Tagged States

State Highlights: Denver, D.C. Clear Homeless Camps; Utah Governor Abruptly Ends Distribution Of Condoms With Suggestive Phrases On Wrappers

Tensions Escalate Over Planned Pro-Gun Rally In Virginia’s Capital After FBI Arrests 3 Suspected Neo-Nazis

Medi-Cal’s Very Big Decade

Medi-Cal had a big decade.

The number of Californians enrolled in the state’s health insurance program for low-income residents swelled by 5.5 million from 2010 to 2019. It now covers 1 in 3 Californians and 40% of children.

The program’s annual budget — a combination of state and federal money — tops $100 billion, more than the entire state budget of Florida.

“Medi-Cal is the largest Medicaid program among all of the states,” said Dr. Andrew Bindman, a professor of medicine at the University of California-San Francisco who helped implement the Affordable Care Act as part of the Obama administration.

It’s most likely going to get bigger. On Friday, California Gov. Gavin Newsom released his 2020-21 state budget blueprint, which would boost Medi-Cal’s annual budget to more than $107 billion and expand coverage to even more people.

Medi-Cal, California’s version of the federal Medicaid program, was transformed in the past decade by federal and state laws — especially the federal Affordable Care Act — and by the ups and downs in California’s economy.

In early 2010, Medi-Cal covered 7.2 million people. Enrollment peaked at 13.7 million in March 2016, and slowly but steadily decreased to 12.8 million people in August 2019, according to the most recent enrollment data from the state Department of Health Care Services. About 4.9 million of them were under age 19.

In 2018, half of enrollees identified as Hispanic, 18% as white, 10% as Asian or Pacific Islander and 8% as black, according to the department. Thirteen percent of enrollees did not report their race/ethnicity.

The federal Affordable Care Act spurred the most significant changes to Medi-Cal since 2010, largely because it allowed states to broaden eligibility for their Medicaid programs to low-income people who had not previously qualified. Thirty-six states plus Washington, D.C., have adopted Medicaid expansions.

In California, Medi-Cal enrollment grew 78% from January 2010 to August 2019, primarily due to the expansion, which began in 2014.

“California went all-in on that,” Bindman said, and reduced its uninsured rate from 18.5% in 2010 to 7.2% in 2018.

Before the change, adults usually didn’t qualify unless they were parents with dependent children, pregnant or had certain conditions or disabilities.

Under the expansion, any adult who met the income guidelines could enroll, which represented a “radical shift” in the way the program operates, said Jen Flory, a policy advocate at the Western Center on Law & Poverty.

It transformed Medi-Cal “to more general low-income coverage,” she said.

The number of adults enrolled through the expansion has hovered around 3.7 million since mid-2016, while the rest of the Medi-Cal population dropped from 10 million to 9 million during the same period. Flory credited a strong economy and low unemployment in part, as more people got jobs that offered employer-based insurance and others surpassed the income limits to qualify.

But Flory and Bindman said other factors might be contributing.

They pointed to fears within immigrant communities over increased immigration enforcement, and policies such as the Trump administration’s “public charge” rule. The rule would allow immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

Federal judges temporarily blocked the rule from taking effect in mid-October, but the Trump administration on Monday asked the U.S. Supreme Court to allow it to implement the rule while the legal battles continue.

As a result of such policies and proposals, they said, some immigrants may not be enrolling in Medicaid and other government programs, even if they are eligible.

In the past decade, Medi-Cal has also changed how it delivers care. In January 2010, roughly half of Medi-Cal enrollees participated in the traditional “fee-for-service” model, in which patients can see any doctor who accepts them, and providers are reimbursed for each medical service or visit.

The other half received care from managed-care plans. Under managed care, the state contracts with health plans to deliver benefits to enrollees and pays them a fixed monthly rate to cover the expense of doing so — a payment system known as “capitation.”

The percentage of enrollees served by managed care climbed to 82% by July 2019 as California, like many other states, looked to that model to save money.

The Trump administration and Republicans in Congress have weakened Obamacare and called for limits on federal spending on Medicaid. Such proposals may accelerate if Republicans retain the White House and regain control of the U.S. House of Representatives this year.

While the federal government moves to restrict funding and enrollment, California lawmakers continue to expand eligibility for Medi-Cal.

Starting this year, low-income young adults up to age 26 became eligible for full Medi-Cal benefits regardless of their immigration status, joining unauthorized immigrant children, who became eligible in 2016.

On Friday, Newsom proposed expanding full Medi-Cal benefits to eligible undocumented immigrant adults ages 65 and over as part of his state budget proposal.

California’s policies offer “a striking contrast to the policies of the current federal administration,” Bindman said.

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

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With Fate Of Roe V. Wade Unsure, Abortion Fight Shifts To New Territory

Jan. 22 marks the 47th anniversary of Roe v. Wade, the landmark case that legalized abortion nationwide. Those on both sides of the furious debate say this could be the year when everything changes.

In March, the Supreme Court will hear its first abortion case since Justice Brett Kavanaugh replaced Anthony Kennedy, who had been the swing vote on abortion cases. A decision is expected by summer.

The case, June Medical Services v. Gee, challenges a Louisiana law that requires doctors who perform abortions to have admitting privileges at a nearby hospital. It’s a reprise of a case decided in 2016, when a five-vote majority (including Kennedy’s) struck down a substantially similar Texas law in Whole Women’s Health v. Hellerstedt.

On Jan. 2, more than 200 Republican members of the House and Senate filed a brief in the Gee case urging the justices to use it to overturn Roe once and for all. “Forty-six years after Roe was decided, it remains a radically unsettled precedent,” the brief said. And the 1992 case that reiterated a curtailed right to abortion, Planned Parenthood of Southeastern Pennsylvania v. Casey, did not help, the members argued. “Casey clearly did not settle the abortion issue, and it is time for the Court to take it up again.”

The court is far more likely to rule narrowly in the case than to use it to overturn Roe and/or Casey because that’s what the Supreme Court tends to do.

Even if the court does not overturn Roe, it might do something that could hasten Roe’s demise: uphold the Louisiana law by ruling that abortion providers cannot sue on behalf of their patients, something the state of Louisiana is urging it to do. That would make it much more difficult to challenge state abortion restrictions because only women seeking abortions would be able to challenge those laws in court. Many pregnant women seeking abortions don’t want to go to the additional trouble of becoming part of a lawsuit that could take years.

“That would be a bigger deal” than finding some legal justification to uphold Louisiana’s law, said Mary Ziegler, a law professor at Florida State University who has written several books on abortion and abortion law.

It’s part and parcel of an anti-abortion strategy: make abortion more difficult to obtain even where it is technically legal. “A right is certainly important, but if you cannot access abortion care, that right is meaningless,” said Elisabeth Smith of the Center for Reproductive Rights, an abortion-rights law firm.

Since 2004, that center has periodically looked at what would happen to abortion laws in the states if the Supreme Court were to reverse its conclusion that abortion, at least in some cases, is a right guaranteed by the U.S. Constitution. In its original report, titled “What If Roe Fell,” and again in 2007 and 2017, the center assessed the likely legal status of abortion in the states, because in the absence of Roe, abortion’s legality would be determined by state lawmakers or state constitutions.

But in its 2019 version of “What If Roe Fell,” the group took a slightly different tack. This latest iteration looks at likely legality, but also at the relative availability of the procedure. The report concludes that if the Supreme Court eliminates federal protections for abortion, the procedure is likely to be immediately prohibited in 24 states, and remain legal and generally available in 21. The five other states and the District of Columbia have not established a right to abortion.

Smith said that, even with Roe still standing, some states, such as Mississippi and Missouri, are already abortion “deserts,” where the procedure is all but unavailable. But “the situation would be much worse if the federal right is limited or overturned,” she said. In fact, some states are “havens” that have made abortions easier to obtain. For now, “abortion is still legal. Every state has at least one abortion clinic,” Smith added.

This is far from the first time it appeared Roe was teetering on the brink. In 1992, after Justice Clarence Thomas replaced Thurgood Marshall, one of the original seven justices in the majority in Roe, the country braced for an overturn. It did not happen. In 2005, when abortion swing vote Justice Sandra Day O’Connor retired and was replaced by Justice Samuel Alito, the alarms were raised again. And again, it did not happen. Then in 2018, when O’Connor’s successor as the abortion swing vote, Kennedy, retired and was replaced by Kavanaugh, the bells rang once more.

The Louisiana case is the first chance for what would appear to be a clear five-vote anti-abortion majority to rule.

Ziegler, the Florida State law professor, warns that overturning Roe would not end the fight. “If this goes back to the states, it’s going to continue indefinitely,” she said. “The endpoint for people who oppose abortion is not just allowing states to decide.”

In other words, if you think the abortion issue is inflammatory now, just wait until Roe is gone.

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Listen: How High-Deductible Plans Hurt Rural America

KHN senior correspondent Markian Hawryluk joined Colorado Public Radio’s Avery Lill on “Colorado Matters” to discuss his recent story on how high-deductible health plans are especially hurting rural America. (His segment begins at 11 minutes and 40 seconds in, after you click on the link for the full show.)

Such insurance plans are more prevalent in rural areas, where incomes tend to be lower, compared with urban areas, leaving patients with hefty bills they cannot afford when a health care crisis occurs.

These plans also pinch rural hospitals: When a patient arrives at a rural hospital needing critical care, the person is often stabilized and transferred to a larger facility. But bills from the first site of care generally get applied to the patient’s deductible. When patients can’t afford their deductible, the smaller hospital winds up eating the costs.

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KHN’s ‘What The Health?’: Trump Takes Credit Where It Isn’t Due


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


The final debate for Democratic presidential candidates before the Feb. 3 Iowa caucuses did not delve as deeply into health care as some earlier debates. But it did include discussion of several health issues that have received relatively little attention, including prescription drug prices and long-term care.

Meanwhile, President Donald Trump is claiming credit for having “saved” federal protections for preexisting health conditions, perhaps the most popular piece of the Affordable Care Act, even as his own administration is in court trying to have the entire health law declared unconstitutional.

And Kansas may soon become the latest state to expand the Medicaid program under the ACA, as the Democratic governor and GOP Senate majority leader strike a deal.

This week’s panelists are Julie Rovner from Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Shefali Luthra of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Some advocates have complained that the Democratic presidential candidates are not discussing threats to abortion rights during the debates. But, generally, candidates look to talk about issues that differentiate them from their primary opponents, and all of the Democrats on stage are supportive of a woman’s right to an abortion.
  • Trump’s claim this week that he was protecting the right of consumers with medical problems to get health coverage was widely derided by ACA supporters. But his contention goes to the heart of the administration’s effort to buttress its health care initiatives ahead of the campaign.
  • At the same time, the Trump administration has set a requirement for plans sold on Obamacare marketplaces to bill consumers separately for the portion of the plan that covers abortion, generally a minuscule amount. That could confuse customers and create billing headaches for insurers and prompt some to discontinue the coverage.
  • Recent action by the Supreme Court may signal some changes coming in its view of abortion rights, now that the court has a stronger conservative majority. The justices refused to take an appeals court decision upholding a Kentucky law that requires doctors to show women seeking an abortion an ultrasound image of the fetus and describe the procedure to them.

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

Julie Rovner: The Deductible’s “Seven for the Twenties: A Futurist Looks at the Next Decade,” by Jeff Goldsmith

Alice Miranda Ollstein: The Wall Street Journal’s “Plan to Revamp Medicaid-Eligibility Checks Draws Criticism,” by Stephanie Armour

Tami Luhby: Vox.com’s “Everybody Covered,” by Dylan Scott, Ezra Klein and Tara Golshan

Shefali Luthra: Kaiser Health News’ “High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals,” by Markian Hawryluk


To hear all our podcasts, click here.

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

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State Highlights: Contraband Phones Allowed Inmates To Reveal Mold, Rats In Troubled Mississippi Jails; New York Murder Trial Uncovers Failure Of Child Welfare System

An Emotional Day In Maryland’s State Legislature As 3 Gun Hearings Draw Advocates From Both Sides Of Debate

State Highlights: Kentucky Invites Clinic To Reapply As Abortion Provider After Being ‘Wrongly’ Denied; In Texas Where Clinics Are Being Shuttered, Women More Likely To Attempt DIY Abortions

From The State Capitols: Gun Legislation, Surprise Billing, Caregiver Payments, Mental Health Coverage And More

State Highlights: Four Gun-Control Bills Pass Virginia Committee For First Time; Oregon Health Authority Seeks $20M For Mental Health Treatment

Federal Funds To Help LA’s Homeless Crisis Come Bundled Up In Strings

Once A Luxury, Concierge Primary Care Is Becoming More Affordable As Practice Grows In Popularity

Oklahoma Attorney General Amps Up Legal War Over Opioid Crisis With New Suit Against 3 Distributors

Broad Bill To Eliminate Religious Exemptions For School Vaccines Unravels In New Jersey

State Highlights: Former Gang Members In Oregon Try To Curb Rising Gun Violence; ‘Horrific’ Abuse Cited In Lawsuit Against New Hampshire Youth Facility

Calif. Governor Wants To Make ‘Radical Shift’ In How State Is Addressing Homeless Crisis

A National Registry Is Needed To Identify Babies Who Have Been Affected By Opioid Crisis, Lawyers Argue

Smokers Need Not Apply: Fairness Of No-Nicotine Hiring Policies Questioned

When U-Haul recently announced it will no longer hire people who use nicotine in any form in the 21 states where such hiring policies are legal, the Phoenix-based moving company joined a cadre of companies with nicotine-free hiring policies.

U-Haul’s announcement is receiving outsize attention because nicotine-free hiring policies are more common at high-profile hospitals such as Cleveland Clinic that are especially protective of their healthy image.

Alaska Airlines has one of the oldest nicotine-free hiring policies, going back to 1985. But at the time, a big part of the stated reasoning was that the industry isn’t conducive to taking smoke breaks.

Now, some employers are making the policy change simply citing health concerns or health care costs — even the city of Dayton, Ohio, has joined the movement.

But the policies are raising concern around labor and medical ethics. Harald Schmidt, a medical ethicist at the University of Pennsylvania, said targeting smokers disproportionately harms poor people.

“To me, this is more about fair equality of opportunity,” he said.

Smoking is a behavior, so Schmidt doesn’t equate it with discriminating on the basis of race, gender or sexual orientation. But he notes that roughly half of unemployed people smoke. And quitting is hard, because nicotine is highly addictive.

“You’re basically posing a double whammy on them,” Schmidt said. “It’s very hard for them to get work, and it’s even harder for people who are already in a vulnerable situation.”

Karen Buesing of the law firm Akerman represents employers and works with them on smoking policies. She said employers are looking out for the health of their employees.

Employers do have some concern about productivity and absenteeism, she said. But it’s more about the risks of cancer and heart and lung disease.

“Obviously, there are higher health care costs associated with smokers. And so many companies would much prefer to have a nonsmoking workforce,” she said.

The corporate cost per smoker is estimated to be in the thousands of dollars per year, though some experts have questioned the accuracy of the figures.

Buesing said discrimination of any kind is so taboo that employers in many states don’t realize they can reject applicants for being smokers. And it’s not allowed everywhere: 29 states and the District of Columbia have various laws that safeguard “off-duty” activity. Many of these laws were passed in recent decades specifically to shield smokers.

“In that context, you now have protections for smokers,” Buesing said of the 29 states. “Certainly under federal law, smokers are not a protected class.”

A 2017 Gallup Poll found that more than half of American smokers feel they’re discriminated against for their nicotine habit.

“Even when I was doing temporary work, people would be like, ‘You’re going on break? Are you going to smoke?’” said Carl Carter of Nashville, Tennessee, who is currently on disability benefits and not working. “I should have the right to do what I want to do.”

It’s not that he doesn’t want to quit. He has tried eight times, most recently on New Year’s Day. But the habit is hard to beat.

Labor groups have not fought nicotine-free hiring policies, but Edgar Ndjatou, executive director of the advocacy nonprofit Workplace Fairness, calls smoker hiring bans “problematic.”

“Someone who uses tobacco could potentially have some form of disability,” he said, adding that addiction could be protected under the Americans with Disabilities Act. “I would argue that these types of bans have to be reasoned.”

Ndjatou and other critics ask, what’s next? Will nicotine-free hiring lead to more policing of worker health?

IT administrator and vaper Scott Bales thinks so.

“I think that it’s interesting that they are demonizing one over the other, and I’ll specifically use alcohol,” he said on a vaping break outside his office in Nashville. “How can you ban one substance without banning the other one?”

The American Civil Liberties Union has come out against nicotine-free hiring, calling it “discrimination.” The organization is critical of other forms of what it calls “lifestyle discrimination.”

“Should an employer be able to forbid an employee from going skiing? or riding a bicycle? or sunbathing on a Saturday afternoon?” an ACLU legislative briefing asks. “All of these activities entail a health risk.”

But companies rejecting smokers point out that tobacco is the most preventable cause of cancer and lung disease. And the employers are the ones who will likely have to pay much of the health bills.

Still, attorney Buesing doesn’t expect the U-Haul announcement to unleash a flood of similar policies. She said rewarding healthy behavior is still seen as the most palatable approach by many employers.

U-Haul said its policy will not apply to existing workers. The company employs 30,000 people around the country, with 4,000 at its headquarters. U-Haul will screen new hires and require them to consent to future drug testing for nicotine, though it’s unclear how that would affect workers who use nicotine gum or patches.

“This policy is a responsible step in fostering a culture of wellness at U-Haul, with the goal of helping our team members on their health journey,” chief of staff Jessica Lopez said in a press release.

U-Haul declined an interview request.

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

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Homeless Californians Adapt To Camp Sweeps And ‘The Caltrans Shuffle’

Every other week, Norm Ciha and his homeless neighbors temporarily relocate their camp from land alongside a freeway off-ramp in Oakland, Calif., to a nearby vacant lot, until state cleanup crews have come and gone. They call it “the Caltrans Shuffle.” (Anna Maria Barry-Jester/KHN)

OAKLAND, Calif. — It’s 5 a.m., and the thermostat reads 44 degrees. Cars round the bend of an off-ramp of state Route 24 in northern Oakland, spraying bands of light across Norm Ciha and his neighbors. They wear headlamps so they can see in the dark as they gather their belongings: tents, clothes, cooking gear, carts piled with blankets, children’s shoes and, in one case, a set of golf clubs.

Shredder, Ciha’s dog, takes a treat and then lets it fall from his mouth. He whines as Ciha walks away with a camping mattress. “I can leave him all day in the tent and he’s fine, but he freaks out every time we have to move,” Ciha said.

Every other week, the residents of this thin slice of state-owned land just off the freeway pack up their possessions and move to another empty lot nearby that they aren’t quite sure who owns. They do it in anticipation of the routine homeless sweeps ordered by the California Department of Transportation, which has jurisdiction over the state’s highways and exit ramps.

The highway crews check that the area is clear of people and their belongings, throwing away any items that remain. Once the trucks leave, the residents move back in. Ciha and his neighbors call it “the Caltrans Shuffle.”

Ciha says he lost his bedding, clothes and hepatitis C medication during a homeless sweep in November 2018. (Anna Maria Barry-Jester/KHN)

Their makeshift neighborhood of tarps and tents is built on one of thousands of public spaces across California where people have set up camp. The state’s homeless population has ballooned in recent years; in 2019, there were more than 150,000 homeless people in California, according to the U.S. Department of Housing and Urban Development, and 72% of them did not have shelter. A range of health concerns has spread among homeless communities. A few years ago, hepatitis A, spread primarily through feces, infected more than 700 people in California, most of them homeless. Ancient diseases such as typhus have resurged. Homeless people are dying in record numbers on the streets of Los Angeles.

Communities up and down California, increasingly frustrated with the growing number of homeless people living on public property, have tasked police and sanitation workers with dismantling encampments that they say pollute public areas and pose serious risk of fire, violence and disease. The roustings and cleanups have become a daily occurrence around the state, involving an array of state and local agencies.

But the response from officials has prompted a public health crisis all its own, according to interviews with dozens of homeless people and their advocates. Personal possessions, including medicines and necessary medical devices, are routinely thrown away. It’s a quotidian event that Leilani Farha, the United Nations special rapporteur on adequate housing, described as a “cruelty” that she hadn’t seen in other impoverished corners of the world.

Ciha, 57, learned the hard way that living on the street means his belongings can be taken in an instant.

Ciha says his dog, Shredder, hates the recurring moves: “I can leave him all day in the tent and he’s fine, but he freaks out every time we have to move.” (Anna Maria Barry-Jester/KHN)

In November 2018, when he was camping by an Ikea in nearby Emeryville, the California Highway Patrol and Caltrans showed up unannounced. He was out buying a tent when they arrived, and the crew designated his belongings as garbage. His fellow campers protested and grabbed what they could. Ciha returned and asked for time to gather his things, but said they were thrown into a compactor.

Along with his bedding and clothes, he lost three weeks of an eight-week supply of the medication he was taking to treat hepatitis C. He’d gotten the drugs through Medi-Cal, California’s Medicaid program. Though the drugs were almost certainly purchased at a discount, his course of treatment retails for around $40,000.

In 2018, a federal court case involving a camping ban in Boise, Idaho, determined that cities can’t cite people for sleeping on public property when there’s nowhere else to go. It doesn’t, however, determine rules about possessions. That question has been argued for decades, with multiple courts determining that destroying or confiscating property without notice is a violation of the constitutional right to personal property. Unlike the Boise case, cities rarely, if ever, fight those decisions, which means that precedent has not been set by a higher court.

Ciha cleans up around the strip of public land where he has camped the past 14 months. (Anna Maria Barry-Jester/KHN)

Lawsuits in California have made the issue more visible in the state than in other places, even though this is a nationwide problem, said Eric Tars of the National Law Center on Homelessness & Poverty. Today, many California cities have policies that either prevent seizing belongings or require storage, but public health and safety exceptions often allow for things to be thrown away without notice. “If cities spent half the energy on trying to provide access to sanitation as they did on trying to find constitutional ways to take people’s belongings, they could address homelessness,” Tars said.

The city of San Francisco contends that it stores people’s belongings when they are seized, the result of a settlement from an earlier lawsuit. Homeless advocates say that isn’t always true.

Chris Herring, a doctoral student in sociology at the University of California-Berkeley, has embedded himself in San Francisco’s homeless community on and off for years, including spending nine months in 2014 and 2015 living on the street and a year studying the police, public health and sanitation workers tasked with cleaning encampments. He said he has witnessed people refusing medical help because they didn’t want to leave their things behind and knows others who lost jobs after missing shifts to salvage personal items. An elderly man, so ill he lay paralyzed on the sidewalk, once called Herring and asked him to look after his stuff before he called 911.

Los Angeles has limited the amount of personal property people can carry with them or store on public property, saying it must fit in a 60-gallon container, the equivalent of a medium-sized outdoor trash bin. Several homeless residents are suing over the rule.

The California Department of Transportation is required to post notices of cleanups before clearing out homeless encampments on state property. Homeless advocates say the agency doesn’t always comply with the rules and are suing the state over seized belongings. (Anna Maria Barry-Jester/KHN)

In Oakland, up the hill from where Ciha camps, Caltrans posts advisories about scheduled cleanups, notifying people when they will come through. Caltrans policy requires the postings, but an ongoing class-action lawsuit against Caltrans claims that the policy isn’t always followed and that the sweeps are a violation of people’s constitutional right to private property.

Ciha has joined the suit. Another defendant said Caltrans took her walker, which she used because an infected wound made it difficult for her to get around. Others have lost ID cards and prescriptions, a setback for making appointments or receiving benefits, according to one of the lawyers on the case, Osha Neumann.

Caltrans workers say they hate doing the cleanups. “It’s like 100 times worse than it was just a few years ago,” said Steve Crouch, director of public employees for Local 39 of the International Union of Operating Engineers, which represents Caltrans workers. “One of the biggest gripes they have is having to clean up the homeless encampments. It’s a nasty job.”

The sweeps also cause psychological damage. Ciha and his neighbors talk about how horrible it is when people driving by throw garbage at them. Herring said the trauma of living on the streets is so intense he hasn’t yet figured out how to write about it in his academic work. “[The city will] say we’re just asking people to move, but if you’re being asked that over and over and you have nowhere to go, and people are acting like you’re worthless or they’re scared of you, that affects you fast,” he said.

Up the hill from where Ciha camps, Caltrans posts advisories about scheduled cleanups. An ongoing lawsuit claims the agency systematically seizes and destroys people’s belongings, violating a constitutional right. (Anna Maria Barry-Jester/KHN)

Ciha got tested for hep C after a friend went from healthy to sick in a matter of months. When his doctor prescribed the treatment, he was told he shouldn’t miss a dose. After his things were discarded, he wandered around Oakland for a week, he said, sleeping in random places. He stumbled across the area he now calls home, which he likes because it has just a few people and, for the most part, everyone keeps their area clean and drama-free.

Ciha went back to the doctor after he moved in and was able to get a refill of his prescription. But he’d gone a week without treatment and hasn’t gone back to see if his hep C is cured.

He has since grown accustomed to the Caltrans Shuffle. In the hours before last month’s sweep, he first lugged his cot to the nearby lot. Then his camping mattress and a plastic bin with pots, pans and utensils. Shredder’s food bowl. A cart holding a suitcase filled with bright-white teddy bears that remind him of his mom, a badminton racket, a comforter and a small landscape painting. Things he’ll use when he gets a place, he said.

He’d moved his belongings and was standing on the sidewalk by the time the Caltrans crew arrived, with two police escorts and five trucks. One of Ciha’s neighbors threw garbage into the back of one of the trucks, while workers checked the property. As the cleanup crew packed up, Ciha stood in the lot next door eating a peanut butter and jelly sandwich. The sun was now above the horizon pushing out the morning cold. He would rest a few minutes, and then move back home.

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

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State Highlights: North Carolina Nursing Program Offers Loving Guidance To Low-Income Moms; Deadly Flu Outbreak In Minnesota Is On Track With Last Year

Lawsuit Against Opioid Drugmakers Seeks Additional Settlement For Babies Exposed During Pregnancy

Experts Skeptical That Newsom’s Plan For California To Sell Its Own Generic Drugs Will Actually Lower Prices

High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals

Kristie Flowers had been sick with the flu for four or five days in July before the 52-year-old registered nurse from Genoa, Colo., acknowledged she needed to go to the ER.

At Lincoln Community Hospital, about 10 miles from her home on the Eastern Plains of Colorado, doctors quickly diagnosed her with pneumonia and sepsis. Her right lung had completely filled with fluid, and Flowers needed much more intensive care than the 15-bed hospital could provide.

Doctors stabilized Flowers and transferred her by ambulance about 80 miles away to St. Francis Medical Center in Colorado Springs. There, doctors put her on a ventilator for 10 days as they slowly nursed her back to health. After two weeks, she returned to Lincoln Community Hospital for another week of rehab before going home.

After her insurance plan had paid its share, Flowers owed $8,000 in medical bills. A big chunk represented the $3,500 deductible from her employer-sponsored health plan. Never one to let the bills pile up, Flowers went to the bank and took out an $8,000 loan to pay off her medical tab.

Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum. But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay those deductibles.

That has hit patients like Flowers hard as they grapple with medical debt when emergencies happen — but small rural hospitals like Lincoln Community are suffering, too. These facilities often stabilize critically ill patients and then transfer them to larger regional or urban hospitals for more definitive care.

But when the hospitals submit their claims, bills from the first site of care generally get applied to a patient’s deductible. And if patients can’t afford to cover that amount, those hospitals often don’t get paid, even as the larger urban hospitals where patients were transferred get close to full payment from the health plan.

“As soon as we send them to the city, those things start being paid by the insurance company,” said Kevin Stansbury, CEO of Lincoln Community, “while we’re still chasing the patient around for collections.”

The result is financial headaches for patients and a substantial rise in the amount of uncollectible “bad debt” written off by all hospitals during the past few years. According to the Healthcare Financial Management Association, hospital bad debt increased by $617 million to nearly $56.5 billion between 2015 and 2018. More hospitals, especially those in rural areas, are left teetering financially.

At least 120 rural hospitals nationwide have shut down in the past decade. Without changes, advocates say,     more will close, leaving patients such as Flowers in remote areas far from access to immediate emergency care.

Shopping On Premiums

According to the nonprofit National Rural Health Association, bad debt for rural hospitals has gone up about 50% since the passage of the Affordable Care Act in 2010.

“People in rural America were buying plans maybe for the first time, but buying plans they couldn’t afford,” said Maggie Elehwany, the group’s vice president for government affairs and policy. The plans “seemed to make sense at the time, until they got sick.”

Part of the problem is that consumers primarily shop based on monthly premiums, and insurance plans can lower the monthly premiums they charge by increasing deductibles and copays. Some consumers take the gamble that they’ll stay healthy and won’t get stuck paying the high deductible. But others simply may not understand they are typically responsible for the full deductible before their insurance kicks in to cover the rest of their bills.

In many rural counties, consumers shopping on their state’s health insurance exchange had little choice. This year, about 10% of enrollees, living in 25% of counties, many of them heavily rural, will have access to just one insurer in their local Affordable Care Act marketplaces, according to a Kaiser Family Foundation analysis. (KHN is an editorially independent program of the foundation.)

“The exchanges have never worked the way they were envisioned,” Elehwany said. “The goal was you go on your computer and it’s going to be like buying an airline ticket, and just shopping around for what makes sense for you. There’s no shopping in rural America. You have one choice.”

In Colorado, for example, the average deductible in 2017 was nearly $5,800 for a bronze-level plan. According to an analysis by the Colorado Center on Law & Policy, 1 in 4 Coloradans would not be able to afford to pay that deductible over the course of a year. The ability to pay was even worse in rural areas.

Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center, said that incomes are generally lower in rural areas than elsewhere, and that higher-income rural residents are more likely to travel to an urban hospital than to stay local. Lower-income rural residents, meanwhile, generally go to their local hospital, he said, but they are less likely to be able to meet a high deductible.

Rural residents are also less likely to be covered by employer-sponsored plans and, therefore, more likely to face high deductibles than their urban counterparts.

“They may never pay us,” said Stella Worley, CEO of the 25-bed Keefe Memorial Hospital in Cheyenne Wells, Colo., near the Kansas line. “They get transferred onto high level of care and the other hospital gets paid. We get paid nothing — a lot.”

Worley recalled one patient who had been treated and transferred to a larger hospital. Keefe Memorial wrote off $14,000 in total charges. The patient was billed $1,000 for his deductible and never paid it. Eventually, the unpaid bill went to a collection agency, which takes a 30% cut if it ever collects the fee.

For many rural residents, paying a monthly premium and still facing thousands of dollars in out-of-pocket costs can feel like having no insurance at all. As a result, patients avoid seeking primary care services that could solve minor problems before they devolve into major health issues with much higher costs.

“Some of the people I know in our community trying to get insurance for their employees had a $10,000 deductible, which is really catastrophic insurance,” said Rob Santilli, CEO of Gunnison Valley Health, in Gunnison, Colo. “It’s not going to help them, and it immediately puts them into bad debt with the first instance when they need coverage.”

To be sure, non-rural hospitals have also seen an increase in bad debt. But most city hospitals are part of a larger health system and can weather the storm better than small, independent rural hospitals operating on razor-thin margins.

Colorado has so far avoided the rural hospital closures that have plagued other states. Nonetheless, 22 rural hospitals in Colorado operated in the red last year, according to Michelle Mills, CEO of the Colorado Rural Health Center. That’s double the number in 2018.

“We’re definitely at a tipping point,” Mills said.

Finding Solutions

Hospital and rural health groups across Colorado are lobbying for changes in insurance plan designs to circumvent the impact from high-deductible plans. Lincoln Community’s Stansbury suggested that primary care services, which help keep rural hospitals afloat and patients healthy, should be exempt from the deductible to encourage patients to keep up with their care.

Another option would be simplifying billing so insurance plans would pay hospital and doctor bills directly and send patients a single bill of what they owe. That approach would solve a common complaint from patients who struggle to reconcile multiple bills from various hospitals, doctors and other health care providers that stem from a single episode of care. It would also shift the burden of collecting the patient’s portion of the bill to insurance companies, and protect the hospitals against uncollectible bad debt, leveling the playing field for the rural hospitals.

The Colorado Hospital Association is working with several state legislators to propose that sort of billing structure during the 2020 legislative session. Stansbury said the approach would also allow rural hospitals to focus on patient care rather than trying to collect payments.

“We just don’t have the expertise for billing,” he said. “We do it badly.”

The National Rural Health Association favors requiring insurance plans that offer Medicare and Medicaid plans in rural areas to also offer exchange plans in those counties. If rural consumers had more options, they might be able to avoid high-deductible plans.

That could minimize bad debt for rural hospitals and pay dividends far beyond health care, Elehwany said.

“When you’ve got a small rural hospital and it closes, it’s a nail in the coffin of that rural community,” she said. “How are you going to attract a business? How are you going to keep your school if you don’t have physicians? In rural America, health care is really part of the whole infrastructure of the community.”

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Family Doctors In Rural America Tackle Crisis Of Addiction And Pain

Dr. Angela Gatzke-Plamann didn’t fully grasp her community’s opioid crisis until one desperate patient called on a Friday afternoon in 2016.

“He was in complete crisis because he was admitting to me that he had lost control of his use of opioids,” recalled Gatzke-Plamann.

The patient had used opioids for several years for what Gatzke-Plamann called “a very painful condition.” But a urine screening one week earlier had revealed heroin and morphine in his system as well. He denied any misuse that day. Now he was not only admitting it, but asking for help.

Gatzke-Plamann is the only full-time family physician in the central Wisconsin village of Necedah, population 916. She wanted to help but had no resources to offer. She and the patient started searching the Internet while still on the phone, trying to find somewhere nearby that could help with addiction treatment. No luck.

Here was a patient with a family and job who had spiraled into addiction because of doctor-prescribed pain pills, yet the community’s bare-bones health system left him on his own to find treatment — which he later did, 65 miles away. If that situation was going to change in Necedah, it was up to Gatzke-Plamann.

“That weekend I went home and I said, ‘I’ve got to do something different,’” she recalled.

In many ways, rural communities like Necedah have become the face of the nation’s opioid epidemic. Drug overdose deaths are more common by population size in rural areas than in urban ones. Amid a nationwide decline in prescribing rates since 2012, rural doctors prescribe opioids more often by far. Rural Americans have fewer alternatives to treat their very real pain, and they disproportionately lack access to effective addiction medication such as buprenorphine.

It used to be rare for primary care physicians outside big cities to take on the challenges of opioid misuse, according to Dr. Erin Krebs, a professor of medicine at the University of Minnesota who researches chronic pain management. Now, Krebs said, it’s becoming increasingly common “out of necessity.”

“We just have a lot of people who need this kind of care, and they need it where they are,” Krebs said.

Both pain management and addiction treatment are specialties, calling for advanced training that many family physicians don’t have. Specialists tend to practice in larger towns and cities, said Dr. Alan Schwartzstein, speaker of the American Academy of Family Physicians Congress of Delegates, “so they’re not as accessible.”

For rural physicians, the burden of responding to the opioid epidemic falls squarely on their already loaded shoulders. And for Gatzke-Plamann, there was no question that she wanted to rise to the challenge.

Downtown Necedah, Wisconsin, population 916(Coburn Dukehart/Wisconsin Watch)

The Necedah Family Medical Center(Coburn Dukehart/Wisconsin Watch)

Reducing Pain Pill Prescriptions

When Gatzke-Plamann came to Necedah in 2010, U.S. opioid prescriptions were peaking. She estimates she inherited 25 to 30 patients with monthly opioid prescriptions. Soon she, like many of her peers around the country, noticed a rise in overdose and misuse.

Around 2012, she stopped taking on new patients using chronic opioid medications to focus on current opioid patients. She weaned many off opioids and tracked how many pills she prescribed for acute issues, like surgeries. Instead of defaulting to prescribing a month’s worth of pills for a patient who underwent a cesarean section, for example, she might prescribe only three to five pills.

“Most of the time those patients really only have that much pain for a couple of days,” Gatzke-Plamann said. “We don’t need to have those pain medications sitting in their medicine cabinets.”

Gatzke-Plamann helped shape her community’s wider discussion about opioids. That included joining the county’s substance abuse prevention coalition and educating her peers.

Today, the hospital Gatzke-Plamann is affiliated with sends her a monthly report of how many of her patients have opioid prescriptions. It varies each month, she said, but usually ranges from seven to 10.

Managing Chronic Pain Patients

For 62-year-old Necedah resident Michael Kruchten, the chronic pain he suffers stems from chemotherapy and radiation therapy treatments he received for lung cancer in 2011.

Kruchten is cancer-free now, but the treatments left him with permanent and severe nerve damage in his hands and feet.

“Sometimes it’s a burning — a continuous burning,” Kruchten said. “Sometimes it’s just like a sharp jolt of pain. And then sometimes it’s just pain, pain, pain.”

The pain was so bad he had to stop working at the ethanol plant in Necedah. Daily chores became challenging. The pain would keep him awake at night, leaving him pounding his pillow in frustration.

Michael Kruchten, a patient of Gatzke-Plamann, takes prescription opioids for chronic pain. “Dr. Gatzke has been a big plus and incentive for me. … She’s one of the main factors why I’m still here. She pulled me through it,” he says.(Coburn Dukehart/Wisconsin Watch)

One reason there are more opioid prescriptions in the rural United States is that Americans living in those areas report more chronic pain. Rural communities skew older, meaning they disproportionately deal with painful conditions related to aging, such as arthritis. Injuries also appear to be more common in communities more dependent on physically demanding jobs, such as mining and logging.

For patients with chronic pain like Kruchten, Gatzke-Plamann tries to avoid prescribing opioids when she can, but alternatives are limited. Though evidence shows that physical therapy, exercise, psychotherapy or some combination of these techniques can help reduce the need for opioids, it’s not easy to get these treatments. The nearest physical therapy is in Mauston, a 17-mile drive south. Treatments such as cognitive therapy for pain require drives to Madison, Marshfield or La Crosse, each at least an hour away.

She first tried prescribing Kruchten two non-opioid medicines: gabapentin and then duloxetine. Neither helped enough. Eventually, she prescribed the opioid hydrocodone, finally allowing him to sleep.

“Without the sleep, I was a couch potato,” Kruchten said. “Once I started to get to sleep [at night], I got rid of my TV and the couch and started becoming more active.”

Agreements For Long-Term Opioid Patients

Gatzke-Plamann’s efforts to carefully manage opioid use with chronic pain patients is supported by other efforts in the community.

Around 2016, Mile Bluff Medical Center — the hospital in Mauston with which Gatzke-Plamann is affiliated — standardized a medication treatment agreement with patients, laying out rules for opioid prescriptions.

Patients such as Michael Kruchten must agree to stipulations before getting a new prescription. That includes getting pills from only one doctor and filling prescriptions at just one pharmacy while also submitting to random pill counts and urine screenings. Kruchten is something of a model patient in that regard, according to Gatzke-Plamann.

“You come in for appointments regularly and you’re always on time and you’re respectful with the staff,” she told him as they reviewed the contract at an appointment in November.

Gatzke-Plamann in her office at the Necedah Family Medical Center with medical assistant Laurie Kenke. She says it’s challenging to make room for a buprenorphine practice as well as a family practice, but she considers it an important responsibility for her community. “There isn’t another me just down the road. I’m the only one here. So if I can fulfill that need, then I should do that.”(Coburn Dukehart/Wisconsin Watch)

Gatzke-Plamann can stop prescribing opioids to patients who violate the agreement. But the contracts aim less to punish than to keep communication open. Reviewing the contract with a patient allows them to revisit the risks and warning signs of addiction.

On his recent visit, Kruchten told the doctor he took only one hydrocodone pill instead of his usual two the previous night, saying it was “satisfactory” in curbing the pain.

“And that’s good that you don’t take it to just put yourself to sleep,” Gatzke-Plamann said. “Because it’s not a sleep medicine. You understand that. We’ve talked about that one before.”

“Yep,” Kruchten agreed.

Addressing The Rural Addiction Treatment Gap

The Friday call for help in 2016 made Gatzke-Plamann realize Necedah was missing a crucial resource in solving the pain puzzle: addiction treatment.

“We don’t have as many resources here,” Gatzke-Plamann said of the surrounding Juneau County, one of the poorest and least healthy in the state. “When I see that there’s a need for something, it’s on me to do something about that.”

She said that’s why she decided to get the required training to prescribe the addiction medicine buprenorphine.

Research shows buprenorphine effectively treats addiction, but the medicine is particularly scarce in rural America. More than 10 million rural Americans — more than one-fifth of the country’s rural population — live in counties without a single clinician licensed to prescribe the drug. (The rural-urban disparity in access has, however, shrunk since 2017.)

In Wisconsin, 18 of 72 counties lack a buprenorphine provider, and 14 of those unserved counties are rural.

Gatzke-Plamann is one of only two people in Juneau County licensed to prescribe buprenorphine. The other is a physician assistant she supervises.

Catina Stoflet has been prescribed the addiction medicine buprenorphine for seven months, being supervised by Gatzke-Plamann. “I probably would have died of a heroin overdose if I didn’t do this program. It’s changed my life,” says Stoflet.(Coburn Dukehart/Wisconsin Watch)

Catina Stoflet is among the buprenorphine patients who benefit.

Stoflet, 35, got addicted to prescription opioids as a 16-year-old in 2001, during the first wave of the nation’s opioid epidemic. She started getting kidney stones in high school. She’s had many surgeries to remove the painful obstructions.

That first prescription was for Tylenol 3, a combination of acetaminophen and the opioid codeine. Doctors soon escalated her to stronger drugs: Vicodin, Percocet, oxycodone.

“It was right around the time that people didn’t know what [opioids were] doing to you,” Stoflet said.

Stoflet said she spent years in recovery beginning in 2007. But she relapsed in 2014, progressing to heroin and methamphetamine. Last year, she decided to quit for good. Stoflet said her primary care doctor introduced her to Gatzke-Plamann, who had recently begun prescribing buprenorphine.

Just like Gatzke-Plamann’s opioid patients, buprenorphine patients must sign contracts, agreeing to participate in a treatment program that includes counseling.

Stoflet works with a counselor and community recovery specialist at the Roche-A-Cri Recovery Center in Friendship, about 20 miles from Necedah. The center opened in September 2018. Without its additional resources, Gatzke-Plamann said, she would not feel comfortable prescribing buprenorphine.

“I am just one part of their treatment plan,” Gatzke-Plamann said. “They need the counseling. They need the psychosocial support. They need the group meetings.”

Doctors like Gatzke-Plamann have an important role to play in the opioid crisis by treating patients where they live, said Erin Krebs of the University of Minnesota. But, she added, funding models don’t always encourage this kind of work.

“I’m not sure we’ve done all we can do to really support small practices taking on this effort,” said Krebs. “There’s hope for people with opioid problems, and we have treatments that work. And so I think the more we can hear about clinicians who are tackling these problems in their own communities and having success the better.”

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

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