Tagged States

Cause Of Polio-Like Illness In Children Continues To Stump Experts Even As Dozens Of More Cases Emerge

“What we do know is that these patients had fever and respiratory symptoms three to 10 days before their limb weakness,” CDC’s Dr. Nancy Messonnier told The Associated Press. “And we know that it’s the season where lots of people have fever and respiratory symptoms. What we need to sort out is what is the trigger for the [acute flaccid myelitis].”

Oregon Releases People Found Not Guilty By Reason Of Insanity More Quickly Than Nearly Every Other State

A ProPublica investigation shines a light on Oregon’s unique process of reviewing the cases of defendants found not guilty by reason of insanity. About 35 percent of the people in that category were charged with new crimes within three years of being freed by state officials.

Local Ties In Suit Against Opioid Manufacturer Makes Case Personal For New Jersey Officials

The Johnson & Johnson subsidiary that New Jersey says minimized the risks of opioid addiction in its marketing messages is based in the state. “It is especially troubling that so much of the alleged misconduct took place right here in our own backyard,”said Gurbir Grewal, the New Jersey attorney general, at a news conference announcing the legal action. “New Jersey’s pharmaceutical industry is the envy of the world, with a long history of developing vital, lifesaving drugs. But we cannot turn a blind eye when a New Jersey company like Janssen violates our laws and threatens the lives of our residents.” Meanwhile, Naloxone can be a lifesaving drug, but not all pharmacies are on board with offering it. News on the epidemic comes out of Oregon, Kansas, New Hampshire and California, as well.

Anthony Bourdain’s Suicide Prompts Those In Notoriously Brutal Culinary Industry To Speak Out About Mental Health Struggles

Insiders have long worried privately about the lifestyle of people who work in the restaurant industry, which has one of the highest rates of illicit drug use and alcoholism and a tradition of masking mental-health struggles. In other news on mental health: farmers devastated by Florence are especially vulnerable to depression and judges are starting to favor outpatient treatment over hospitalization.

With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment

When mental illness hijacks Margaret Rodgers’ mind, she acts out.

Rodgers, 35, lives with depression and bipolar disorder. When left unchecked, the conditions drive the Alabama woman to excessive spending, crying and mania.

Last autumn, Rodgers felt her mind unraveling. Living in Birmingham, she was uninsured, unable to afford treatment and in the throes of a divorce. Although Rodgers traveled south to her brother’s house in Foley, Ala., for respite, she couldn’t escape thoughts of suicide, which one day led her to his gun.

“I hit bottom,” she recalled. But she didn’t pull the trigger.

Rodgers told her brother about the close call. News of the incident reached her mother, who then alerted authorities to Rodgers’ near attempt.

Within days, Rodgers was handcuffed and hauled in front of a judge who ordered her to undergo mental health treatment — but not a hospital commitment. Instead, the judge mandated six months of care that included weekly therapy sessions and medication, all while Rodgers continued living with her family.

Rodgers entered assisted outpatient treatment, also known as involuntary outpatient commitment.

Since its inception, the court-ordered intervention has generated controversy. Proponents say it secures the comprehensive care that people with severe mental illnesses might not recognize they need. Yet other health experts question the effectiveness of the intervention and suggest it represents a quick fix in a mental health system that is not adequately serving patients.

“It’s a stopgap measure that works in the short term,” said Dr. Annette Hanson, director of the University of Maryland Forensic Psychiatry Fellowship, who co-authored a book on the intervention. “But it’s not a good long-term solution because you still have lots of people who need voluntary care who can’t get” it.

Assisted outpatient treatment requires a judge’s order. While the eligibility requirements and compliance standards vary by state, participants typically have a history of arrests and multiple hospitalizations. They stay in their communities while undergoing treatment.

The American Psychiatric Association endorsed its use in 2015, saying assisted outpatient treatment has generally shown positive outcomes under certain circumstances. To effectively treat patients, the position paper said, the APA recommends that the intervention be well-planned, “linked to intensive outpatient services” and last for at least 180 days.

A key advantage to assisted outpatient treatment, supporters say, is that it provides care for people who might not recognize the severity of their illness.

A court’s involvement also increases the likelihood of a participant complying with the program, a phenomenon called the “black robe effect,” they add.

“That is really what we’ve found to be the secret sauce” for success, said John Snook, executive director of the nonprofit Treatment Advocacy Center.

But many areas do not have the necessary community mental health services to provide assisted outpatient treatment effectively, said Ira Burnim, legal director for the Judge David L. Bazelon Center for Mental Health Law.

He also said the law already provides options for hospital treatment for people considered a danger to themselves or others. Any person recommended for assisted outpatient treatment for these reasons should be in a hospital receiving intensive inpatient care, Burnim said, not in the community.

“You know, when people don’t take their medication,” he said, “that’s a clinical problem, not a legal problem.”

Most States Allow The Programs

Assisted outpatient treatment gained popularity after Andrew Goldstein, who was diagnosed with schizophrenia but wasn’t taking his medication, pushed Kendra Webdale in front of an oncoming train in New York City in 1999, killing her. Webdale’s family fought for a change in the law after learning that Goldstein had repeatedly refused treatment while living on his own.

Today, 47 states and the District of Columbia have laws allowing localities to set up assisted outpatient treatment, according to the Treatment Advocacy Center, a nonprofit group that strongly supports assisted outpatient treatment.

Yet, there is no tally of the number of programs or the number of people involuntarily placed in one, said David DeVoursney, chief of the Community Support Programs Branch at the Substance Abuse and Mental Health Services Administration.

There is also little research on its effectiveness. Two randomized studies produced contradictory results about the intervention’s effect on hospitalization rates and the number of arrests afterward. However, other analyses have shown improved outcomes, particularly among participants in New York.

Despite the ambiguity, Congress created grants in 2014 that made up to $60 million available over four years to new assisted outpatient treatment programs. Additionally, the 21st Century Cures Act, passed in 2016 to accelerate drug development, allowed some Department of Justice funding for the intervention.

Experts acknowledge that the scarcity of mental health providers and treatment options causes many patients to go without care. Instead of doctors’ offices, many people with mental illnesses end up in jail — an estimated 2 million every year, according to the National Alliance on Mental Illness.

“What we say very often is basically we have a system that allows people to have heart attacks over and over again,” Snook said. “And then once they have that heart attack, we take them to jail. And then we wonder why the system isn’t working.”

Margaret Rodgers now sees a therapist once a week. A nurse at AltaPointe Health Systems Inc., a community health center, gives her a shot of an antipsychotic drug once a month. (Meggan Haller for KHN)(Meggan Haller for KHN)

A Morning Surprise

One recipient of federal funding is AltaPointe Health Systems Inc., a community health center that provides services to residents — including Rodgers — in two Alabama counties. The program has received nearly $1.1 million in federal funding, according to Cindy Gipson, assistant director of intensive services.

She said the center applied for the federal grant to reduce the number of hospitalizations among residents living with severe mental illnesses.

“We were having a lot of people who would go to the hospital, then be discharged,” she said. “And they’d do well for a couple of weeks — maybe even a month. Then, they’d go right back in.”

The program, which began in 2017, has served 71 patients, Gipson said. On average, patients stay about 150 days. And roughly 60 percent of referrals come from family members, she said. The majority of people entering have a history of multiple hospitalizations and arrests.

Rodgers said she had never been in handcuffs before the day the Alabama police officer came to her brother’s home and awakened her around 7 a.m. The sheriff gave her five minutes to change and brush her teeth. He then cuffed her wrists, placed her in the back of his car and drove her straight to court. After she was asked a few questions about how she was doing, Rodgers said, she sat down in front of a judge and learned about assisted outpatient treatment for the first time.

Despite how she entered care, Rodgers said the mandated treatment has brought her stability. She sees a therapist once a week, and once a month a nurse at the community health center administers a shot of the antipsychotic drug Abilify. She now is working part time cleaning condos and lives with her mother. She said she has learned strategies to not dwell on the past.

After her first six months of treatment, Rodgers and her care team decided to continue care through the rest of the year. She plans to return to Birmingham and find a better job after completing the program.

Right now, she said, “staying positive is the main thing I want.”

An Underused Strategy For Surge In STDs: Treat Patients’ Partners Without A Doctor Visit

If patients return to Dr. Crystal Bowe soon after taking medication for a sexually transmitted infection, she usually knows the reason: Their partners have re-infected them.

“While you tell people not to have sex until both folks are treated, they just don’t wait,” she said. “So they are passing the infection back and forth.”

That’s when Bowe, who practices on both sides of the North and South Carolina border, does something doctors are often reluctant to do: She prescribes the partners antibiotics without meeting them.

Federal health officials have recommended this practice, known as expedited partner therapy, for chlamydia and gonorrhea since 2006. It allows doctors to prescribe medication to their patients’ partners without examining them. The idea is to prevent the kind of reinfections described by Bowe — and stop the transmission of STDs to others.

However, many physicians aren’t taking the federal government’s advice because of entrenched ethical and legal concerns.

“Health care providers have a long tradition of being hesitant to prescribe to people they haven’t seen,” said Edward Hook, professor at the University of Alabama’s medical school in Birmingham. “There is a certain skepticism.”

A nationwide surge of sexually transmitted diseases in recent years, however, has created a sense of urgency for doctors to embrace the practice. STD rates have hit an all-time high, according to the Centers for Diseases Control and Prevention. In 2017, the rate of reported gonorrhea cases increased nearly 19 percent from a year earlier to 555,608. The rate of chlamydia cases rose almost 7 percent to 1.7 million.

“STDs are everywhere,” said Dr. Cornelius Jamison, a lecturer at the University of Michigan Medical School. “We have to figure out how to … prevent the spread of these infections. And it’s necessary to be able to treat multiple people at once.”

A majority of states allow expedited partner therapy. Two states — South Carolina and Kentucky — prohibit it, and six others plus Puerto Rico lack clear guidance for physicians.

A 2014 study showed that patients were as much as 29 percent less likely to be re-infected when their physicians prescribed medication to their partners. The study also showed that partners who got those prescriptions were more likely to take the drugs than ones who were simply referred to a doctor.

Yet only about half of providers reported ever having prescribed drugs to the partners of patients with chlamydia, and only 10 percent said they always did so, according to a different study. Chlamydia rates were higher in states with no law explicitly allowing partner prescriptions, research published earlier this year showed.

Because of increasing antibiotic resistance to gonorrhea, the CDC no longer recommends oral antibiotics alone for the infection. But if patients’ partners can’t go in for the recommended treatment, which includes an injection, the CDC said that oral antibiotics by themselves are better than no treatment at all.

“Increasing resistance plus increasing disease rates is a recipe for disaster,” said David Harvey, executive director of the National Coalition of STD Directors. The partner treatment is important for “combating the rising rates of gonorrhea in the U.S. before it’s too late.”

The CDC recommendations are primarily for heterosexual partners because there is less data on the effectiveness of partner treatment in men who sleep with men, and because of concern about HIV risk.

Bowe said that even though she writes STD prescriptions for her patients’ partners, she still worries about possible drug allergies or side effects.

“I don’t know their medical conditions,” she said. “I may contribute to a problem down the road that I’m going to be held liable for.”

Physician Crystal Bowe, who practices in North and South Carolina, said she occasionally writes prescriptions for her patients’ partners but worries about possible drug allergies or side effects. “I don’t know their medical conditions,” she says. “I may contribute to a problem down the road that I’m going to be held liable for.” (Courtesy of Crystal Bowe)

In many cases, doctors and patients simply do not know about partner therapy. Ulysses Rico, who lives in Coachella, Calif., said he contracted gonorrhea several years ago and was treated by his doctor. He didn’t know at the time that he could have requested medicine for his girlfriend. She was reluctant to go to her doctor and instead got the required antibiotics through a friend who worked at a hospital.

“It would have been so much easier to handle the situation for both of us at the [same] moment,” Rico said.

Several medical associations support partner treatment. But they acknowledge the ethical issues, saying it should be used only if the partners are unable or unwilling to come in for care.

Federal officials are trying to raise awareness of the practice by training doctors and other medical professionals, said Laura Bachmann, chief medical officer of the CDC’s office of STD prevention. The agency posts a map with details about the practice in each state.

Over the past several years, advocates have won battles state-by-state to get partner treatment approved, but implementation is challenging and varies widely, said Harvey, whose National Coalition of STD Directors is a member organization that works to eliminate sexually transmitted diseases.

The fact that some states don’t allow it, or haven’t set clear guidelines for physicians, also creates confusion — and disparities across state lines.

The Planned Parenthood affiliate that serves Indiana and Kentucky sees this firsthand, said clinical services director Emilie Theis. In Indiana, providers can legally write prescriptions for their patients’ partners, but they are prohibited from doing so in Kentucky, even though the clinics are only a short drive apart, she noted. A similar dynamic is at play along the South Carolina-North Carolina border, where Bowe practices.

California started allowing partner treatment for chlamydia in 2001 and for gonorrhea in 2007. The state gives medication to certain safety-net clinics, a program it expanded three years ago. However, “it has been an incredibly difficult sell” because many medical providers think “it’s a little bit outside of the traditional practice of medicine,” said Heidi Bauer, chief of the STD control branch of California’s public health department.

At APLA Health, which runs several health clinics in the Los Angeles area, nurse practitioner Karla Taborga occasionally gives antibiotics to patients for their partners. But she tries to get the partners into the clinic first, because she worries they might also be at risk for other sexually transmitted infections.

“If we are just treating for chlamydia, we could be missing gonorrhea, syphilis or, God forbid, HIV,” Taborga said. But if prescribing the drugs without seeing the patients is the only way to treat them, she said, “it’s better than nothing.”

Edith Torres, a Los Angeles resident, said she pressured her then-husband to go to the doctor after he gave her chlamydia several years ago: She refused to have sex with him until he did. Torres said she wanted him to hear directly from the doctor about the risks of STDs and how they are transmitted.

If he had taken the medication without a doctor visit, he wouldn’t have learned those things, she said. “I was scared, and I didn’t want to get it again.”


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

‘This Isn’t Just My Lane. It’s My Highway’: Doctors Outraged Over NRA’s Suggestion That They Stay Out Of Gun Debate

The NRA’s tweet saying doctors should “stay in their lane” over the gun control debate sparked furious, and sometimes graphic, responses from physicians who deal with gun shot victims frequently. “Do you have any idea how many bullets I pull out of corpses weekly?” Judy Melinek tweeted. Another doctor posted: “My lane is paved by the broken bodies left behind by your products.” Meanwhile, media outlets examine the widespread mental health effects of mass shootings.

Listen: Teen Vaping Sparks FDA Crackdown

Federal regulators want to ban the sale of most flavored e-cigarettes at retail locations like gas stations and convenience stores. They also want to require anyone buying e-cigarettes online to verify their age. The new restrictions come as the Food and Drug Administration has been trying to rein in a dramatic increase in vaping by young people. Smoking of traditional tobacco cigarettes has fallen to a record low, but the popularity of e-cigarettes among youth is raising alarm bells.

Colorado Public Radio’s John Daley reports on the effort for Kaiser Health News and NPR’s All Things Considered.


KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Listen: Teen Vaping Sparks FDA Crackdown

Federal regulators want to ban the sale of most flavored e-cigarettes at retail locations like gas stations and convenience stores. They also want to require anyone buying e-cigarettes online to verify their age. The new restrictions come as the Food and Drug Administration has been trying to rein in a dramatic increase in vaping by young people. Smoking of traditional tobacco cigarettes has fallen to a record low, but the popularity of e-cigarettes among youth is raising alarm bells.

Colorado Public Radio’s John Daley reports on the effort for Kaiser Health News and NPR’s All Things Considered.


KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

As Mass Gun Violence Rises, Debate Intensifies Over Strategy On How To Proceed In Active Shooter Situations

The recent shooting at a bar in California highlights how difficult it is to decide on how emergency responders should handle highly dangerous situations. Meanwhile, The Associated Press looks at California’s gun laws, which are some of the strictest in the country. And a community grieves.

Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find

For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.

But the new benefits will not be widely available, and they won’t be easy to find.

Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.

That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.

Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options.

Even if people sign up for those plans, they won’t all be eligible for all the benefits. Advantage members will need a recommendation from a health care provider in the plan’s network. Then they may need to have a certain chronic health problem, a recent hospitalization or meet other eligibility requirements.

Medicare counselors from California to Maine say key details are not included on the government’s website. In some cases, if insurers offer the new benefits, the plan finder “will indicate ‘yes’ or ‘no,’” said Georgia Gerdes a health care choices specialist at AgeOptions, the Area Agency on Aging in Oak Park, Ill., outside Chicago. That’s hardly enough, she said.

“There is a lot of information on the plan finder, but there is a lot of information missing that requires beneficiaries to do more research,” said Deb McFarland, Medicare services program supervisor at the Southern Maine Agency on Aging.

Nonetheless, officials say the added benefits will help Advantage members prevent costly hospitalizations. Federal approval of additional benefits is “one of the most significant changes made to the Medicare program,” Seema Verma, the head of the Centers for Medicare & Medicaid Services, told an insurers’ meeting last month. She said she expects plans to expand services in coming years.

Medicare Advantage plans, which are an alternative to traditional Medicare, serve 21 million beneficiaries and limit their out-of-pocket expenses. But they also restrict members to a network of doctors, hospitals and other medical providers. They often offer benefits not available in traditional Medicare, such as dental and vision care, hearing aids and gym memberships.

The federal government pays a set amount to the plans to help cover the cost of each member. The Trump administration gave insurers more money to spend on benefits next year — an average pay raise of 3.4 percent, seven times more than the rate of increase in 2018.

Enrollment is underway for Medicare Advantage plans, as well as for people in traditional Medicare who want to buy a policy for drug coverage. The deadline for choosing either type of plan is Dec. 7.

Among the new benefits that some Medicare Advantage plans said they will offer are:

  • Trips to the pharmacy or fitness center in addition to doctor’s appointments for plan members, depending on where they live or their health conditions.
  • A monthly or quarterly allowance for over-the-counter pharmacy products such as cold and allergy medications, eye drops, vitamins, supplements and compression stockings.
  • House calls by doctors or other health care providers, under certain conditions.
  • A home health care aide for a limited number of hours to help with dressing, eating and other daily activities, possibly including household chores and light housekeeping.

However, plans offering these and other services will likely have only some of the options and will have different eligibility criteria and other limitations. The same services likely won’t be available in every county the plan serves.

For example, next year an estimated 150,000 Humana Medicare Advantage members in Texas and South Florida — two of the 43 states Humana serves — who cannot be left alone at home will be able to get a free in-home personal care aide for up to 42 hours a year, so that their regular caregiver can get a break. And more than half of the members in Cigna-HealthSpring Advantage plans will have access to free transportation services in all but five of the 16 states and the District of Columbia where the company sells coverage.

To find these supplemental benefits, seniors can use the online plan finder. After they enter their ZIP code and get a list of plans available locally, they can click on a plan name. That will take them to another page that offers more details about coverage, including a tab for health and drug plan benefits. That page might say whether the new services are offered.

But often the website will simply indicate that specific benefits are available — and perhaps not name them — and advise consumers to contact the plan for more information. A Medicare spokesperson confirmed that there is currently not an indicator on the plan finder for plans offering these expanded health-related supplemental benefits.

In addition to extra benefits, other variables should be considered when choosing an Advantage plan, such as which health care providers and pharmacies participate in a plan’s network, which drugs are covered and the costs.

Where available, several insurers say the new services will be free with no increase in monthly premiums.

“We certainly believe that all of the ancillary benefits we provide will help keep our members healthy, which is good for them, and it’s good for us in the long run,” said Steve Warner, head of the Medicare Advantage product team at UnitedHealthcare, which insures about 5 million seniors or 1 in 4 Medicare Advantage members.

Insurers are betting that services will eventually pay for themselves.

Dawn Maroney, consumer president at Alignment Healthcare, which serves eight counties in Southern California, said it’s much cheaper to give an air conditioner to someone with congestive heart failure to keep that patient healthy than to pay for more expensive medical treatment.

But if the new benefits are such a good idea, they should be available to the majority of older adults in traditional Medicare, said David Lipschutz, a senior policy attorney at the Center for Medicare Advocacy.

For free help with Medicare Advantage and drug plan enrollment, contact the federally funded State Health Insurance Assistance Program (www.shiptacenter.org), the Medicare Rights Center, 800-333-4114 or its website, www.medicareinteractive.org. The Medicare Plan Finder website is available at https://www.medicare.gov/find-a-plan/questions/home.aspx or call 800-633-4227.