking of Medicaid, New Hampshire pumped the brakes on its new work requirements following reports that more than 17,000 people (yes, you read that right) would be found to be noncompliant with the rules after its first month. The state has been making the rounds with mailings, phone calls and even a door-knocking campaign, but officials still suggest the problem is that most people aren’t aware they need to report their hours. The experience mirrors Arkansas’ (almost down to the exact number of people who would be booted) and highlights the inherent obstacles states face when putting such rules in place.

Modern Healthcare: New Hampshire Delays Its Medicaid Work Requirement

A mother whose 19-month-old daughter died after being detained by ICE spoke at a House hearing this week about reports of the inhumane conditions at the facilities. “The world should know what happened,” Yazmin Juárez said during deeply emotional testimony. The name of the hearing — “Kids in Cages: Inhumane Treatment at the Border” — set the tone and reflected the state of affairs on Capitol Hill over the issue.

The Washington Post: ‘Kids in Cages’: House Hearing Examines Immigration Detention As Democrats Push for More Information

About 20% of the nation’s hospice facilities have safety lapses that are serious enough to endanger patients. What does that look like, beyond the dry terminology of an inspector general’s report? Gangrene so bad that a patient’s leg needed to be amputated; maggots burrowing near wound openings; and unnoticed sexual assault. But the report highlights another issue: There’s not much CMS can do about all of it. It would take an act of Congress to give CMS the power to fine the industry’s bad actors.

NPR: Roughly 20% of U.S. Hospice Programs Cited for Serious Deficiencies, Inspectors Say

In the miscellaneous file for the week:

• There are lots of voices in the abortion wars these days. Many of them, though, are from white leaders — on both sides of the issue — while the unique nuances and challenges that black communities face are missing from the debate. For women of color, race is tied to abortion in a way that white advocates rarely have to contend with.

The New York Times: When ‘Black Lives Matter’ Is Invoked in the Abortion Debate

•  An alleged mix-up at a fertility clinic that resulted in a woman having two babies who were not related to either her or each other highlights the real pitfalls of human error and advanced medicine.

USA Today: IVF Couple Sues California Clinic, Alleges Babies Weren’t DNA Match

• On paper, as medical aid-in-dying laws continue to pass across the country, more Americans are gaining control over how they end their lives. The reality looks a lot different, though.

The New York Times: Aid in Dying Soon Will Be Available to More Americans. Few Will Choose It.

• A Disney Channel star’s death this week highlighted the dangers of epilepsy-linked sleep deaths. Although it is rare, SUDEP is responsible for more deaths than SIDS (sudden infant death syndrome) and yet few people have heard of it.

CNN: Cameron Boyce’s Death: How Seizures Can Kill People With Epilepsy

• A new Secret Service report on mass violence incidents reveals that two-thirds of perpetrators had made threats before the attacks.

CNN: A New Report on Mass Attacks in the US Shows Common Traits Among Assailants

• A hospital in Ohio fired 23 employees in the wake of murder charges against one of its doctors in a case related to patients’ painkiller-linked deaths. There are a lot of issues here, but of particular note is how systemic such problems can become. One medical professional might be the root problem, but, at some point, that infection can spread to many interlocking parts within a health system.

The New York Times: Hospital C.E.O. Resigns and 23 Employees Are Fired After Ohio Doctor Is Charged in Murders

And, as election season kicks up, I really don’t blame any of the candidates for grabbing the Purell. Have a great weekend!

Medicare Going In ‘Right Direction’ On Opioid Epidemic

Prescriptions for two drugs used to treat opioid addiction increased significantly from 2016 to 2018 for people on Medicare, according to a federal report out Wednesday.

About 174,000 Medicare beneficiaries received such a medication — either buprenorphine or naltrexone — to help them with recovery in 2018, according to the Office of Inspector General in the Department of Health and Human Services.

In addition, prescriptions for naloxone, the drug that can reverse an opioid overdose, spiked since 2016, rising 501% ― and that is likely an underestimate because it doesn’t include doses of the nasal spray Medicare members might have received through local programs, the OIG said.

“For now, the numbers are going in the right direction,” said Miriam Anderson, lead investigator on the report. “But this is a national crisis and we must remain vigilant and continue to fight this epidemic and ensure that opioids are prescribed and used appropriately.”

During the two years studied, the threat of new addictions appeared to slow. Prescriptions for an opioid through Medicare Part D decreased by 11%. The numbers of the beneficiaries considered at serious risk for misuse or overdose ― either because they received extreme amounts of opioids or appeared to be “doctor shopping” ― dropped 46%. And there were 51% fewer doctors or other providers flagged for prescribing opioids to patients at serious risk from 2016 through 2018. 

The report says the OIG and other law enforcement agencies will investigate the highest-level prescribers for possible fraud and signs that some providers operate pill mills. The report mentions a physician in Florida who provided 104 high-risk Medicare patients with 2,619 opioid prescriptions.

It will be up to Medicare to follow up with patients whose opioid use suggests addiction, recreational use or resale. In one case, a Pennsylvania woman received 10,728 oxycodone pills and 570 fentanyl patches from a single physician during 2018. A Medicare member in Alabama acquired 56 opioid prescriptions from 25 different prescribers within one year. 

In a statement, the Centers for Medicare & Medicaid Services said: “Fighting the opioid epidemic has been a top priority for the Trump administration. We are encouraged by the OIG’s conclusion which finds significant progress has been made in our efforts to decrease opioid misuse while simultaneously increasing medication assisted treatment in the Medicare Part D program.”

The agency points to recent efforts to curb opioid misuse including a seven-day limit on first-time opioid prescriptions, pharmacy alerts about Medicare beneficiaries who receive high doses of pain meds and drug management programs that may restrict a patient’s supply. CMS says it does not use a “one size fits all” approach. Medicare patients in long-term care facilities or hospice care and those in cancer treatment are exempt from the opioid-prescribing restrictions.

The opioid-prescribing limits are raising alarms among some Medicare recipients, especially those who qualify based on a long-term disability and deal with severe, chronic pain.

Jae Kennedy, a disability policy expert at Washington State University, said cutting back on opioid prescriptions is generally a good development.

“But we hear from people in the disability community who feel like they’re being victimized by this new, very stringent set of dispensing limits,” said Kennedy. “People have been managing their pain, in some cases for many years without a problem, and now they’re being kind of criminalized by this new bureaucratic backlash.”

Anderson said the OIG agrees that “some patients need opioids and they should receive those needed for their condition. This report raises concerns that some patients may be receiving opioids above and beyond those needs.”

While most Medicare beneficiaries are 65 or older, the 15% who are under 65 and disabled may be the key piece of this report. Kennedy’s research shows they are up to three times more likely to describe persistent pain than are other adults and 50% more likely to report opioid misuse. A 2017 OIG report found that 74% of Medicare beneficiaries at serious risk for addiction and overdose deaths were under age 65.

Kennedy said it’s good to see Medicare expanding access to medication assisted treatment, known as MAT, for addiction, but the agency needs to make sure that more buprenorphine prescribers accept all patients, not just the ones who are easiest to manage. Patients with disabilities often need many different medications for multiple physical and mental health conditions.

“Saying, ‘Well, because you’ve got schizophrenia or manic depressive disorder, we can’t treat you,’ I think is discriminatory,” Kennedy said. “It’s happening with private buprenorphine prescribers in this country because there are so few.”

Americans 65 or older have the lowest rates of opioid overdose deaths. Even so, the CDC says the number of deaths among seniors increased by 279% from 1999 to 2017.