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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As if those sky-high medical bills weren’t bad enough, apparently California teachers also must pay substitutes to cover for them — even while undergoing treatment for breast cancer.

Which is the perfect segue into what you may have missed this week (almost like I planned it).

President Donald Trump waded into the turf wars among doctors, hospitals and insurers Thursday when he called for an end to surprise medical bills. The issue has been gaining attention across the country as stories about $48,512 cat bites and $109,000 heart attacks resonate with voters who are sick of paying an arm, a leg and a mortgage for health care even when they have insurance.

It’s not exactly a controversial issue — it’s listed as a top concern among voters, and lawmakers are lining up in droves to sign their names to any potential legislation. But, as is often the case with health care costs, the devil’s in the details. The costs don’t just disappear because the president doesn’t want patients to have to pay them. Physician groups tend to favor arbitration, while insurers argue that method is flawed because it still relies on bill charges. Instead, the industry wants set prices, with rates in line with what they would consider reasonable for the procedures. Each side hates the other’s opinion. So … good luck to the lawmakers who have to balance those two big interest groups!

The New York Times: Trump Said He Wanted to Work With Democrats on Surprise Medical Bills. Then He Attacked Democrats.

(FWIW: Two stories of the patients who were featured at the White House event were previously highlighted in KHN and NPR’s “Bill of the Month” series. Check them out here.)

Kicking off a veritable blitz of bills, House Democrats voted on legislation that would ban the Trump administration from granting states waivers for health law regulations. Over the next couple of weeks, Dems are expected to go hard on their campaign promises to shore up the bruised and battered health law. Some of the topics of those bills: short-term “junk insurance” plans, outreach funding, “reinsurance” payments, drug rebates and more.

The New York Times: With Insurance Bill Passage, House Democrats Begin Health Care Blitz

Speaking of waivers, Tennessee is set to ask for one to shift its Medicaid program into a block grant model. Block grants — aka Republicans’ longtime dream system — as an idea have a long history riddled with controversy and criticism, and the request, if granted, is all but certain to draw a court challenge. Now the question is: How far is CMS ready to go in pushing the envelope on Medicaid changes? Especially when other waivers are getting knocked down left and right in court?

Modern Healthcare: Tennessee Will Test CMS’ Willingness to Block-Grant Medicaid

Meanwhile, the Trump administration is proposing a change to the formula to calculate poverty. That may seem fairly dry, but since government assistance (like Medicaid and food stamps) is tied to that line, millions could lose health care coverage and/or have to go hungry.

The New York Times: Trump Administration Seeks to Redefine Formula for Calculating Poverty

Pharma companies are going to start to have to include list prices in their TV ads under a new rule that’s central to the Trump administration’s war on high drug costs. While most people think, in general, it’s a good step, many doubt it will accomplish much. It’s not as if sick consumers can then go negotiate a different price, as they would with cars.

As Ben Wakana, the executive director of Patients for Affordable Drug Prices, told NPR: “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

NPR: New Rule for Drugmakers: Disclose Drugs’ List Prices in TV Ads

Drug prices were a hot topic this week (and most weeks, amiright?), with the Senate Finance Committee holding a hearing on the idea of setting an international price index. Other countries set lower prices and “we look like chumps,” said Sen. John Kennedy (R-La.).

Modern Healthcare: GOP Senators Warn Drug Price Controls Could Come

And, yup, there’s still more news: Despite HHS Secretary Alex Azar’s concerns about safety, Trump backed Florida’s plan to import drugs from other countries. The kicker here: Florida will surely be a battleground state in the 2020 election, and drug prices routinely top voters’ list of concerns. The potential for a winning talking point is huge.

The Associated Press: Trump Backs Fla. Plan to Import Lower-Cost Meds From Abroad

In somewhat tangential news, Gilead announced it will donate its drug that reduces the risk of HIV transmission for up to 200,000 people a year. The price of the life-changing medication has long been a barrier to the goal of ending HIV transmissions, and many advocates were thrilled with the decision. Still, others were disappointed, saying that will cover only a fifth of what the country needs.

The Associated Press: Drugmaker Will Donate Meds for US Push to End HIV Epidemic

But everyone was cheering a new study out of Europe. Out of nearly 1,000 gay male couples where one partner had HIV and was taking antiretroviral drugs, there were zero cases of HIV transmission even without the use of condoms.

Reuters: AIDS Drugs Prevent Sexual Transmission of HIV in Gay Men

Fed up with the strategy to slowly chip away at abortion rights, Alabama lawmakers are poised to go all in. The legislation (which was almost up for a vote this week, but was delayed because of a ruckus over rape and incest amendments) would effectively ban all abortions and criminalize the act of performing the procedure. The supporters of the bill aren’t being coy at all about their intention: They want to challenge Roe v. Wade with a simple, “clean bill” on the legality of abortions.

The New York Times: As States Race to Limit Abortions, Alabama Goes Further, Seeking to Outlaw Most of Them

And over in Georgia, abortion rights advocates have one message to Republican Gov. Brian Kemp, who just signed a heartbeat bill: “We will see you, sir, in court.”

The Associated Press: Opponents of Georgia Abortion Ban Promise Court Challenge

On a sad note: Legendary New York Times reporter Robert Pear passed away this week from complications of a stroke. Although I did not have the pleasure of meeting or working with him, his byline became a familiar friend of mine. He has shaped my world for the past several years with the stories he continuously broke. It is a loss for journalism, for health care and for the people he helped through the light he shined on Washington.

His last story is a perfect example of that: looking at legislation that carried promises of helping people with preexisting conditions but failed to live up to them.

The New York Times: Robert Pear, Who Covered Washington for 45 Years, Dies at 69

The New York Times: Republicans Offer Health Care Bills to Protect Patients (and Themselves)

In the miscellaneous files of the week:

• Traditionally, HHS has received, on average, one complaint related to “conscience” violations from health care workers per year. Last year, that rose to 343. What on earth happened? (Hint: It does not mean the problem actually worsened.)

NPR: Why Are Health Care Workers’ Religious and Moral Conscience Complaints Rising?

• It might seem like the anti-vaccination movement is a new phenomenon spurred on by social media, but there’s a long history of resistance in the country. And it’s not as random as it might appear at first. Usually, it’s tied to time periods that are marked by great resentment toward government.

Los Angeles Times: Why the Measles Outbreak Has Roots in Today’s Political Polarization

• Stories about student heroes stopping mass shooters and dying in the process highlight just how grim our reality has become as young people find themselves thrust into violence.

The New York Times: Colorado School Shooting Victim Died Trying to Stop the Gunman

• Not only is the United States’ maternal mortality rate abysmal, a new study finds that many of those deaths — 60%! — are preventable. What’s more, African American and American Indian/Alaska Native women are three times more likely to die from pregnancy and childbirth than white women.

USA Today: Pregnancy and Childbirth Deaths Are Largely Preventable, CDC Says

• Beneath the bright, tantalizing promises of the stem cell industry (targeted at the most desperate patients) festers a dark underbelly of greed and profit.

ProPublica: The Birth-Tissue Profiteers

Have a great weekend, and remember, as National Nurses Week wraps up, to hug (or otherwise appropriately thank) the nurses in your life. Their job can be quite tough.

Warren Hopes Opioid Message Will Reach Through Partisan Hostility In Ohio And West Virginia, Both Hit Hard By Crisis

Sen. Elizabeth Warren (D-Mass.) announced a plan this week that would funnel $100 billion toward combatting the opioid epidemic. She’s on the road to talk about it, stopping in states that have been deeply impacted by the drug crisis. In other news: a Trump administration official talks about boosting funding; prescription opioid use plummets; spending on the epidemic sky-rockets; and more.

Much Of Public Officials’ Attention Has Focused On Jewish Community, But Vaccination Resistance Spreads Far Beyond It

The majority of the dozens of New York City schools that had less than 90 percent of their children vaccinated for measles in the last school year were not ultra-Orthodox Jewish. Meanwhile, a look into history shows that vaccination resistance is nothing new in the U.S., and it tends to be tied tumultuous times of social upheaval and distrust in our institutions.

Surprise! Fixing Out-Of-Network Bills Means Someone Must Pay

President Donald Trump called on Republicans and Democrats to pass legislation this year to end surprise medical bills, in remarks made in the White House’s Roosevelt Room on Thursday. “We’re determined to end surprise medical billing for American patients,” Trump said.

Bills like those have been featured in the NPR-Kaiser Health News series launched in February 2018. Two patients whose medical bills were part of the series attended the event.

Austin, Texas, teacher Drew Calver talked about the six-figure bill he received after having a heart attack. “I felt like I was exploited at the most vulnerable time in my life,” he said. His bill was reduced to $332 after the NPR-KHN story was published.

A bipartisan group of senators has been working to come up with a plan for the past several months. They said Thursday that they hope to have a bill to the president by July.

But will bipartisanship be enough? Even political will might not overcome divisions within the health industry.

Specifically, lawmakers aim to address the often-exorbitant amounts patients are asked to pay out-of-pocket when they receive care at health facilities that are part of their insurance network but are treated by out-of-network practitioners. Legislators are also looking to address bills for emergency care at a facility that doesn’t have a contract with patients’ insurers.

“We’re getting really close to an approach that we’ll be able to unveil pretty soon,” Sen. Maggie Hassan (D-N.H.) told reporters on a conference call Thursday with Sen. Bill Cassidy (R-La.).

And it’s not just politicians and patients: Out-of-network doctors, insurance companies and hospital groups say they want the problem for consumers fixed, too.

Despite that broad agreement, a hurdle remains. Insurers and health care providers each oppose the other side’s preferred solution to end surprise bills. That conflict makes it almost impossible for lawmakers to come up with a fix that won’t leave one of the influential groups unhappy.

“It’s a different axis than the partisan [conflicts] we’re used to,” said Loren Adler, who has been studying the surprise-bill problem for the USC-Brookings Schaeffer Initiative for Health Policy. The fight over how to fix it is less likely “to break down between Republicans and Democrats and more likely to break down to where the money is” and which group will have to take less of it.

“I don’t see a coalescence around a solution,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities.

The divide is wide, despite the overall interest in protecting consumers.

“What we’d most like to see is clarity for the patients,” said Bob Kneeley, a senior vice president for Envision Healthcare, which employs physicians to staff a variety of hospital departments, such as emergency rooms, neonatal units and anesthesiology. “This is a system that’s just not working well for the patient, and we need to establish some appropriate guardrails.”

“We want this to be solved. We know it needs federal legislation,” agreed Molly Smith, a vice president at the American Hospital Association. She said hospitals believe that patients should “not have to be involved in any process if there’s a dispute between the payer and the provider.”

States have been working on the problem for several years. Nine now have programs aimed at protecting patients from surprise bills. But state laws cannot reach those with employer-provided insurance — more than half of all Americans — because those plans are regulated by a federal law called the Employee Retirement Income Security Act, or ERISA. That means only Congress can fix it for everyone.

Patients and groups that represent them say the problem is more urgent than ever.

“We are talking about situations in which families — despite enrolling in health insurance, paying premiums, doing their homework and trying to work within the system — are being left with completely unanticipated and sometimes financially devastating bills,” Frederick Isasi, executive director of the consumer group Families USA, told a House Education and Labor subcommittee hearing in April. “This is inexcusable behavior on the part of hospitals, doctors and insurers. They each know — or should know — that patients have no real way to understand the financial trap they have just walked into.”

Dr. Paul Davis, whose daughter received a bill for a $17,850 for a urine test after back surgery, also spoke at the White House on Thursday: “The situation is terrible. It is a national disgrace, and I think a lot of people would support me on that,” Davis told a reporter. Their story was the first featured in the “Bill of the Month” project.

Still, it’s not clear where compromise might be found.

By and large, doctors favor some sort of negotiated-fee system when there is a dispute about a bill, such as binding arbitration, in which an independent third party makes the ultimate payment decision.

“That’s consistent with what’s working in some states,” said Envision’s Kneeley.

Among those frequently cited by doctors’ groups is New York, which has one of the strongest state laws on surprise billing. There patients are not required to pay more than they would for an in-network doctor or hospital. For the remaining bill, an independent arbitrator settles any dispute between the provider and insurer.

But the insurance industry worries about that approach. “Our larger concern with arbitration is that it still relies on bill charges,” said Adam Beck, a vice president for America’s Health Insurance Plans, an insurance industry trade group. And insurers think those charges are too high.

A senior administration official also said on Thursday that the administration does not favor the arbitration approach, either.

Insurers — and many consumer groups — “believe if you have a clear benchmark pegged to reasonable rates, that will really solve this problem,” Beck said, because insurers would be more likely to cover charges they found more in line with what they consider reasonable.

A “benchmark” payment might correspond to what Medicare pays for the same service, for instance.

But doctors don’t like that idea one bit. “Even if [the benchmark] is on the high side, it’s still rate-setting,” said Kneeley.

Hospitals don’t like it, either.

“We can’t get behind any sort of rate-setting in statute,” said Smith of the AHA. “We have too many concerns about getting that wrong.” For example, she said, if the rate is set too low, hospitals might have trouble finding doctors willing to provide care.

Meanwhile, insurers and hospitals want to ban out-of-network providers from billing patients for whatever part of the charge the insurer won’t cover, a practice called “balance billing.”

Such bans are anathema to doctors, who instead believe insurers bear responsibility for doctors not being in their networks because they “don’t have an incentive to offer fair rates,” said Kneeley. Although insurers often feel they must contract with specific high-profile hospitals, he explained, the doctors who work there are often “invisible providers.”

Addressing the underlying causes of high health costs, however, will be difficult, said Adler of USC-Brookings.

Doctors want to be paid more than insurers typically offer, he said, which is why some do not join insurance networks. And insurers “want the problems [with surprise bills to patients] to go away.” The question for them, he said, is, “How much are insurers willing to pay to have their patients not get surprise bills?”

In the end, a settlement that eliminates surprise bills but builds the excess into everyone’s premiums doesn’t truly address health care’s spending problem.

“I think there’s a good chance it gets solved,” Adler said, and that lawmakers will eventually agree on a plan. “But I’m pessimistic it gets solved in a way” that deals with health care’s high costs.

KHN senior correspondent Fred Schulte contributed to this report. 

State Bans Pesticide Linked To Developmental Problems

California will ban the use of a widely used pesticide in the face of “mounting evidence” that it causes developmental problems in children, state officials announced Wednesday.

Several studies have linked prenatal exposure of chlorpyrifos to lower birth weights, lower IQs, attention deficit hyperactivity disorder and autism symptoms in children.

The chemical is mostly used on crops — including citrus, almonds and grapes — but is also applied on golf courses and in other non-agricultural settings.

The ban “is needed to prevent the significant harm this pesticide causes children, farm workers and vulnerable communities,” Jared Blumenfeld, secretary of the California Environmental Protection Agency (CalEPA), said in a statement.

California’s ban comes as federal regulators fight to keep the chemical on the market.

Almost two decades ago, the U.S. Environmental Protection Agency, which regulates pesticides at the federal level, prohibited the sale of chlorpyrifos for residential use.

But under the Trump administration, the agency rejected a proposal to ban its use altogether, ignoring the recommendations of its own scientists. It continues to defend the use of chlorpyrifos in court.

Some states aren’t waiting for the federal government to act, California Healthline reported last month. The New York legislature last week sent a proposed ban to Democratic Gov. Andrew Cuomo for consideration. A bill in the California legislature to ban chlorpyrifos was pending at the time of the CalEPA’s announcement. Oregon and Connecticut lawmakers also are considering bans.

Hawaii was the first state to enact a state ban last year.

“Because the science is pretty clear that this a dangerous chemical, it’s long past time to get it off the market,” said Virginia Ruiz, director of occupational and environmental health at the Washington, D.C.-based nonprofit Farmworker Justice. “There’s momentum now, and people and policymakers are becoming better educated about chlorpyrifos.”

Chlorpyrifos can be inhaled during application and as it drifts into nearby areas or ingested as residue on food. People also can be exposed through drinking water if their wells have been contaminated by it.

Globally, several companies make chlorpyrifos products. In the U.S., the most recognized brand names are Dursban and Lorsban, manufactured by Corteva Agriscience, formerly known as Dow AgroSciences.

Corteva Agriscience did not respond to requests for comment.

California citrus growers are among the groups that oppose the ban. They worry that eliminating chlorpyrifos could result in disease outbreaks among their fruit trees.

Casey Creamer, president of California Citrus Mutual, pointed to the Asian citrus psyllid, a tiny insect that feeds on citrus leaves that can transmit a disease known as Huanglongbing, or citrus greening, as one risk.

“The impacts are potentially significant,” he said. If farmers “don’t have the tools to effectively manage the psyllid, people are going to switch out or stop growing citrus.”

Implementing the ban in California could take up to two years as the state wades through the administrative process and tries to find safer options, CalEPA said in its announcement.

On Thursday, Democratic Gov. Gavin Newsom is expected to propose $5.7 million as part of his 2019-20 budget to support the transition to “safer, more sustainable alternatives,” the announcement said.

The agency added that its decision to ban chlorpyrifos “follows mounting evidence … that the pesticide causes serious health effects in children and other sensitive populations,” even at low levels of exposure.

The California Farm Bureau Federation warned that food may get pricier as a result of the ban, leaving state residents more dependent on produce grown in states with less stringent regulations.

“Protecting our food supply, rural economy and the many jobs that depend on California agriculture will require state agencies to be open-minded and realistic in evaluating ways to fight pests and plant diseases,” said Jamie Johansson, the federation’s president.

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

Podcast: KHN’s ‘What The Health?’ ‘Conscience’ Rules, Rx Prices and Still More Medicare

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

In a new set of rules, the Trump administration wants to let not just doctors but almost any health care worker or organization decline to provide, participate in or refer patients for any health service that violates their conscience or religion.

Also this week, the Trump administration is ordering prescription drugmakers to include list prices in their television ads for nearly all products.

And there’s yet another entry in the growing group of bills aimed at overhauling the nation’s health system. This one is “Medicare for America.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Jen Haberkorn of the Los Angeles Times and Alice Miranda Ollstein of Politico.

Also, Rovner interviews Joan Biskupic, author of “The Chief: The Life and Turbulent Times of Chief Justice John Roberts.” Biskupic talks about the behind-the-scenes negotiations that led to the 2012 decision upholding the constitutionality of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • Robert Pear, who died this week, was the dean of health policy reporters and will be remembered not just for the many front-page stories he produced for The New York Times, but also as a generous and kind colleague who helped mentor many reporters new to the beat.
  • The Trump administration’s announcement last week of new regulations to protect health care workers from having to do anything they believe violates their religious beliefs is a stronger policy than past Republicans have adopted. But it follows other efforts to expand past conservative policies, such as the current administration’s more stringent Title X family planning rules.
  • The administration’s new rule requiring drugmakers to add list prices to their TV ads could confuse some consumers, since few of them actually pay that price. Their insurers often negotiate better prices, and other factors, such as geography and type of pharmacy, affect the consumer’s bottom line.
  • President Donald Trump this week told Health and Human Services officials to work with Florida on its plan to import drugs from Canada to take advantage of lower prices there. HHS Secretary Alex Azar said he would see if it can be done without jeopardizing the safety of the drugs. That is the rub that his predecessors have used to stop importation efforts, dating to the 1990s.
  • The increasing interest in Democratic proposals such as “Medicare for All,” which would set up a government-run health care system, and “Medicare for America,” which would offer a government-run option for consumers and businesses, suggests that a public option is not the political hot potato it was during the debate setting up the ACA. It’s also not clear whether consumers are ready to give up their current insurance.
  • Tennessee is getting ready to ask federal officials for a major change in its Medicaid system. The state wants to switch to a block grant, in which its federal funding would be limited but would come with much more flexibility for spending. The proposal is likely to end up in court because advocates for the poor argue the change would cut off services to some people and would violate laws that have defined Medicaid.

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

Julie Rovner: CNBC’s “Insiders Describe Aggressive Growth Tactics at uBiome, the Health Start-Up Raided by the FBI Last Week,” by Christina Farr, and “Health Tech Start-Up uBiome Suspends Clinical Operations Following FBI Raid,” by Christina Farr and Angelica LaVito

Joanne Kenen: ProPublica and the New Yorker’s “The Birth-Tissue Profiteers,” by Caroline Chen

Jen Haberkorn: The Los Angeles Times’ “Health Insurance Deductibles Soar, Leaving Americans With Unaffordable Bills,” by Noam N. Levey

Alice Miranda Ollstein: Bloomberg News’ “Trump May Redefine Poverty, Cutting Americans From Welfare Rolls,” by Justin Sink

To hear all our podcasts, click here.

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All That Political Uncertainty Over The Health Law Gave Insurers Some Of Their Best Financial Annual Performances Yet

Last year stood as the best financially for insurers in the individual market since 2011, with monthly average individual market gross margins per member more than doubling from $78 in 2017 to $167 in 2018. In other health industry news: the Elizabeth Holmes trial, health care claims, the False Claims Act, public health and TV shows, apps and more.

Mississippi Prison Reforms Have Been Touted As A Model To Follow, But In Reality They’ve Been Mostly Broken Promises

Mississippi vowed to take steps to help prisoners better prepare for life outside bars, send offenders to drug courts for treatment rather than to prison, and to help keep offenders guilty of technical probation violations from returning to prison, among other things. But none of that has happened.

Family Of Robert F. Kennedy Jr. Publicly Chastise Him For Disseminating ‘Dangerous Misinformation’ About Vaccinations

Robert F. Kennedy Jr.’s sister, brother and niece wrote an op-ed piece that denounces Kennedy’s stance on immunizations. “On this issue, Bobby is an outlier in the Kennedy family,” they wrote. Kennedy is chairman of the board of Children’s Health Defense, a groups that’s website links to information and videos that blame vaccines for food allergies and claim that vaccines against diphtheria, pertussis and tetanus are killing people. Other news on vaccinations comes out of California, Kentucky, Texas and Oregon.

Needle Exchanges Find New Champions Among Republicans

Once repellent to conservative politicians, needle exchanges are now being endorsed and legalized in Republican-controlled states.

At least four legislatures have considered bills to allow hypodermic needle exchanges, and two states, Georgia and Idaho, made them legal this year. In each of these states, the House and Senate are controlled by Republicans and the governor is a Republican.

Florida, Missouri, Iowa and Arizona have introduced bills this legislative session that would allow needle exchanges in their state. The measures were all sponsored or co-sponsored by Republicans.

As much as this has been a series of victories for public health officials who see how needle exchanges — also called syringe exchanges — stymie the spread of blood-transmitted diseases, it has been a triumph of public health policy research. For years, research has shown the benefit of needle exchanges, but now that the opioid epidemic and infectious diseases have affected their own communities, lawmakers are listening.

“The reality is maybe 10 or 15 years ago this wasn’t where Georgia was,” said Republican state Rep. Houston Gaines, the sponsor for Georgia’s needle-exchange law. “But the medical and science community has shown that this works. My hope is as Republicans, we can always be willing to embrace programs and ideas if they’re proven to work.”

Republicans have not always held this mindset.

Needle-exchange programs, pioneered in Amsterdam in 1983, allow individuals to get sterile needles free of charge and safely dispose of dirty needles and syringes used for drug injection. The programs have been proved to reduce the risk of getting and transmitting HIV, viral hepatitis and other bloodborne infections through sharing needles.

Syringe exchange programs also give public health officials an opportunity to offer educational and medical services, such as referrals to substance use disorder programs and HIV or hepatitis testing.

Currently, 28 states and the District of Columbia allow needle exchanges.

In 1988, Tacoma, Wash., established the nation’s first exchange program and with it came Republican opposition. North Carolina Republican Sen. Jesse Helms led Congress in banning the use of federal funds for needle-exchange programs that year. An ultra-conservative, Helms said allowing needle exchanges was the same as the government saying, “It’s not only all right to use drugs, but we’ll give you the needles.”

Despite the federal government refusing to fund research on the exchange programs, public health evidence of their effectiveness started to stack up, as did the number of states allowing the programs.

Multiple studies found that exchanges reduced the spread of hepatitis B, hepatitis C and HIV. These programs could also be cost-effective; a 2014 study found that for every dollar invested in expanding a needle exchange, $6 could be saved in HIV treatment. Other research found that going to an exchange program led drug users to enroll in substance abuse treatment programs.

The tipping point for many Republicans, however, came in a 2015 HIV outbreak related to the injection-drug epidemic in Scott County, Ind., a strong GOP state. In a matter of months, more than 150 people were newly diagnosed with HIV in a rural county with 24,000 residents.

Mike Pence, then the governor and now the vice president, was initially opposed to needle-exchange programs. Two months after the HIV outbreak was detected, Pence declared a public health emergency and allowed a limited needle exchange in Scott County.

Pence’s White House staff did not respond to several requests for comment.

Asal Sayas, director of government affairs at amfAR, the Foundation for AIDS Research, said this was a critical moment for Republicans with rural constituents. “A lot of communities realized they were also vulnerable and had situations similar to Scott County, where there was minimal HIV care and no syringe exchange,” said Sayas.

The syringe exchange in Scott County was effective, and it had a ripple effect.

An analysis by amfAR found that after Scott County’s needle-exchange program, the number of exchange programs across the country spiked. The organization’s most recent count is at 320.

Other Republican-leaning states also passed legislation allowing needle exchanges — Kentucky and Ohio in 2015, North Carolina in 2016 and Louisiana, North Dakota, Tennessee and Virginia in 2017.

Though critics said Pence waited too long to implement the program, the move has been hailed by conservative state lawmakers who in the ensuing years began supporting needle-exchange programs.

Attitudes among Republicans on the federal level are also shifting.

In December 2015, three congressional Republicans from states hit hard by the opioid crisis, Sen. Shelley Moore Capito of West Virginia and Senate Majority Leader Mitch McConnell and Rep. Hal Rogers, both of Kentucky, inserted language into an omnibus spending bill that partially repealed the federal funding ban. That provision allows federal dollars to be used for operating needle-exchange program operations, just not for the drug-injection devices themselves.

Following President Donald Trump’s recent announcement that he wants to end the HIV epidemic, Secretary of Health and Human Services Alex Azar expressed his support for needle exchanges. “Syringe-services programs aren’t necessarily the first thing that comes to mind when you think about a Republican health secretary, but we’re in a battle between sickness and health, between life and death,” Azar said at the National HIV Prevention Conference in Washington in March. “The public health evidence for targeted interventions here is strong.”

AmfAR’s Sayas said it’s important to remember how effective needle exchanges could be in achieving Trump’s HIV goals. “The administration’s plan targets 48 counties with high HIV diagnoses and seven states with a high rural burden of HIV,” said Sayas. “In six of those seven rural states, needle exchanges are illegal. If we’re serious about wanting this plan to work, we need to consider that.”

Despite the movement among some Republicans to accept needle exchanges, 13 states still have laws that make them illegal. All of those have Republican governors and Republican-majority legislatures, except for Kansas, which has a Democratic governor.

Nine states have either no law that prohibits syringe programs or only locally permitted needle exchanges, which means that it is up to each city or county to decide whether to operate needle exchanges.

In states that have given localities control of needle-exchange programs, there has been some movement to shut down the programs. Charleston, W.Va., suspended its needle exchange in 2018 after law enforcement officers complained about needles littering the streets and the mayor joined the opposition. Two programs in Indiana shut down in 2017 because of local opposition, although one has since reopened through a nonprofit health center.

Republican Rep. Ed Clere was one of the authors of Indiana’s needle-exchange legislation. He said local control of the needle exchanges often means decisions now play out among local conservative lawmakers.

“I don’t want you to think that I don’t like local approval. It’s just the way the approval process works, it just tends to be very political,” Clere said in an interview. “The people who make the decision, the commissioners, don’t have medical or research background. Instead of talking about the research evidence, the discussion ends up being about needles on playgrounds or drug use, which is just not useful.”

Three Board Members of Maryland Medical System Resign As Second Contract Adds To ‘Health Holly’ Kickbacks Scandal

Following the resignation of Baltimore Mayor Catherine Pugh for her alleged financial ties to medical firms, the board chairman of the University of Maryland Medical System and two other board members resigned Tuesday, including Dr. Scott Rifkin. His firm had an “active agreement” with the hospital providing software.

Just Weeks After Columbine Anniversary, Colorado School Shooting Leaves 1 Student Dead, 8 Wounded

Sheriff Tony Spurlock of Douglas County said the suspects, who were armed with a handgun and other weapons, confronted law enforcement officers when they arrived, but that they were not injured. Spurlock said neither suspect had been on law enforcement’s radar before the shooting and that the motive was unknown.

Federal Regulations Weren’t The Reason Insurers Shied Away From Selling Over State Lines, Health Companies Say

CMS wants to make it easier for insurers to sell across state lines, but those companies say it’s not regulations that are stopping them. “These states have each taken a different approach, none of which has, to date, resulted in insurers offering comprehensive health insurance in a state in which it is not licensed,” the National Association of Insurance Commissioners said in a comment letter. “This shows that the impediments to interstate sales are not in federal law but are inherent in the business of health insurance.” In other health law and insurance news: accountable care organizations, preexiting conditions protections, and enrollment.

Candidates Should ‘Be Honest’ With Voters About Harsh Realities Of ‘Medicare For All,’ 2020 Hopeful Sen. Bennet Says

Sen. Michael Bennet (D-Colo.) says his opponents need to tell Americans the truth about the negative sides of “Medicare for All.” Bennet and Sen. Tim Kaine (D-Va.) rolled out their “Medicare X” plan last month that would allow for a public health care option, modeled after Medicaid, to be made available alongside private insurance. Politico looks at where all the candidates stand on universal health care, among other things.