FDA approved the first nonprescription, “over-the-counter” naloxone nasal spray, Narcan

Dr. Sara McLin thought she made the right choice by going to an in-network emergency room near her Florida home after her 4-year-old burned his hand on a stove last Memorial Day weekend.

Her family is insured through her husband’s employer, HCA Healthcare, a Nashville-based health system that operates more hospitals than any other system in the nation. So McLin knew that a nearby stand-alone emergency room, HCA Florida Lutz Emergency, would be in their plan’s provider network.

But McLin said a doctor there told her she couldn’t treat her son, Keeling, because he had second- and third-degree burns that needed a higher level of care. The doctor referred them to the burn center at HCA Florida Blake Hospital, about a 90-minute drive away.

McLin, who is a dentist, said the doctor told her the stand-alone ER would not charge for the visit because they did not provide treatment.

“I don’t remember exactly how she phrased it. But something along the lines of, ‘Well, we won’t even call this a visit, because we can’t do anything,’” McLin said.

At Blake Hospital, she said, a doctor diagnosed Keeling with a second-degree burn, drained the blisters, bandaged his hand, and sent them home with instructions on how to care for the wound.

“I didn’t think anything more of it,” McLin said.

Then the bills came.

The Patient: Keeling McLin, now 5, is covered by UnitedHealthcare through his father’s employer.

Medical Service: At the stand-alone emergency room, a physician assessed Keeling and sent him to another facility for treatment. “Keeling needs a burn center,” the doctor wrote in the record of his visit.

Service Provider: Envision Physician Services, which employed the emergency room physician at HCA Florida Lutz Emergency in Lutz, Florida, near Tampa, and HCA Florida Trinity Hospital, the main, for-profit hospital to which the stand-alone emergency room belonged.

Total Bill: For the emergency room visit, Envision Physician Services billed $829 to insurance and about $72 to the family. HCA Florida Trinity Hospital billed Keeling about $129, noting it had applied an “uninsured discount.” An itemization showed the original charge had been nearly $1,509 before adjustments and discounts.

What Gives: The stand-alone emergency room and ER doctor, who saw Keeling but referred him to another hospital, billed for his visit. But McLin soon learned she was unable to dispute some of the charges — because her young child’s name was on one of the bills, not hers.

Months after the ER visit, McLin received a bill addressed to the “parents of Keeling McLin” from Envision Physician Services, the provider staffing service that employed the ER doctor at Lutz. McLin recalled the doctor’s promise that they would not be billed. “I should have made them write something down to that effect,” she said.

She said she called her insurer, UnitedHealthcare, and a representative told her not to pay the bill.

She received an insurance statement that identified the bill from Envision’s doctor — an out-of-network provider working in an in-network emergency room — as a “surprise bill” for which the provider may charge only copays or other cost-sharing costs under federal law. McLin said she had not heard anything since then about the bill.

After being contacted by KHN, Aliese Polk, an Envision spokesperson, said in an email that Envision would waive the debt, apologizing to Keeling’s family “for the misunderstanding.”

She described the ER doctor’s evaluation, determination, and referral as a medical service. She said the bill was for cost sharing for the visit — not the difference between what the doctor charged and what insurance paid, as the law prohibits.

“We recognize the patient’s family may have understood at the time of treatment that there would be no charge for the visit, including the medical service provided by our physician,” Polk said. “Unfortunately, this courtesy adjustment was not captured when the claim was processed.”

Maria Gordon Shydlo, a UnitedHealthcare spokesperson, said the insurer believed the matter had been resolved and did not follow up on requests for an interview, even after McLin waived federal health privacy protections, which would allow the insurer to speak to the reporter about the case.

McLin also received a bill from HCA Florida Trinity Hospital for its stand-alone ER at Lutz and decided to dispute the charges.

But after calling the hospital to appeal, McLin said, the billing department would not discuss the debt with her because the statement was in her young son’s name.

“They had him as the guarantor,” McLin said. Unlike Envision, which billed Keeling’s parents and their insurance, McLin said the hospital listed the child as “unemployed, uninsured.”

The child’s ER record also included his date of birth and doctor’s notes referencing his age. McLin said she wrote to HCA in November asking to appeal the bill and that a billing representative told her over the phone that it would put the debt on hold and review the dispute.

“I never heard anything back and assumed we were good,” McLin said.

Then, in January, she received a letter from Medicredit, a collection agency and an HCA subsidiary, stating that Keeling owed $129 and that he had until mid-February to contest the debt. KHN was unable to make contact with Medicredit representatives, and HCA Healthcare did not respond to requests for comment from its subsidiary.

Once again, Sara McLin’s name was not on the debt collector’s letter, and she said Medicredit representatives refused to discuss the debt with her because it was in her son’s name. She said she called HCA, too. “They said, ‘We can’t help you. We don’t have the case anymore,’” she said.

Erin Fuse Brown, a law professor and director of the Center for Law, Health & Society at Georgia State University, said McLin did everything right and that it is unusual for a parent to be barred from discussing a debt related to their minor child.

“The fact that the hospital wouldn’t even talk to her strikes me as the part that is absurd. It’s absurd as a business matter. It’s absurd as a privacy matter,” Fuse Brown said, adding that federal health privacy laws allow a parent or legal guardian to access their dependent’s medical information.

Fuse Brown said the hospital should have been able to correct the error quickly with more information, such as a birth certificate or other document establishing that McLin was Keeling’s parent. At the very least, she said, it could have given McLin notice before sending the bill to collections.

“You get the feeling that it’s this large, automated process, that there’s no human to get through to, that there’s no human to talk to and override the mistake,” Fuse Brown said. “Maybe it’s routine, but she couldn’t even talk to someone to correct a correctable billing error, and then the system just steamrolls over the patient.”

The Resolution: When the collection agency’s deadline passed without resolution, McLin said she felt frustrated. “Nobody can explain to me who has to approve talking to me,” she said. “I don’t know who that person is or what the process is.”

After KHN contacted the health system, HCA Healthcare canceled the family’s debt. HCA representatives declined to be interviewed on the record despite also receiving a privacy waiver from McLin.

“We have attempted to contact Mrs. McLin to apologize to her for the inconvenience this has caused her and to let her know that there is a zero balance on the account,” Debra McKell, marketing director for HCA West Florida Division, said in an email on March 3. “We also will be sharing with her that we are reviewing our processes to ensure this does not happen again.”

McLin later received a letter from HCA stating that the account had been cleared. She also said she received a call from a customer service representative informing her that the debt had not been reported to any credit agencies.

She said she was pleased, but that patients should not have to struggle to correct a billing error before it is sent to a collection agency and potentially ruins their credit.

“It’s the principle of the thing that’s annoying me at this point,” she said.

The Takeaway: Though the notion of a debt collector pursuing a 4-year-old boy may seem farcical, it happens. When seeking medical care for a minor, it is important for the parent or guardian to ensure their name is listed as the responsible party.

Consumers who find themselves fighting a medical billing error need to “think like a lawyer,” Fuse Brown said, including documenting every interaction with the debt collector, getting any promises in writing, and recording phone calls. (State laws vary about how many parties on a call must give permission to record a conversation.)

Patients do not have to give up once a bill goes to collections, Fuse Brown said. “Once you hear from a debt collector, it’s not like the game is over and you lose,” she said. “Consumers do have rights.”

François de Brantes, a home health company executive and expert on how money flows through the health care system, said that hospital billing errors are not uncommon but that he had never heard of a situation like the one McLin experienced. He called it “puzzling” that HCA would issue a formal claim in a dependent child’s name.

De Brantes said those in a similar situation should also ensure that the collection agency removes any record of a debt against a minor to protect the child’s financial future.

“This stuff happens, where you have children who are improperly billed for stuff that they shouldn’t be billed, and they end up in collection,” he said. “Then the kid finds themselves with a collection record and they can’t get loans in the future, potentially student loans.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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SACRAMENTO, Calif. — Republican lawmakers say that, before California spends even more money battling homelessness, the public deserves to know exactly how the tens of billions of dollars already put toward the epidemic are being spent and whether the state is getting results. Among the GOP lawmakers calling for greater accountability is state Sen. Roger Niello, a businessman who returned to the Capitol in December after a 12-year hiatus.

As a fiscal conservative from the Sacramento suburbs, with more than a decade of experience in local and state politics, Niello wants to work with Democrats. But he characterized the volume of money poured into fighting homelessness in recent years as runaway spending, saying Democratic Gov. Gavin Newsom hasn’t yet proved the money is working adequately to place homeless people into services and permanent housing.

“There’s nothing more urgent for us to address, in some successful way, than homelessness,” Niello told KHN. “But I do believe that just spending money without actually measuring those achievements is generally a waste of money.”

He argues that Newsom and his fellow Democrats, who control the legislature, shouldn’t allocate any more taxpayer funding for homelessness policies unless the state can show that current spending is reducing homelessness. Niello and other Republicans have pushed for an audit of homelessness spending — and this year were joined by some Democratic lawmakers, who increasingly are also calling for more accountability. A legislative committee in late March approved their audit request.

Newsom says that the state has already placed 68,000 homeless people into temporary or permanent housing and that California can reduce homelessness by 15% in two years. Yet more low-income people are falling into homelessness, and many are living with untreated mental health conditions and addiction disorders.

Since Newsom took office in 2019, he and state lawmakers have dedicated more than $20 billion to move people off the streets and into shelters or housing. That’s on top of more than $12 billion in additional state spending slated for new behavioral health and social services, largely aimed at serving vulnerable low-income residents experiencing homelessness or those at risk of falling into crisis on the streets. And Newsom is proposing more spending, including a 2024 ballot initiative that would allocate as much as $6 billion for new behavioral health treatment beds and mental health housing for homeless people.

Niello sees opportunities for bipartisanship on homelessness and behavioral health. The Republican supports one of the governor’s more controversial initiatives, passed last year to compel people with serious mental illness into court-ordered treatment: the Community Assistance, Recovery, and Empowerment Act, or CARE Court. And Niello is working with the Democratic chair of the Senate Health Committee, Sen. Susan Talamantes Eggman, on bills that would expand the state’s ability to put people into court-ordered conservatorships by redefining who is gravely disabled.

Eggman said it’s important to work across the aisle on solutions that can benefit not just seriously mentally ill individuals and their families but also the community.

“The level of vitriol and blame we’re seeing contributes to the angst and anxiety people are feeling,” Eggman said. “It’s important to work with Republicans to alleviate that and help people who are unwilling, or unable, to help themselves.”

Niello, who believes Republicans should work with Democrats to find solutions, discussed the state’s homelessness crisis with KHN senior correspondent Angela Hart. The interview has been edited for length and clarity.

Q: Are Californians seeing the results of this unprecedented investment and how do you think the governor is handling the crisis so far?

What we’re doing is not working. Homelessness has never really existed outside the urban core before. It’s getting worse, not better.

When the governor talks about his efforts on homelessness, he often talks about all of the money that has been spent under his administration. But spending is not a metric. We spent $20 billion, but I can’t find any measure of results that relates the spending on programs showing people actually getting out of homelessness and into supportive programs — or, aspirationally, even, to self-sufficiency. What Republicans would like to see is some measurement of the results.

The problem is we don’t know if it’s being well spent; it appears, based on evidence on the streets, that it’s not being well spent. The homeless counts have increased rather substantially.

If you’re not going to measure results more effectively, you may as well hold back on the money completely until you’re willing to do that.

Q: How can California improve its homelessness response?

One of the problems that we have with homelessness, both federally and in the state of California, is we have a policy called “Housing First,” which was adopted in California in 2016, and it eliminates any public money to any program that requires treatment for the entry to the program, and we’ve only seen the homeless counts explode since then.

It’s hard to deny that there isn’t some relationship there. And I believe there is. I think it’s too restrictive and compromises getting results. Under the Housing First approach, the philosophy is you offer housing and shelter, and you offer services, but don’t require it. And people can stay in the shelter and continue to use substances or not get mental health treatment. I think we should do more to allow for programs that require treatment and sobriety within those programs.

And for the people who have been touched by this dizzying array of different programs, we need to try to assess the successes in terms of getting people into housing, getting people into treatment, and getting people out of homelessness and into self-sufficiency.

Q: Your Senate Bill 232 expands the definition of “gravely disabled” in the context of mental health treatment, which could compel more people into court-ordered conservatorship. Why is this important?

While not all homelessness is caused by substance abuse and mental illness, I think that is probably the largest single contributor. And it is virtually impossible to compel mentally ill people into treatment.

There is a definition of “gravely disabled” in California’s Lanterman-Petris-Short Act that if somebody is gravely disabled, they can be compelled to treatment. But it’s a rather simple and limited definition.

So I have a bill, just like Sen. Susan Eggman has a bill. And we intend to work together in a way that redefines gravely disabled, to include what we think is a better definition of somebody who truly is gravely disabled. It includes redefining it with a clinical condition explaining that somebody is literally severely disabled.

We think that if we have this new definition, then we will be able to compel more people into treatment or, if needed, conservatorship. Then they can work toward a recovery, whereas the alternative is they continue to languish on the streets with a severe and disabling condition.

It is consistent with the governor’s CARE Court initiative that compels treatment for people like those who are homeless living under freeway overpasses or rummaging through garbage cans.

Counties have to provide the services, but they need more money. Here is a fiscally conservative Republican who is going to say that treating mental illness is very expensive. And we have to fund it.

Q: Newsom has called on cities to make more progress on ending homelessness before giving them more money. But separately from direct homelessness funding, you’re saying counties need more money for treatment and services?

We can’t expect counties to be the service delivery of health treatment, which they are, unless they have the resources to provide the service. And I think that with the revised definition of gravely disabled, I think it would be easier for CARE Court to be implemented.

There’s one definition of a good society, and you judge it by how a society takes care of the least advantaged of their citizens. And this is a good example of that, and to allow people to continue to live in unhealthy conditions is going to cause them to die at a much earlier age. So not trying to help is just plain wrong.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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For decades, U.S. hospitals have generally stonewalled patients who wanted to know ahead of time how much their care would cost. Now that’s changing — but there’s a vigorous debate over what hospitals are disclosing.

Under a federal rule in effect since 2021, hospitals nationwide have been laboring to post a mountain of data online that spells out their prices for every service, drug, and item they provide, including the actual prices they’ve negotiated with insurers and the amounts that cash-paying patients would be charged. They’ve done so begrudgingly and only after losing a lawsuit that challenged the federal rule.

How well they’re doing depends on whom you ask.

The rule aims to pull back the curtain on opaque hospital prices that may vary widely by hospital for the same service or even within the same hospital. The expectation is that price transparency will boost competition, giving consumers and employers a way to compare prices and make informed choices, ultimately driving down the cost of care. Whether that will happen is not yet clear.

Insurers and large employers are also required to post their negotiated prices with all their providers, under separate rules that took effect last summer.

Hospitals have made “substantial progress,” according to an analysis by the federal Centers for Medicare & Medicaid Services of 600 randomly selected hospitals that was published in the journal Health Affairs last month. The agency looked at whether hospitals had met their obligation to post price information online in two key formats: a “shoppable” list of at least 300 services for consumers, and a comprehensive machine-readable file that incorporates all the services for which the hospital has standard charges. This file should be in a format that allows researchers, regulators, and others to analyze the data.

CMS found that 70% of hospitals published both lists in 2022. An additional 12% published one or the other. By contrast, the agency’s previous progress assessment in 2021 found that just 27% of 235 hospitals had both types of lists.

The 2022 analysis “represents a marked improvement,” said Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at CMS, in a statement. But she also said the advances are still “not sufficient” and CMS will continue to use “technical assistance and enforcement activity” so that all hospitals “fully comply with the law.”

The American Hospital Association said the CMS assessment demonstrated the progress hospitals had made under very challenging circumstances as they grappled with the covid-19 pandemic.

“These are complicated policies that went into effect in the most complicated time in hospitals’ history,” said Molly Smith, group vice president for policy at the trade association. “And we have seen increases in compliance over the past 18 months.”

Some groups that have looked at the hospitals’ posted price data, though, were less upbeat. In an analysis published last month, Patient Rights Advocate examined 2,000 hospitals’ listings and found that only 489 of them, 24.5% of the total, were compliant with all the requirements of the rule. An earlier analysis in August 2022 found that 16% met all the requirements.

The advocacy group’s analysis covered not only the two types of lists that CMS looked for but also checked whether the hospitals included required data on specific types of standard charges for every service offered, such as the gross or “chargemaster” charge before any discounts are applied, the discounted cash price, and the negotiated charge by insurer.

Although most hospitals have published files online, too often the data is incomplete, illegible, or not clearly associated with specific health plans or insurers, said Cynthia Fisher, founder and chair of Patient Rights Advocate, which promotes health care price transparency.

“As hospitals continue to post incomplete files with swaths of missing prices, patients are unable to accurately compare prices across hospitals and across plans to make the best health care decisions and protect themselves from overcharges,” Fisher said. Such hospitals were considered noncompliant in the PRA analysis.

The hospital association faulted PRA’s analysis. The contracts that hospitals have with health plans vary substantially from one to the next, and prices are not always based on a simple dollar amount, said Terry Cunningham, AHA’s director of policy. They might be based on a bundle of services or on volume, for example, he said.

“It’s both frustrating and problematic for these other organizations to be weighing in, saying, ‘This cell shouldn’t be blank,’” Cunningham said.

In their 2020 lawsuit, hospitals argued that they should not be required to disclose privately negotiated prices, and maintained that doing so would confuse patients and lead to anti-competitive behavior by insurers.

Last summer, price transparency requirements took effect in the health insurance industry as well, complementing and providing a cross-reference tool for what hospitals have posted. The insurer transparency requirements are even broader than those for hospitals: Insurers and self-funded employers must list every negotiated rate they have with every doctor, hospital, and other health care providers.

Some critics charge that data isn’t user-friendly either. Sens. Maggie Hassan (D-N.H.) and Mike Braun (R-Ind.) sent a letter March 6 to CMS Administrator Chiquita Brooks-LaSure encouraging the agency to take steps to close “technical loopholes” such as large files and a lack of standardization that make it difficult to use the data they’re reporting.

That’s where pricing platforms like Turquoise Health come in. The data becoming available from hospitals and insurers is a vast treasure trove the company is mining to devise user-friendly tools that consumers and businesses can use to discover and compare prices.

In its own analysis of how effective hospital price transparency efforts were in 2022’s third quarter, Turquoise Health found that 55% of the more than 4,900 acute care hospitals that posted machine-readable files were “complete,” meaning they posted the cash, list, and negotiated rates for a “significant quantity” of items and services. Twenty-four percent of hospitals were judged to be “mostly complete.” (The analysis didn’t evaluate the second type of posting, the list of shoppable services.)

According to Chris Severn, Turquoise Health co-founder and CEO, the company uses a scoring algorithm of 60 variables to assess how complete a hospital’s file is.

“What you end up with is a more nuanced look at these files that hopefully takes into consideration shades of gray,” Severn said, rather than a simple pass-fail rating.

Regardless of the differences in how the hospital disclosures are evaluated, experts generally agree that CMS should require data be reported in a standardized format for ease of comparison and enforcement. CMS has developed a template, but hospitals aren’t required to use it.

For price transparency to work, enforcement also needs consistent attention, experts say. The Biden administration increased the maximum potential penalty to more than $2 million annually per hospital for 2022. Still, last year CMS penalized just two hospitals for noncompliance even though 30% of hospitals didn’t meet the requirement to post both a machine-readable file of prices as well as a shoppable list.

CMS provided technical assistance to many hospitals to help them come into compliance, said Seshamani, and it also plans stronger enforcement actions.

She said the agency will “continue to expedite” the time frame hospitals have to reach full compliance after submitting a corrective action plan, which indicates they have fallen short on some posting requirements. “CMS also plans to take aggressive additional steps to identify and prioritize action against hospitals that have failed entirely to post files,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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HHS EPA encourage states to use funding to reduce and remove lead

Uno de cada 4 adolescentes en Colorado informó que podía acceder a una pistola cargada en 24 horas, según los resultados de una encuesta publicada el lunes 27 de marzo. Casi la mitad de esos adolescentes dijeron que les tomaría menos de 10 minutos conseguir un arma.

“Eso es tener mucho acceso y en poco tiempo”, dijo Virginia McCarthy, estudiante de doctorado en la Escuela de Salud Pública de Colorado y autora principal de la carta editorial que describe los hallazgos de la investigación publicados en la revista médica JAMA Pediatrics.

Los resultados de la encuesta se publicaron en un momento difícil para los habitantes de Colorado, que hace poco enfrentaron otro tiroteo en una escuela.

El 22 de marzo, un estudiante de 17 años disparó e hirió a dos administradores escolares en la secundaria East High School en Denver. La policía encontró su cuerpo en las montañas al oeste de Denver, en el condado de Park, y confirmó que había muerto de una herida de bala autoinfligida. Otro estudiante de East High School murió de un disparo en febrero mientras estaba sentado en su auto afuera de la escuela.

El tiempo que toma acceder a un arma es importante, dijo McCarthy, especialmente en casos de intento de suicidio, decisiones que para los adolescentes suelen ser impulsivas. En una investigación de personas que intentaron suicidarse, casi la mitad dijo que el tiempo entre pensar en hacerlo y actuar fue menos de 10 minutos.

Al tomar medidas que limiten el acceso a las armas de fuego, como guardar las pistolas bajo llave y descargadas, se extiende el tiempo en que la persona puede actuar por impulso y aumenta la probabilidad de que se arrepienta o de que alguien intervenga.

“La esperanza es comprender el concepto de acceso para alargar ese lapso y mantener a los niños lo más seguros posible”, agregó McCarthy.

Los datos de la investigación provienen del estudio Healthy Kids Colorado, una encuesta realizada cada dos años con una muestra aleatoria de 41,000 estudiantes de escuela media y secundaria. La encuesta de 2021 le hizo la siguiente pregunta a los jóvenes: “¿Cuánto tiempo te llevaría estar listo para disparar un arma cargada sin el permiso de tus padres?”.

En Colorado, los estudiantes indígenas americanos reportaron el mayor acceso a armas cargadas, de un 39%, incluyendo un 18% que dijeron poder obtener un arma en 10 minutos (comparado con el 12% de todos los jóvenes que participaron en la encuesta). Los jóvenes indígenas americanos y nativos de Alaska también tienen las tasas más altas de suicidio.

Casi el 40% de los estudiantes en zonas rurales reportaron tener acceso a armas de fuego, en comparación con el 29% de residentes de ciudades.

Colorado está pasando por una etapa tensa con respecto a la violencia armada entre los jóvenes. A principios de este mes, cientos de estudiantes dejaron sus aulas y caminaron casi 2 millas hasta el Capitolio estatal para abogar por leyes de control de armas y escuelas más seguras. Enfrentaron a los legisladores nuevamente la semana pasada, luego del tiroteo en la escuela secundaria del día 22.

La Legislatura estatal está considerando varios proyectos de ley para prevenir la violencia armada.

Estos incluyen aumentar la edad mínima para comprar o poseer un arma a 21 años; establecer un período de espera de tres días para poder comprar un arma de fuego; limitar las protecciones legales para los fabricantes y vendedores de armas y ampliar el grupo de personas que pueden solicitar órdenes de protección por riesgo extremo para confiscar las armas de personas que están en riesgo de lastimar a otras o de suicidarse.

Según los Centros para el Control y la Prevención de Enfermedades (CDC), en 2020 las armas de fuego fueron la principal causa de muerte entre las personas de 19 años o menores, al superar el número de muertes por accidentes automovilísticos. Y las muertes de niños por armas de fuego aumentaron durante la pandemia, con un promedio de siete niños por día muriendo a causa de un arma, en 2021.

En los últimos 25 años, Colorado ha sufrido una serie de tiroteos en escuelas, incluyendo en Columbine High School en 1999, Platte Canyon High School en 2006, Arapahoe High School en 2013 y STEM School Highlands Ranch en 2019.

Aunque los tiroteos en las escuelas reciben más atención, la mayoría de las muertes de adolescentes por armas de fuego son suicidios.

“El problema del suicidio en los adolescentes es mayor que nunca”, dijo el doctor Paul Nestadt, investigador del Johns Hopkins Center for Gun Violence Solutions. “Esto tiene que ver en parte con el hecho de que cada vez hay más armas accesibles para los jóvenes”.

Si bien la posesión de armas presenta un mayor riesgo de suicidio para todos los grupos etarios, los adolescentes son particularmente vulnerables, dado que las habilidades para controlar los impulsos no suelen estar completamente desarrolladas en sus cerebros.

“Un adolescente puede ser inteligente y saber cómo manejar correctamente un arma de fuego, pero ese mismo adolescente en un momento de desesperación puede actuar impulsivamente sin pensar en las consecuencias”, dijo la doctora Shayla Sullivant, psiquiatra de niños y adolescentes en el hospital infantil Children’s Mercy Kansas City. “Las áreas del cerebro que se ocupan de tomar decisiones no están completamente maduras hasta la adultez”.

Otras investigaciones han demostrado que los padres y sus hijos tienen distintas ideas sobre el acceso a las armas de fuego en el hogar. Un estudio de 2021 indicó que el 70% de los padres que tienen armas en sus casas piensan que sus hijos no pueden agarrarlas, pero el 41% de los niños de esas mismas familias dijeron que podrían conseguir esas armas en dos horas.

“Hacer que las armas sean inaccesibles no significa solo bloquearlas. Significa asegurarse de que el niño no sepa dónde están las llaves o no pueda adivinar la combinación”, dijo Catherine Barber, investigadora principal del Harvard Injury Control Research Center de la Escuela de Salud Pública TH Chan de la Universidad de Harvard. “Los padres se olvidan con qué facilidad sus hijos pueden adivinar la combinación o verlos ingresar los números, o ver dónde se guardan las llaves”.

Si un adolescente tiene sus propias armas para la caza o el deporte, estas también deben mantenerse bajo el control de los padres cuando no se están usando, dijo.

El próximo paso de los investigadores de Colorado será indagar más a fondo para entender en dónde los adolescentes están consiguiendo armas, para poder adaptar las estrategias de prevención a distintos grupos de jóvenes.

“Al darle un poco más de contexto a estos datos, podremos comprender mejor qué tipos de educación y prevención se pueden implementar”, dijo McCarthy.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A U.S. lawmaker is taking action after a KHN investigation exposed weaknesses in the federal system meant to stop repeat Medicare and Medicaid fraud and abuse.

Rep. Lloyd Doggett (D-Texas) said he decided to introduce a bill in the House late last week after KHN’s reporting revealed what he called a “shocking loophole.”

“The ability of fraudsters to continue billing Medicare for services is outrageous,” Doggett said. “This is an obvious correction that is needed to safeguard our system. Wherever there are large amounts of government money available, someone tries to steal it.”

KHN found a laundry list of weaknesses that allows people accused or convicted of fraud to easily sidestep bans imposed by federal officials. Among those gaps is the Centers for Medicare & Medicaid Services’ lack of authority to deny or revoke National Provider Identifier, or NPI, numbers after federal regulators have prohibited a person or business from receiving payments from government programs.

Doctors, nurses, other practitioners, and health businesses use the unique, 10-digit NPI numbers to bill and file claims with insurers and others, including Medicare and Medicaid.

Taking away the NPI would “be equivalent of prohibiting a practitioner from practicing in total,” Dara Corrigan, director of CMS’ Center for Program Integrity, wrote in an email response to questions about KHN’s investigation. CMS declined to comment on Doggett’s proposed legislation.

The bill, HR 1745, would give CMS the authority to deactivate NPIs tied to anyone convicted of waste, fraud, or abuse and whose name appears on the exclusions list kept by the Office of Inspector General for the U.S. Department of Health and Human Services. The proposed law would also require CMS to implement recommendations that the inspector general has made to improve NPI reporting and provider transparency.

“This strikes me as what should be an easy bipartisan measure,” Doggett said, adding that he had presented the bill in a face-to-face meeting with Rep. Jason Smith (R-Mo.), who chairs the House Ways and Means Committee. Doggett also alerted that panel’s health subcommittee chair, Rep. Vern Buchanan (R-Fla.).

“They both talk about the need to eliminate fraud, and this is one modest but important way to do it,” Doggett said. Neither Smith’s nor Buchanan’s offices responded to requests for comment.

The OIG declined to comment.

Former Justice Department officials told KHN that repeat violators are savvy and find ways to circumvent the system. KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on the OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents.

KHN found:

• Eight people appeared to be serving or served in roles that could violate their bans;
• Six transferred control of a business to family or household members;
• Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system;
• And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion.

Doggett’s bill is “a pretty smart step in the right direction in fixing this issue,” said John Kelly, a former assistant chief of health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg. Kelly had previously recommended that NPIs should be “essentially wiped clean” when a person is on the exclusions list.

Kelly, who confirmed that Doggett’s office reached out to him after KHN’s investigation was published in December, said taking the NPI number away “certainly doesn’t eliminate all risk” but it’s a move “in the right direction.”

“If you want to bill Medicare, you have to have a valid NPI,” Kelly said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Community wellness grants to Ohio following train derailment

One in 4 Colorado teens reported they could get access to a loaded gun within 24 hours, according to survey results published Monday. Nearly half of those teens said it would take them less than 10 minutes.

“That’s a lot of access and those are short periods of time,” said Virginia McCarthy, a doctoral candidate at the Colorado School of Public Health and the lead author of the research letter describing the findings in the medical journal JAMA Pediatrics.

The results come as Coloradans are reeling from yet another school shooting. On March 22, a 17-year-old student shot and wounded two school administrators at East High School in Denver. Police later found his body in a nearby park and confirmed he had died from a self-inflicted gunshot wound. Another East High student was fatally shot in February while sitting in his car outside the school.

The time it takes to access a gun matters, McCarthy said, particularly for suicide attempts, which are often impulsive decisions for teens. In research studying people who have attempted suicide, nearly half said the time between ideation and action was less than 10 minutes. Creating barriers to easy access, such as locking up guns and storing them unloaded, extends the time before someone can act on an impulse, and increases the likelihood that they will change their mind or that someone will intervene.

“The hope is to understand access in such a way that we can increase that time and keep kids as safe as possible,” McCarthy said.

The data McCarthy used comes from the Healthy Kids Colorado Study, a survey conducted every two years with a random sampling of 41,000 students in middle and high school. The 2021 survey asked, “How long would it take you to get and be ready to fire a loaded gun without a parent’s permission?”

American Indian students in Colorado reported the greatest access to a loaded gun, at 39%, including 18% saying they could get one within 10 minutes, compared with 12% of everybody surveyed. American Indian and Native Alaskan youths also have the highest rates of suicide.

Nearly 40% of students in rural areas reported having access to firearms, compared with 29% of city residents.

The findings were released at a particularly tense moment in youth gun violence in Colorado. Earlier this month, hundreds of students left their classrooms and walked nearly 2 miles to the state Capitol to advocate for gun legislation and safer schools. The students returned to confront lawmakers again last week in the aftermath of the March 22 high school shooting.

The state legislature is considering a handful of bills to prevent gun violence, including raising the minimum age to purchase or possess a gun to 21; establishing a three-day waiting period for gun purchases; limiting legal protections for gun manufacturers and sellers; and expanding the pool of who can file for extreme risk protection orders to have guns removed from people deemed a threat to themselves or others.

According to the federal Centers for Disease Control and Prevention, firearms became the leading cause of death among those ages 19 or younger in 2020, supplanting motor vehicle deaths. And firearm deaths among children increased during the pandemic, with an average of seven children a day dying because of a firearm incident in 2021.

Colorado has endured a string of school shootings over the past 25 years, including at Columbine High School in 1999, Platte Canyon High School in 2006, Arapahoe High School in 2013, and the STEM School Highlands Ranch in 2019.

Although school shootings receive more attention, the majority of teen gun deaths are suicides.

“Youth suicide is starting to become a bigger problem than it ever has been,” said Dr. Paul Nestadt, a researcher at the Johns Hopkins Center for Gun Violence Solutions.

“Part of that has to do with the fact that there’s more and more guns that are accessible to youth.”

While gun ownership poses a higher risk of suicide among all age groups, teens are particularly vulnerable, because their brains typically are still developing impulse control.

“A teen may be bright and know how to properly handle a firearm, but that same teen in a moment of desperation may act impulsively without thinking through the consequences,” said Dr. Shayla Sullivant, a child and adolescent psychiatrist at Children’s Mercy Kansas City. “The decision-making centers of the brain are not fully online until adulthood.”

Previous research has shown a disconnect between parents and their children about access to guns in their homes. A 2021 study found that 70% of parents who own firearms said their children could not get their hands on the guns kept at home. But 41% of kids from those same families said they could get to those guns within two hours.

“Making the guns inaccessible doesn’t just mean locking them. It means making sure the kid doesn’t know where the keys are or can’t guess the combination,” said Catherine Barber, a senior researcher at the Harvard University T.H. Chan School of Public Health’s Injury Control Research Center, who was not involved in the study. “Parents can forget how easily their kids can guess the combination or watch them input the numbers or notice where the keys are kept.”

If teens have their own guns for hunting or sport, those, too, should be kept under parental control when the guns are not actively being used, she said.

The Colorado researchers now plan to dig further to find out where teens are accessing guns in hopes of tailoring prevention strategies to different groups of students.

“Contextualizing these data a little bit further will help us better understand types of education and prevention that can be done,” McCarthy said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing “988,” or the Crisis Text Line by texting “HOME” to 741741.

In the weeks after Stanford University soccer goalie Katie Meyer, 22, died by suicide last March, her grieving teammates were inseparable even when not training.

Coaches adjusted practices to give the athletes time and space to make sense of losing their friend and team captain. They offered to cancel the spring season, but the players declined, said Melissa Charloe, who started as a Stanford assistant women’s soccer coach the day Meyer died.

“It’s hard because there’s no playbook on how to do this,” Charloe said.

No playbook exists because, until recently, it was relatively uncommon for student-athletes to die by suicide. But at least five NCAA athletes, including Meyer, ended their lives in a two-month period last year. And a 2021 NCAA poll released in May found that student-athletes say they are experiencing more mental health concerns, anxiety, and depression than they reported in surveys conducted before the covid-19 pandemic took hold in 2020.

Suicide is the second-leading cause of death on college campuses. And despite the overall rise in mental health concerns there, universities have been caught off guard when student-athletes have died by suicide. Traditionally, sports psychologists focused on mental health as it related to performance on the field. Their goal was to help athletes improve physically — jump higher, run faster — not navigate mental health crises, largely because of a misperception that college athletes were less susceptible to mental health concerns.

What little research exists about student athletes and mental health is inconsistent and inconclusive. But many experts thought athletes were insulated from risk factors such as depression and social isolation, in part because physical activity is good for mental health and athletes have a steady stream of people around them, including coaches, trainers, and teammates, said Kim Gorman, director of counseling and psychological services at Western Carolina University.

“They’re kind of used to pain — it’s not so foreign to them,” added organizational psychologist Matt Mishkind, deputy director of the Helen and Arthur E. Johnson Depression Center at the University of Colorado’s Anschutz Medical Campus.

Still, athletes face pressures that their peers in the general student population don’t, such as balancing sports, schoolwork, fears of career-ending injuries, and mistakes that can lead to ridicule that gets amplified on social media. With suicide rates in the general population on the rise and the effects of the pandemic continuing to threaten well-being, high-profile suicides highlight how to deal with the unthinkable — and how to try to prevent it from happening again.

In the wake of such suicides, schools are reevaluating the kind of mental health support they provide. Creating a safe space to talk about grief with someone who understands suicide is a critical first step, said psychologist Doreen Marshall, a vice president at the American Foundation for Suicide Prevention.

“Many professionals are good with grief, but suicide grief can be a little different,” she said, as it often involves guilt and questions about why someone would end their life.

Gina Meyer, Katie’s mother, and her husband, Steve, have developed an initiative, Katie’s Save, to ensure that all students have a trusted advocate to turn to in times of trouble. “We know that the bravest thing you can do is ask for help,” she said.

The Meyers filed a wrongful death lawsuit against Stanford in November alleging that their daughter ended her life after receiving an email from the university about disciplinary action against her. Stanford University spokesperson Dee Mostofi did not answer questions about the case, but Stanford posted a statement on its website saying the Meyers’ suit contains misleading information and the school disagrees with their allegations that it is responsible for Katie’s death.

“Like other colleges and universities across the country, Stanford has seen a sharp increase in demand for mental health counseling and other well-being resources over the last two years,” Mostofi said. “Mental health remains not only an ongoing challenge but our most urgent priority.”

After Meyer died, Stanford provided mental health counselors and a sports psychologist to her teammates, but the players said they lobbied the university to pay for Zoom sessions with a specialist, Kimberly O’Brien, a clinical social worker in the Sports Medicine Division’s Female Athlete Program at Boston Children’s Hospital.

O’Brien has professional and personal experience dealing with sports and suicide: She was an ice hockey player at Harvard in 1998 when one of the athletes in her university house died. “I wasn’t even extremely close to her, but it affected me profoundly,” she said. “There were no resources to deal with it.”

That’s changing. Colleges are trying to hire more mental health therapists to meet increasing and varied needs. Some, including Stanford and Washington State University, are working with The Jed Foundation, which provides suicide prevention programming for high school and college students. And crisis support doesn’t happen just in the student health center: Colleges are establishing campus-wide “postvention” programs to prevent suicide contagion.

Before cross-country runner Sarah Shulze, 21, died by suicide at the University of Wisconsin-Madison in April 2022, the athletics department was expanding its professional mental health support from two staffers to six to help the school’s approximately 800 student-athletes, said David Lacocque, the department’s director of mental health and sport psychology. The department, known until eight months ago as “clinical & sport psychology,” changed its name in part because student-athletes were asking for mental health support.

In addition to scheduled appointments, the sports liaisons attend practices, team meetings, training sessions, and competitions to help normalize mental health concerns.

“Gone are the days when we sit in our office and wait for people to knock on the door and talk to us,” Lacocque said.

Student-athletes can also seek free help from the university’s mental health professionals or providers in the community under contract with the University of Wisconsin athletics department. And some women’s cross-country athletes at the school now keep an eye on their teammates when coaches aren’t around, letting the team’s liaison know if they’re concerned about someone’s mental health.

“We don’t want anyone slipping between the cracks,” said teammate Maddie Mooney. “It’s a hard time for everybody, and everybody grieves at different paces and processes things differently.”

Teammate Victoria Heiligenthal, who shared a house with Shulze, said she avoided talking to campus counselors for months after her close friend died. “I only wanted to be alone or be with my friends who really understood the situation,” she said.

Heiligenthal couldn’t bear to stay in the home where she and Shulze had lived, so the university put her and Mooney up in a hotel for a week, and then she stayed awhile at Mooney’s apartment. Once back in her own place, teammates, coaches, training staff, and psychologists checked in on her and Mooney.

But the real game changer for the two was connecting last spring with Stanford soccer players Sierra Enge and Naomi Girma (who now plays professionally). Enge reached out after seeing something Mooney posted on Instagram. Since then, the four have met via Zoom. They have also talked with O’Brien and will join her on a mental health panel at a conference in Boston in June to talk about their experiences of losing a teammate to suicide.

“It was powerful hearing the parallels,” Heiligenthal said. “It made you realize Maddie and I weren’t alone; there were others who were experiencing similar things to us.”

At the University of Wisconsin-Madison and Stanford, athletes honored their late teammates last fall by raising mental health awareness. At a major meet in October, the Wisconsin runners painted green ribbons on the course, put ribbons in race packets, and contributed to a video. At Stanford’s game against UCLA in November, spectators wore green ribbons to highlight the importance of addressing mental health issues.

Stanford won the game, handing UCLA its first loss of the season. The victory was bittersweet. A year earlier, Meyer had spearheaded the team’s first mental health awareness game.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Dr. Jacqui O’Kane took a job with a hospital in southern Georgia in 2020, as the lone doctor in a primary care clinic in a small town that’s a medically underserved area. She soon attracted nearly 3,000 patients.

But she said the hospital pressed her to take more new patients, so she had to work nights and weekends — not ideal for the mother of two young daughters. She thought about opening her own practice in town, which would give her more control over her schedule.

The problem was that her three-year contract included a noncompete clause barring her from practicing within 50 miles of the hospital for two years after it ended.

So, she has decided to join a practice in South Carolina. That means she and her husband will sell their house, move hundreds of miles, and enroll their children in a new school.

“It sucks,” she said. “I know my patients very well, and I feel like I’m being forced to abandon them. But I can’t stay in this job because it’s unhealthy for me to work this much.”

In January, the Federal Trade Commission proposed to end predicaments like O’Kane’s by prohibiting noncompete clauses in employment contracts. “The freedom to change jobs is core to economic liberty and to a competitive, thriving economy,” said Lina Khan, the FTC chairperson.

The proposed rule would prohibit employment contract provisions that block employees or contractors from working for a competing employer when they move on, or from starting a competing business. Such contracts typically bar people from working within a certain geographic area for a period after the job ends.

The FTC estimates that 30 million workers are bound by noncompete clauses. It says ending those provisions would boost economic competition, reduce prices, and increase workers’ earnings overall by up to $296 billion a year.

Eliminating noncompete contracts would allow doctors to practice wherever their services are needed, which would improve patients’ access to care. They say it would free them to speak out about unsafe conditions for patients, since they wouldn’t have to worry about getting fired and not being able to continue working in their community.

But the FTC’s proposal faces resistance from employers in all industries, including hospitals and private equity-backed medical groups that employ thousands of physicians, nurse practitioners, and other medical professionals.

It’s about money for them, too. They say eliminating noncompetes would drive up the cost of hospital care because hospitals would have to pay physicians more to keep them. They also say noncompete clauses are necessary to protect proprietary information and investments in employee training, and to prevent employees from taking clients and patients with them when they leave.

Business and hospital groups are likely to sue to block the rule, arguing that Congress hasn’t authorized the commission to regulate noncompete clauses. While there is bipartisan support in Congress for legislation that would restrict noncompete clauses and authorize FTC action, the bill hasn’t advanced; similar legislation stalled in past years.

Health care industry groups hope to block any change with the argument that the FTC lacks statutory authority to regulate nonprofit, or tax-exempt, hospitals, which account for nearly 60% of all U.S. community hospitals. In the proposed rule, the FTC acknowledged that entities not conducting business for profit may not be subject to the rule because they are exempt from coverage under the Federal Trade Commission Act, the law that gives the agency its authority.

“The rule would create an unlevel playing field because we compete with nonprofit and public hospitals that wouldn’t be subject to it,” said Chip Kahn, CEO of the Federation of American Hospitals, which represents for-profit hospital systems.

But other experts aren’t sure the FTC lacks authority over nonprofits. While the FTC Act exempts nonprofits, the commission has acted many times under the Sherman Act and the Clayton Act, federal antitrust laws used to block anti-competitive conduct by nonprofit hospital systems. It’s not clear whether the FTC will clarify this issue before it finalizes the rule.

“We fully support having the noncompete ban apply to all hospitals,” said Dr. Jonathan Jones, president of the American Academy of Emergency Medicine, half of whose members are bound by noncompetes.

California, North Dakota, and Oklahoma already ban enforcement of noncompete clauses for all employees, while six other states prohibit enforcement of noncompete clauses for physicians. Even in states without bans, judges have invalidated noncompetes when they found them to be overbroad or unreasonable.

But it can cost tens of thousands of dollars in legal fees to challenge a noncompete clause, and other employers may not want to take the risk of hiring a person in the middle of a legal fight, said Luke Campbell, a Seattle attorney who represents physicians.

The FTC rule also would bar the use of nondisclosure or training repayment agreements in employment contracts if they functioned as de facto noncompetes.

Hospitals often require nurses to sign training repayment agreement provisions, called TRAPs, which nursing groups say lock nurses into jobs by demanding they pay as much as $20,000, for what’s essentially job orientation, if they leave before two years. National Nurses United, a labor union, wants the FTC to explicitly prohibit TRAPs.

As of last year, nearly three-quarters of all U.S. physicians were employed by hospital systems or other companies, with many working under noncompete agreements. A 2018 survey found that nearly half of primary care physicians in California, Illinois, Georgia, Pennsylvania, and Texas were bound by noncompetes.

Private equity-owned staffing firms such as TeamHealth, Envision Healthcare, and Sound Physicians, which provide emergency physicians and other medical professionals to work in hospitals, commonly use noncompete provisions. None of those three companies agreed to talk about their employment contracts. As for-profit employers, noncompete clauses in their contracts clearly would be barred even if their employees were working in nonprofit hospitals.

Hospitals, insurers, and physician-owned medical groups also use noncompetes in employing doctors and other medical professionals.

Hospital-based doctors — emergency physicians, anesthesiologists, hospitalists, radiologists, and pathologists — refute the industry’s argument that they would take patients or proprietary information with them.

“We don’t have any trade secrets and we don’t have the capability of stealing patients because we don’t have our own patient referral base,” said Dr. Robert McNamara, the chair of emergency medicine at Temple University.

Instead, he said, noncompetes are a way for the physician staffing firms to lock in their contracts with hospitals. “The private equity group can say to the hospital, ‘You might not like what we’re doing, but if you get rid of us, every single one of your doctors must be replaced,’” McNamara said.

Dr. Vanessa Urbina, a general practice physician in central Florida, also worries about the impact on patients. She left a corporate-owned medical practice in Altamonte Springs last year because of what she said was an abusive environment. Hobbled by a noncompete agreement she signed forbidding her from practicing within 15 miles of the clinic, she opened her own primary care clinic in rural Mount Dora, 19 miles away.

She had to stay in the area because of a child custody agreement. Fighting the noncompete cost her $25,000 in legal fees and lost income. Even though she now must drive farther to transport her daughter to school and back, she’s happier in her new practice. But she’s angry she can’t take care of her former patients.

“They forced me to abandon my patients,” she said. “Now they have to wait three months for an appointment. Noncompetes should be illegal.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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KHN senior correspondent Angela Hart discussed California’s contract with Civica to make lower-cost insulin on KQED’s “Forum” on March 23. She also discussed California’s potential plan to use Medicaid funding to cover up to six months of rent for low-income enrollees on KCBS’ “State of California” on March 22.

• Click here to hear Hart on “Forum”
• Read Hart’s “California Picks Generic Drug Company Civica to Produce Low-Cost Insulin”
• Click here to hear Hart on “State of California”
• Read Hart’s “Prescription for Housing? California Wants Medicaid to Cover 6 Months of Rent”

KHN South Carolina correspondent Lauren Sausser discussed prior authorization on WNHN’s “The Attitude With Arnie Arnesen” on March 21.

• Click here to hear Sausser on “The Attitude With Arnie Arnesen”
• Read Sausser’s “Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients”

KHN Montana legislative fellow Keely Larson discussed Montana’s vaccine exemption legislation on the Montana Free Press’ “The Session” on March 20.

• Click here to hear Larson on “The Session”
• Read Larson’s “Montana Considers New Wave of Legislation to Loosen Vaccination Rules”

KHN Midwest correspondent Bram Sable-Smith discussed insulin costs on NPR’s “Weekend Edition Saturday” on March 18.

• Click here to hear Sable-Smith on “Weekend Edition Saturday”
• Read Sable-Smith’s “Eli Lilly Slashed Insulin Prices. This Starts a Race to the Bottom” and “Armed With Hashtags, These Activists Made Insulin Prices a Presidential Talking Point”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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DOL and HHS tackling child labor violations

I was back in the crowded East Room of the White House on Thursday, as I was 13 years ago, this time standing under a portrait of first first lady Martha Washington, when President Joe Biden entered for a lunchtime event focused on the Affordable Care Act.

The room looked much the same as it did on March 23, 2010, when I had rushed over to the White House to witness President Barack Obama signing his historic health bill into law. I knew from that moment — standing under a portrait of President Teddy Roosevelt, who was the first chief executive to espouse a need for national health insurance — that my life as a health journalist would never be the same.

Yet, when Biden scheduled an event to commemorate the 13th anniversary of the health law, I was unsure of the need to keep commemorating its birthday.

After all, on the 13th anniversary of President Lyndon Johnson signing Medicare and Medicaid into law — July 30, 1978 — the Democratic president in the White House did not hold an event to commemorate the date when tens of millions of older Americans and lower-income people gained coverage. Then-President Jimmy Carter spent that Sunday at Camp David.

But with the ACA in 2010, after a century of debate, the U.S. health system was getting hit with a thunderbolt that would enable millions of people to gain medical coverage. The law made many changes affecting hospitals, doctors, insurers, drugmakers, and employers in an effort to live up to its lofty name by lowering costs.

Those sweeping provisions, the years spent implementing them, and efforts by Republicans and the courts to repeal or change the law have kept the Affordable Care Act in the news for even longer than I had anticipated. After 13 years, the job is still not done. North Carolina on Thursday became the 40th state to expand Medicaid under the ACA.

Biden used the health law anniversary to tout the law’s influence. He reminded his audience that Republicans still want to strip many of its benefits. He also stressed that the country has unfinished business to lower drug costs for many and expand health coverage to people who still don’t have it. Indeed, more than 2 million people are without coverage in the 10 states — highly populous Florida and Texas among them — that have yet to expand Medicaid.

Many former Obama staffers who helped get the law passed were there — including some who work in the Biden White House. (Obama was not there.) So, too, were several Democratic lawmakers who helped pass the law, including former House speaker Nancy Pelosi and former California congressman and now Health and Human Services Secretary Xavier Becerra.

“Look, 13 years ago today, we gathered in this room as President Obama signed into law the Affordable Health Care Act,” Biden began with his remarks. “Hard to believe 13 days ag- — 13 years ago. It seems like 13 days ago.”

“And I remember the three words I used at the time,” he said as many in the audience recalled the swear word he was caught whispering to Obama via a live microphone. “I thought it was. I thought it was a big deal. And I stand by the fact it was a big deal.”

Biden said that the health law has been called by many names, but that the most appropriate is Obamacare.

The law has become ingrained into the fabric of the country, Biden said. Over 40 million Americans are covered by Medicaid or online insurance marketplace plans, the highest on record, the Biden administration said Thursday. That’s a 36% increase from 2021.

But a 13th anniversary celebration? Jessica Altman, who helped implement Obamacare in the Obama administration and is now CEO of Covered California, one of the Obamacare exchanges, said it was important to take time to remind people what the American health system used to look like as well as the many challenges remaining to improve it. (Altman is the daughter of KFF’s president and CEO. KHN is an editorially independent program of KFF.)

“We still have places to go, and we still have work to do and the people in that room are excited to keep doing it,” Altman said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Certified Community Behavioral Health Clinic (CCBHC) expansion

Andrew Johnson lets his clients choose what music to play in the car.

As an employee of Family Outreach in Helena, Montana — an organization that assists developmentally disabled people — part of his workday involves driving around, picking up clients, and taking them to work or to run errands.

“What’s up, gangsta?” Johnson said as a client got in the car one day in March.

The pair fist-bumped and Johnson asked what type of music the client liked.

“Gangsta stuff,” came the response. Rap, mainly.

Snoop Dogg played in the background as Johnson and his client drove to McDonald’s, where Johnson helps his client work. The duo washed dishes for two hours in the back of the fast-food restaurant, where it smelled like maple syrup and sulfur.

About two weeks earlier, Johnson testified at a hearing at the Montana Capitol in support of a bill that seeks to raise health providers’ Medicaid reimbursement rates to levels aligned with the average cost of the care they provide. The bill is informed by a 2022 study that recommended benchmark rates after its authors found that Montana Medicaid providers like Family Outreach were being significantly underpaid.

“The provider rates need to be funded so people that work in this field or that work in adjacent fields can have solid ground, a place where you can build a career,” said Johnson, who makes $16.24 per hour in his position as an individual living specialist.

Republican Gov. Greg Gianforte and legislators agree that Medicaid rates need to rise; where they disagree is by how much. The proposals range from the bill Johnson testified for — Democratic Rep. Mary Caferro’s bill to raise rates to the study’s benchmarks — to Gianforte’s plan to fund 91% of that benchmark in 2024 and 86% in 2025.

Meanwhile, the Republicans leading the House Appropriations Committee, a key budget panel, are proposing an average increase of 92% for fiscal year 2024 and 97% in 2025.

Providers and leaders who work in behavioral health, developmental disability, long-term care, and family support services have attended the multiple hearings on rate adjustments, saying thanks for the proposed increases but asking for more. Many providers said the benchmark rates in the study are already outdated.

Providers across the United States say they haven’t seen significant reimbursement increases in more than a decade, according to Shawn Coughlin, president of the National Association for Behavioral Healthcare. Behavioral health can be an afterthought for policymakers, resulting in lower rates than for medical or surgical reimbursement, he said

Michael Barnett, associate professor of health policy and management at the Harvard T.H. Chan School of Public Health, said the supply of staff is inadequate to meet demand for behavioral health care across the U.S.

“And it’s not clear we’re going to meet any of that without paying people more,” Barnett said.

Some health providers have raised wages but still struggled to draw workers and keep the ones they’ve got. Family Outreach raised the wages of some direct care workers from $11 per hour to $12.20 per hour this year, and by more in places where the cost of living is higher, such as Bozeman. But even starting wages of $16 or $18 an hour aren’t attracting enough people to work there, Family Outreach Program Manager Tyler Tobol said.

“It’s a field that not a lot of people want to get into, so those that we can find, I think being able to pay a higher wage, a living wage, I think that would be the best benefit we get out of the rate increase,” Tobol said.

The organization went from 153 employees in 2020 to 128 today. The staffing shortage means employees now focus mainly on making sure clients have the basics — medications and meals — instead of providing additional community integration and activity support services.

At Florence Crittenton in Helena, where moms 18 to 35 with substance use disorders can live with their young kids while undergoing treatment, a mom entered the kitchen where women are taught life skills like learning to cook dinner. The woman told a staff member she was making juice for her child.

“This is where life happens,” said Daniel Champer, Florence Crittenton’s clinical and residential services director.

Executive Director Carrie Krepps said the organization’s two main sources of revenue are Medicaid reimbursements and fundraising. Fundraising, which used to account for 30% of revenue, now makes up between 60% and 70% of the money coming in.

“It’s the reason we’re still open,” Krepps said.

At any given time, an average of 15 to 18 of Florence Crittenton’s 50 staff positions are vacant. If Medicaid rates don’t increase, she said, the organization will have to consider if it can continue operating the recovery home at its current capacity.

“The full rates would just barely cover where we are today,” Krepps said of raising Medicaid reimbursement rates to benchmark levels.

In 2021, Florence Crittenton closed a youth maternity home for pregnant youths and young moms ages 12 to 15, the only home in the state that took teens under 16. Krepps said Florence Crittenton didn’t take Medicaid fees there because the rates were too low.

“It’s heartbreaking,” Champer said. “It’s like clockwork on Monday morning. I come in and see the inquiries and referrals about moms who need treatment and we can’t function at full capacity because we don’t have staff.”

Dennis Sulser, the CEO of Youth Dynamics, which provides home support, case management, and community-based psychiatric rehabilitation across the state, said his organization is paying its staff more than it can afford. Even with the rate increase, he said, they’d only break even.

In the past three years, Youth Dynamics has lost 56 full-time employees. The covid-19 pandemic made people realize they could find other jobs that paid more and even allowed them to stay home, Sulser said.

Two years ago, the entry-level pay for Youth Dynamics was $10.70 per hour, and it now averages $13.70. Still, staffing shortages led to the closure of a group home in Boulder and one in Billings, shrinking the organization’s capacity from 80 to 64 beds statewide.

Ashley Santos, program manager for the organization’s three remaining group homes in Boulder, said she is trying to figure out how to attract enough staff to reopen the closed home there. An increase in pay supported by the provider rate increase could give her flexibility to provide extra incentives, she said.

But it’s hard to attract workers when Hardee’s has a starting wage of $18 per hour compared with Youth Dynamics’ $16, she said. And fast-food jobs don’t come with the emotional toll of working with kids who have a severe emotional disturbance diagnosis like PTSD or depression.

Back in Helena, Johnson made his last stop of the day for Family Outreach. He sat next to a client on the couch at the house where the client lives with his mom. Johnson called the number on the back of his client’s debit card to see how much money was left on it before they went out to run errands.

Johnson and the client then headed to a local supermarket. Trips like these give his client a chance to interact with other people, while his mom gets some time to herself.

“You look nice,” Johnson said to the client as they got into the car, the folksy music of Dougie Poole, the choice of Johnson’s previous client, playing in the background.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Sen. Bernie Sanders, who rose to national prominence criticizing big business in general and the pharmaceutical industry in particular, claimed the spotlight Wednesday on what might at first seem a powerful new stage from which to advance his agenda: chairmanship of the Senate health committee.

But the hearing Sanders used to excoriate a billionaire pharmaceutical executive for raising the price of a covid-19 vaccine showed the challenges the Vermont independent faces.

Though its formal name is the Committee on Health, Education, Labor, and Pensions (HELP), the panel Sanders chairs has little if any authority over drug prices. In the Senate, most of that leverage lies with the Finance Committee, which oversees Medicaid, Medicare, and Obamacare.

As far as drug prices go, the platform Sanders commands is essentially a bully pulpit. So Sanders was left to bully his way toward results. And while some committee Republicans sympathized with his complaints, others bristled at his approach.

By the end of the hearing, seeming to acknowledge the limits of his power, the former presidential candidate was pleading with Moderna chief executive Stéphane Bancel for a relatively modest concession on vaccine pricing.

The CEO made no promises. Then again, pulpit proclamations can lead to corporate action, even if delayed and informal; in the weeks following President Joe Biden’s State of the Union call for cheaper insulin, the companies that make it drastically cut their prices.

Sanders began Wednesday’s hearing with his usual fire and brimstone.

“All over this country people are getting sicker, and in some cases dying, because they can’t afford the outrageous cost of prescription drugs, while companies make huge profits and executives become billionaires,” Sanders thundered.

Bancel had won his place in the witness chair with federal assistance. Moderna, which was founded in 2010 and had not brought a drug to market before the pandemic, received billions in government funds for research, guaranteed purchases, and expert advice to help develop and produce its successful covid vaccine. The payoff has been handsome. As of March 8, Bancel held $3 billion in Moderna stock. He also held options to buy millions of additional shares.

Government research and support are foundational to many of the expensive drugs and vaccines in use today. But Bancel made himself the perfect foil for Sanders when he announced in January that Moderna planned to increase the price of its latest covid shot from about $26 to $110 — or as much as $130.

Denouncing greed, Sanders expounded on his dream of a system in which the government fully funds drug development — and in exchange controls drug prices. “Is there another model out there where, when a lifesaving drug is made, it becomes accessible to all those who need it?” he asked. “What am I missing in thinking that it’s cruel to make a medicine that people can’t afford?’”

Sanders’ overt moralizing and harsh attacks on big business make him an outlier in the Senate, even in his own party. Yet distaste for soaring drug prices extends across the aisle. On the HELP Committee, at least, Republican politicians seem about evenly split between populist and pro-business takes on the problem, showing both the possibilities and the pitfalls that Sanders faces.

Sen. Mike Braun (R-Ind.) expressed disgust with the lack of transparency in the health care system and called Moderna’s planned price hike “preposterous.” Sen. Roger Marshall (R-Kan.) called it “outrageous.”

Sen. Rand Paul (R-Ky.), who often bucks mainstream GOP views and has expressed rancor for the biomedical establishment, claimed Bancel was downplaying vaccine injuries to make money. (Paul vastly exaggerated those risks.)

Ranking member Bill Cassidy (R-La.), who has pledged to work with Sanders, responded to the chairman’s opening remarks with both a hedge and a warning. “I’m not defending salaries or profits,” Cassidy said, but he added that he hoped the hearing’s goal wasn’t to “demonize capitalism.”

Only Sen. Mitt Romney (R-Utah), a former private equity executive, came heartily to Bancel’s defense. “If I’m an investor, I have to expect that if a product I’m backing works, I get to make an awful lot of money,” he said. “I’ve heard people say, ‘That’s corporate greed.’ Yeah, that’s how it works.”

Sanders’ idealized vision of the pharmaceutical industry is, in any case, moot. Even the Biden administration, which successfully browbeat insulin makers into drastically lowering prices in March, revealed this week it would not use “march-in” rights to lower the price of a cancer drug, Xtandi, developed with government-licensed patents.

March-in rights were established in the 1980 Bayh-Dole Act, which enabled companies to license federally funded research and use it to develop drugs. But federal courts and administrations have consistently said the government can seize a product only if the license holder has failed to make it available — not because the price is too high. The administration did, however, announce a review of whether price might be considered in future march-in decisions.

Sanders said before the hearing that he was “extremely disappointed” with the Xtandi decision. But he was ultimately realist enough to aim his bully pulpit at a lower target. Late in Wednesday’s hearing, Sanders pushed for a minimal gimme from Moderna. “Will you reconsider your decision to quadruple the price of your vaccine to the U.S. government and its agents?” he asked politely.

Bancel dodged, saying pricing was more complex now that Moderna faced an uncertain market, had to fill separate syringes with its vaccine, and needed to sell and distribute the vaccine to thousands of pharmacies, where previously the government did all that work. Later, he left open the possibility that negotiations could drive down the price paid by some government agencies or private insurers.

For all the theatrics of such hearings and the mix of opinions among the senators, interrogations of figures like Bancel may help inspire a shift in how the National Institutes of Health “does business in giving away its science to the private sector,” said Tahir Amin, co-executive director of I-MAK, a nonprofit that advocates for equitable access to medicines.

“You have to prosecute it so you at least get these public comments on record,” Amin said. Eventually, he said, this type of hearing could lead to a recognition that, ‘Hey, we need to do this.’”

Despite the HELP Committee’s lack of direct jurisdiction over drug prices, said John McDonough, a Harvard professor who was senior adviser for health reform on the HELP Committee from 2008 to 2010, Sanders “uses his position of authority and influence to draw attention to this in a way that has been helpful.”

KHN correspondent Rachana Pradhan contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

OCR and DOJ voluntary settlement agreement with Dearborn Obstetrics and Gynecology, P.C. to resolve an alleged federal civil rights violation.

Today HHS announced they will extend 12 months of comprehensive coverage after pregnancy through Medicaid for women in Oklahoma.

New report shows more than 40 million people are enrolled in Marketplace or Medicaid expansion coverage related to provisions of the Affordable Care Act