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Thousands Mistakenly Enrolled During California’s Medicaid Expansion, Feds Find

March 28, 2018

California signed up an estimated 450,000 people under Medicaid expansion who may not have been eligible for coverage, according to a report by the U.S. Health and Human Services’ chief watchdog.

In a Feb. 21 report, the HHS’ inspector general estimated that California spent $738.2 million on 366,078 expansion beneficiaries who were ineligible. It spent an additional $416.5 million for 79,055 expansion enrollees who were “potentially” ineligible, auditors found.

Auditors said nearly 90 percent of the $1.15 billion in questionable payments involved federal money, while the rest came from the state’s Medicaid program, known as Medi-Cal. They examined a six-month period from Oct. 1, 2014, to March 31, 2015, when Medicaid payments of $6.2 billion were made related to 1.9 million newly eligible enrollees.

There were limitations to the California review, however. The audit extrapolated from a sample of 150 beneficiaries. The authors reported a 90 percent confidence level in their results — whereas 95 percent would be more common. That meant that the number of those ineligible could have been as low as 260,000 or as high as 630,000.

“If HHS has a strong reason to believe that California is systematically making enrollment errors, it would be helpful to show that in a more robust analysis,” said Ben Ippolito, a health care economist at the American Enterprise Institute, a conservative think tank. “The federal government should ensure that states are being good stewards of federal money.”

Nonetheless, the audit highlighted weaknesses in California’s Medicaid program, the largest in the nation with 13.4 million enrollees and an annual budget topping $100 billion, counting federal and state money. Medicaid covers 1 in 3 Californians.

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The inspector general found deficiencies in the state’s computer system for verifying eligibility and discovered errors by caseworkers. The Medicaid payments cited in the report covered people in the state’s fee-for-service system, managed-care plans, drug treatment programs and those receiving mental health services.

California’s Department of Health Care Services, which runs Medi-Cal, said in a statement that it agreed with nearly all of the auditors’ recommendations and that the agency “has taken steps to address all of the findings.”

In a written response to the inspector general, California officials said several computer upgrades were made after the audit period and before publication of the report that should improve the accuracy of eligibility decisions.

Among the 150 expansion enrollees analyzed in detail, 75 percent, or 112, were deemed eligible for the Medicaid program in California. Auditors discovered a variety of problems with the other 38 enrollees.

During the audit period, 12 enrollees in the sample group had incomes above 138 percent of the federal poverty line, making them ineligible financially for public assistance, according to the report.

In other instances, beneficiaries were already enrolled in Medicare, the federal health insurance for people 65 and older or who have severe disabilities, and did not qualify for Medi-Cal. One woman indicated she didn’t want Medi-Cal but was enrolled anyway.

In 2014, the state struggled to clear a massive backlog of Medi-Cal applications, which reached about 900,000 at one point. Many people complained about being mistakenly rejected for coverage, or their applications were lost in the state or county computer systems.

California was one of 31 states to expand Medicaid under the 2010 Affordable Care Act. The health law established a higher federal reimbursement for these newly eligible patients, primarily low-income adults without children. After expansion started in 2014, the HHS inspector general’s office began reviewing whether states were determining eligibility correctly and spending taxpayer dollars appropriately.

In a similar audit released in January, the inspector general estimated that New York spent $26.2 million in federal Medicaid money on 47,271 expansion enrollees who were ineligible for coverage. (The sample size there was 130 enrollees.) Overall, New York had far fewer expansion enrollees and related spending compared to California.

Audits of other states’ records are planned.

“It is inevitable that in a big rollout of new eligibility for any public program there are going to be glitches in implementation,” said Kathy Hempstead, a health-policy expert and senior adviser at the Robert Wood Johnson Foundation. “The inspector general wants to make sure that states are being sufficiently careful.”

Nationwide, Medicaid, the state-federal health insurance program designed for the poor, is the country’s largest health insurance program, covering 74 million Americans. In the past year, Republican efforts to reduce Medicaid funding and enrollment have sparked intense political debates and loud protests over the size and scope of the public program.

The federal government footed the entire cost of Medicaid expansion during the first three years, instead of taking the usual approach of splitting the costs with states. Now, states are picking up more of the bill. Their share of the costs grows to 10 percent by 2020.

The California audit didn’t request a specific repayment from the state, but the findings were sent to the U.S. Centers for Medicare & Medicaid Services for review. CMS officials didn’t return a request for comment.

Donald White, a spokesman for the inspector general’s office, said the agency stood by the report’s findings and declined to comment further.

For One Father And Son In Puerto Rico, Hurricane Maria’s Cloud Has Not Lifted

March 23, 2018

To reach the Martinez home in Puerto Rico’s central mountains, social worker Eileen Calderon steers around piles of dirt, treacherous potholes and power company trucks that block the road. Finally, she pulls up to a sagging, cement home, its roof done in by Hurricane Maria. Laundry hangs under a tarp, and a cat is tied to a leash outside the door.

Calderon, who is based in San Juan, and works for VarMed, a company that handles complex medical cases in Puerto Rico, has brought two colleagues — a nurse, Anamelia Velazquez, and a primary care physician, Dr. Carla Rossotti — to check in on Osvaldo Martinez and his son, Osvaldo Daniel Martinez.

Inside a darkened bedroom, the elder Martinez, a 67-year-old former star pitcher in the local baseball league, spoons rice and sausage into his son’s mouth. The younger Martinez lies in a hospital bed, his arms and fingers spasm and his eyes loll around in his head. He’s 37, born in Chicago, a former security guard.

Three years ago, after he and his father moved back to Puerto Rico from Illinois, the younger Martinez started showing early signs of multiple sclerosis. During the past year, his world became this room, then this bed.

His father points to the ceiling — leaking from the morning’s rain and covered in mold.

“All of this leaking that you can see came out because of the hurricane,” he said.

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The power came back on in his house about a month ago, and the family has running water, so he is able to keep his son clean. The father carries a plastic basin into the bathroom and draws the water. Then, as he does a few times each day, he returns to the bedroom to bathe his adult son and gently change his diaper.

But Rossotti, whose company, VarMed, has been paid by the Puerto Rican government to help take care of the junior Martinez, said the younger man can’t yet get an appointment to see a neurologist to confirm his multiple sclerosis and start treatment. There is a chronic shortage of neurologists on the island, and those who remained after the storm have few slots in their schedules for Medicaid patients.

Calderon, the social worker, said she has been trying for a year to get an appointment for Martinez, but receptionist after receptionist tells her the neurologists they work for are taking no new patients. “We have a patient who was stable a year ago, and now he’s bedridden,” Rossotti said. “He hasn’t been able to get that neurologist evaluation.”

The roof of the Martinezes’ home in Cayey, Puerto Rico, was damaged in Hurricane Maria, leading to moisture and mold problems in the house. (Sarah Varney/KHN)

People here in Puerto Rico talk about life “before Maria” and life after. Accessing medical care here has always been a challenge, given the island’s chronic shortage of physicians and its unusual system for Medicaid — known as a block grant. The government provides a certain amount of money for each citizen in the program, no matter how great the needs are for care.

And for many of the island’s most vulnerable residents, like the Martinez family, the 2017 storm turned a challenge into a full-blown medical crisis that cannot be easily reversed. Since the turn of the century, a number of effective medicines that treat MS have come on the market, transforming the lives of people with the progressive disease, which can damage nerve conduction to anywhere in the body — the eye, the brain, the bladder, the legs. Treatment both helps slow progression and resolves symptoms. But it is less effective once damage to the nervous system is done.

The island’s financial crisis has sent doctors fleeing to the States during the past decade; Hurricane Maria added further fuel to that exodus. There is no exact accounting yet of just how many physicians have left the island, but from 2006 to 2016, the number of doctors dropped from 14,000 to 9,000, according to the Puerto Rico College of Physicians and Surgeons.

Nearly half of Puerto Ricans on the island rely on Medicaid — compared with around 20 percent of the population in the continental U.S. The territory’s government has long struggled to cover the costs of health care.

Currently, Molina Healthcare, a California-based company that provides insurance coverage to low-income people on Medicaid in Puerto Rico and elsewhere in the U.S., is ostensibly responsible for guaranteeing access to needed doctors.

A spokeswoman for Molina, Laura Murray, said the company cannot comment on the Martinez case, or that of any individual patient, because of privacy laws. But in a written statement, the company representative reported that it contracts with 41 neurologists in Puerto Rico’s eastern and southwestern regions, and meets “the network adequacy requirements in our contract.”

“However,” the statement continued, “we recognize that there is an island-wide shortage of physicians — particularly specialists — and we are proposing suggestions to [the Puerto Rican government] on how we could work together to remediate this.”

The island government recently announced that it will overhaul how Medicaid contracts are awarded.

Osvaldo Martinez tends to his son, Osvaldo Daniel Martinez, whose world, over the past year, has slowly become one room, then one hospital bed.  (Sarah Varney/KHN)

For now, the younger Martinez languishes — each day and night no different than the next, as the disease lays siege to his central nervous system, disrupting the vital connections between brain and body.

Without a confirmed diagnosis, he can’t get certain public disability benefits. And he isn’t getting medication for his condition or his pain; the agency Rossotti works for can only advocate for patients, not treat them.

The outward perseverance of father and son belies the true terror of their confinement. As the elder Martinez describes his son’s decline, tears come to his eyes; his son, who can understand everything, rolls on his side and begins to weep.

“I have to do all that needs to be done for him,” Martinez said. But he is not in good health himself, with severe arthritis and a painful bulge in his abdomen. During the months they went without power, he said, the hospital bed didn’t go up and down. He showed a photo of his arm — black-and-blue and swollen — from pressing against the metal bars of the bed as he leaned down to tend to his son.

But it’s his son’s withering away that pains him most.

“If something would happen to me,” the father said, clasping his hands together in prayer — “I don’t know.”

Medicaid Is Rural America’s Financial Midwife

March 12, 2018

ZANESVILLE, Ohio — Brianna Foster, 23, lives minutes away from Genesis Hospital, the main source of health care and the only hospital with maternity services in southeastern Ohio’s rural Muskingum County.

Proximity proved potentially lifesaving last fall when Foster, pregnant with her second child, Holden, felt contractions at 31 weeks — about seven weeks too soon. Genesis was equipped to handle the situation — giving Foster medication and an injection to stave off delivery. After his birth four weeks later – still about a month early, at 5 pounds 12 ounces — Holden was sent to the hospital’s special care nursery for monitoring.

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

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Mother and son went home after a few days. “He was pretty small — but he’s picking up weight fast,” said Foster of Holden, now almost 4 months old.

Medicaid, the federal-state health insurance program for low-income people — including Foster, who most recently worked as a preschool teacher’s aide — is responsible for much of her good fortune.

Started in 1965, the program today is part of the financial bedrock of rural hospitals like Genesis. As treatments have become increasingly sophisticated — and expensive — health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people.

Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid covers nearly 24 percent of rural, nonelderly residents and offers some financial stability to rural facilities by reducing uncompensated care costs at hospitals that would otherwise be in dire straits. In some cases, it enables them to provide costly but vital services, such as high-risk maternity care.

Medicaid pays the tab for close to 45 percent of all U.S. births annually, and about 51 percent of rural births, according to research. In Ohio, Medicaid pays for about 52 percent of births, according to 2016 state data, the most recent available.

But efforts to control Medicaid costs are consistently high on Republicans’ to-do list. The Trump administration has encouraged states to introduce work requirements and other changes to Medicaid — changes that would almost certainly reduce the number of people it covers and the money rural hospitals receive. Ohio lawmakers have recently signaled they intend to require that Medicaid enrollees also be employed.

Matthew Perry, Genesis’ CEO, who identifies as conservative and finds plenty of fault in Obamacare, is concerned about high government spending. But he acknowledges that cuts to Medicaid would be deeply problematic for his hospital, affecting what services it can afford to provide. Perry keeps a map in his office to track local options for medical care, and the next-closest OB ward is an hour away in Columbus. What happens, hypothetically, if you take Genesis Hospital off the map?

“That’s a huge problem,” he said.

Brianna Foster sits with sons Carson (left) and Holden at her Zanesville, Ohio, home on Jan. 29, 2018. Foster, a Medicaid recipient, gave birth to Holden at a hospital just minutes from her home. (Maddie McGarvey for KHN)

Squeezed Hospitals, Cutting Costs

Like many rural hospitals Genesis is this area’s health care hub, the access point for primary care as well as mental health care, routine surgeries and other medical needs.

It is also central to the local economy.

Here in Zanesville, population 25,000, it seems as if almost everybody knows someone employed by the hospital.

Main Street is quiet — a stretch of scattered restaurants and pubs, county buildings and churches. Ten minutes away, across the river, Genesis anchors a stretch that would otherwise claim little more than fast-food chains, used car dealerships and cellphone shops.

This hospital, the flagship of a larger Ohio health system, is the product of a 2015 merger of two older town hospitals: Bethesda and Good Samaritan. Its 300 beds are the main source of health care across six counties — a quarter million people — and it delivers 1,500 babies per year.

Genesis Hospital, an acute-care facility in Zanesville, Ohio, is the main source of health care and the only hospital with maternity services in rural Muskingum County. The next nearest option is 60 miles away. (Maddie McGarvey for KHN)

Ask a woman in town where she would plan to deliver, and the answer is practically a given: Genesis, of course. Locals say it’s hard to conceive of a reality in which the hospital didn’t deliver babies.

In recent years, it’s also doubled down on other services, like cancer care, neurosurgery and open-heart surgery — which experts say can cushion a rural hospital’s bottom line, even if need isn’t as great.

Still, hospitals like Genesis often struggle with tight budgets and regular debates about whether cash flow can continue to support certain types of services. Rural hospitals have seen a sharp decline in the past decade. Nationally, 80 have closed since 2010 and the trend is expected to continue.

“When rural hospitals are squeezed, they have to look at what fixed costs they can shed,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who studies obstetrics access. “The fixed costs of providing obstetrics services are very clear, and very distinct.”

Obstetrics requires pricey specialists, expensive malpractice insurance and, in the 21st century, the capacity to deal with extreme preemies and high-risk deliveries. At the same time, Medicaid reimburses hospitals less for this service— often below the cost of the care — than any other insurance program, making it a balance-sheet loss.

Already, about 45 percent of rural communities do not have a hospital with dedicated maternity care. From 2004 to 2014, almost 1 in 10 rural counties lost their hospital-based obstetrics programs, suggests research published last fall.

In Ohio, nine rural hospitals have dropped obstetrics since 2007 — including one that closed. The state currently has 73 small and rural hospitals in operation.

“We’ve seen a slow erosion of obstetrics in rural areas,” said Michael Topchik, national leader of the Chartis Center for Rural Health, an analytics and consulting firm. “And I’m afraid that further [Medicaid] cuts would exacerbate that trend.”

That scenario is part of the reason why rural health advocates have fiercely criticized GOP efforts at the federal and state level to cut Medicaid or to eliminate the Affordable Care Act’s option for states to expand eligibility for the program.

Research suggests that states’ expansion of Medicaid eligibility led to greater financial stability for rural hospitals. Also, more generous Medicaid coverage increases the odds that rural areas have any kind of obstetrics program.

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Potential cutbacks offer a complicated calculation in this conservative town, with practical considerations bumping into politics.

“Things like trauma and obstetrics and behavioral medicine … they’ve got to be subsidized by other, more profitable things,” said Perry, the hospital CEO. “You can’t repeal the laws of economics.”

Still, Muskingum County backed Donald Trump over Hillary Clinton by more than 2-to-1. Its most recent congressional representative, Republican Pat Tiberi, was a vocal Obamacare critic who, until an early retirement this past January, consistently voted to repeal the ACA and pushed efforts to reduce Medicaid’s size and scope.

It’s obvious that better prenatal care means better outcomes. Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate

(Maddie McGarvey for KHN)

A Public Health Concern

When pregnant women are geographically farther from health care, they and their babies are more likely to have poor outcomes, like lower birth weights, research suggests.

Foster said that if she had to travel to Columbus, she likely would not have made as many prenatal appointments. Each visit means scrounging up gas money and finding someone to watch her older son for at least three hours.

“It’s obvious that better prenatal care means better outcomes,” said Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate about a five-minute drive from the hospital.

And without an operational delivery unit, hospitals are unlikely to keep on staff obstetricians who are experienced in complicated births, experts said.

Keeping rural maternity services open with Medicaid funding also engages new mothers with the local health system in regions with high rates of chronic illness, drug addiction and smoking. The national opioid epidemic is acute in this corner of Ohio.

“What we see is someone who comes in with no teeth, or all rotted teeth or can’t eat. And she’s not complaining about dental work. She’s here worried about her pregnancy,” Goodarzi said.

Even as Obamacare repeal appears on pause, Medicaid remains vulnerable. In Ohio, many state lawmakers are pushing a cap on the state’s expanded Medicaid program — a controversial move that would almost certainly squeeze hospital revenue. Nationally, Republican leaders are weighing cuts to Medicaid, Medicare and other safety-net programs.

“If you pull too many of those foundational blocks out of the system that support the safety net … it can crumble,” said Perry, who worries about the effect of such cuts. “People can assume something’s always going to be there, when in reality, that assumption is not always true.”

States Strive To Curb Costs For A Crucial — But Exorbitant — Hemophilia Treatment

March 06, 2018

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

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The child is well-known in the halls where state bureaucrats oversee health care for millions of Californians — not by name, but by a number: $21 million.

His medications alone cost state taxpayers that much in a single year, not including other health care. The boy, whose identity has not been released, was California’s most expensive Medicaid patient in recent years. His case was singled out in a tweet last year by the state’s top health care official to highlight the public insurance program’s extraordinary obligations as a backstop for low-income patients.

How on earth can a single child’s treatment cost that much? The answer: He has hemophilia and needs large quantities of a pricey drug — known as clotting factor — that makes blood coagulate.

Hemophilia drugs are among the most costly drugs in the nation, and taxpayers are footing the bill for many patients on Medicaid who could never afford them on their own. Officials in California and other states are doing what they can to manage the costs, but it’s a daunting task that highlights the complexity and secrecy of prescription drug pricing.

Kaiser Health News is examining how America has become a “Medicaid Nation” — where tens of millions of poor and disabled people now rely on the support of the federal and state insurance program. Hemophilia is one those diseases that helps explain its burgeoning cost.

Medications for hemophilia are crucial to patients — overwhelmingly male — with the rare genetic condition that prevents clotting and puts them at great risk of bleeding to death, even from a minor injury. There is no question the drugs prolong and save lives, and state officials are not arguing that they should be withheld.

Kevin Tuite was born with severe hemophilia with a complication known as an inhibitor – an antibody that makes his regular blood factor infusions less effective. He plays a game on the phone while he waits for his blood factor infusion on Feb. 23, 2018. (Heidi de Marco/KHN)

“It’s a highly vulnerable population,” said Ken Kizer, a veteran federal and state health administrator who formerly oversaw Medi-Cal, California’s version of Medicaid. “If anyone has seen a hemophiliac in crisis, you’re not going to say no.”

But drugmakers profit handsomely, competing vigorously for the limited number of patients.

The U.S. hemophilia market, which serves about 20,000 patients, is worth $4.6 billion a year, according to AllianceBernstein, a research and investment firm.

“There are millions being made out there on these kids — it’s a huge business,” said Dr. Doris Quon, medical director of the Orthopaedic Hemophilia Treatment Center at UCLA.

Contributing to the costs is the fact that there is no cure for hemophilia and no cheaper substitute for blood factor. Factor may be prescribed at high doses for a lifetime, even more so when a patient has an injury or complications.

Nationwide, a third of adults and children living with hemophilia are covered by Medicaid. And the Medicaid program’s three most expensive drugs per prescription are for hemophilia, according to an analysis by the Kaiser Family Foundation. (California Healthline is produced by Kaiser Health News, an editorially independent publication of the foundation.)

In 2015 alone, Medicaid paid about $353 million for prescriptions of Advate, the most commonly prescribed blood-clotting medication for hemophilia — a 273 percent increase from 2011.

Generally speaking, the price of hemophilia drugs rise as rival drugs hit the market. But, in addition, doctors are prescribing ever more clotting factor for prevention of joint-damaging bleeds and for improved long-term health. The increase in the cost of Advate, for example, was nearly all attributed to increased use.

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Tab For 145 Kids: $195 Million

The California boy whose drugs cost $21 million in a single year was an extreme case, and the circumstances of his care have not been disclosed because of confidentiality protections. Still, medications to treat hemophilia on average cost more than $270,000 annually per patient, according to a 2015 Express Scripts report, and they can easily soar past $1 million annually.

In contrast to more common diseases like hepatitis C, hemophilia treatment is not a state “budget buster” per se: Only about 4,000 patients live in California. About 1,100 of them are covered by Medi-Cal or two other government-funded programs for chronically ill children in California, according to Jennifer Kent, director of the state Department of Health Care Services and author of last year’s tweet. But the amount of money spent per person dwarfs that spent on people with other serious diseases.

One Stanford University study of 34,000 California kids with severe chronic diseases found that the tiny portion of children who needed blood factor accounted for 41% of the state’s outpatient drug spending on this entire patient population. About $195 million was spent on just 145 kids over a three-year period, although some of that money came back to the state in rebates from drug companies — a portion of the cost that Medicaid can recoup after purchase.

Vials of Bayer’s factor VIII product Kogenate at the company’s factory in Berkeley, Calif. (Eric Kayne for KHN)

Caitlin Carroll, director of public affairs for PhRMA, the pharmaceutical industry lobbying group, said high development costs and a complicated and lengthy manufacturing process play a role in how hemophilia drugs are priced. She added that federally mandated rebates significantly reduce the cost of blood factor. They amount to 17 percent of the average manufacturer price per unit.

Manufacturers also note that some newer and more expensive hemophilia drugs last longer and do not need to be administered as frequently, so they can prove less costly to payers overall.

Even so, some patients require a monumental investment to survive.

‘Extremely Fortunate’

Colleen Tuite’s son Kevin, 7, has severe hemophilia with a complication known as an inhibitor — an antibody that makes his regular blood-factor infusions less effective. Inhibitors can dramatically increase the cost of care, because massive doses of blood factor or expensive, specialized blood products known as bypassing agents may be needed.

Tuite and her husband initially were Kevin’s foster parents, then adopted the boy as a toddler. Because he has been a foster child, Kevin qualifies for Medi-Cal until he is 26.

The Monrovia, Calif., family also has private health insurance, which pays for about half of Kevin’s medical bills. These can run upward of $200,000 per month, Tuite said.

“We definitely would not have been able to adopt him without the help of Medi-Cal,” Tuite said. “We’ve been extremely fortunate.”

With the support of drug manufacturers and hemophilia advocacy groups, patients and their families have significant political clout. Some experts say they also have a moral claim on public resources: In the early days of the AIDS epidemic, thousands of the nation’s hemophilia patients died after they contracted HIV through transfusions before the virus could be eliminated from the blood supply.

State health officials say the costs of hemophilia are hard to anticipate and control, even with rebates.

“We do a really aggressive job of collecting rebates on our pharmacy costs,” said Kent, California’s top Medicaid official. “But there’s just not any way around blood factor. It is just a very, very expensive product. It’s nonnegotiable for people that require it.”

In 2016, California’s Medicaid program paid at least $205 million for medications used to treat hemophilia, according to a Kaiser Health News analysis of federal Medicaid data. That figure doesn’t account for the federal rebates.

States can negotiate “supplemental” rebates with drugmakers for individual medications — but those must be kept secret under federal and some state laws. Such secrecy is becoming increasingly controversial as states continue to confront spiraling drug prices.

Limited Options For States

In 2016, Pfizer sued Texas’ state health agency for giving data on the drug company’s supplemental Medicaid rebates to state lawmakers who requested it. The drugmaker alleged that releasing the confidential information would undermine the company’s competitiveness and give away trade secrets, and warned that the discounts it gave Texas could disappear.

In early October, a judge ruled that lawmakers should be able to obtain some of that data, noting dryly that “in Pfizer’s view, legislators are not necessary to carry out the state’s Medicaid program.”

Instead of seeking additional rebates from manufacturers for blood factor, some states, including Washington and Oregon, have chosen to require patients to get their blood factor only from federally designated Hemophilia Treatment Centers. That allows state Medicaid programs to take advantage of a federal drug-discount program known as “340B.”

However, officials in California said they studied that option and determined it wouldn’t save them any more money than the rebates they negotiate with drugmakers.

Whatever their approach, state health officials say they are struggling against forces they are nearly powerless to change.

“There aren’t a lot of options available to Medicaid programs in terms of controlling costs, because we don’t set the initial costs,” said Deborah Weston, pharmacy program manager for Oregon’s Medicaid program.

Kaiser Health News data correspondent Sydney Lupkin contributed to this report.

CMS Issues Split Decision On Arkansas Medicaid Waiver

March 05, 2018
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The Trump administration on Monday approved Arkansas’ request for a Medicaid work requirement but deferred a decision on the state’s request to roll back its Medicaid expansion that has added 300,000 adults to the program.

Arkansas had sought to reduce the number of people eligible for Medicaid by allowing only those with incomes below the federal poverty level, or about $12,140 for an individual, to qualify. For the past four years, Arkansas Medicaid covered everyone with incomes under 138 percent of the poverty level, or about $16,750. The new policy would have cut the number of people eligible for Medicaid in the state by about 60,000 people.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, who announced the decision, has said her goal as head of the program was to grant states more flexibility in running their Medicaid programs than they’ve had before.

Arkansas follows Indiana and Kentucky this year in winning CMS’ approval for the work requirement. Arkansas plans to start the new requirement affecting adults under age 50 by June, making it the first to do so.

Verma recused herself on CMS’ decisions involving Indiana and Kentucky because she used to consult with those state Medicaid agencies before joining the Trump administration in 2017. As a health care consultant, she also worked with Arkansas. But Verma decided to personally approve the Arkansas waiver on Monday and flew to Little Rock, Ark., to make the announcement with Republican Gov. Asa Hutchinson.

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CMS officials did not respond to questions about why she did not recuse herself again.

But a top Senate Democrat lambasted Verma’s decision.

“She pledged during her confirmation to recuse herself from working on many states’ Medicaid waivers to avoid conflicts of interest, including Arkansas, Sen. Ron Wyden (D-Ore.) said in a statement. “The Trump Administration has simply made a mockery of the HHS ethics process.”

It is unclear why she deferred deciding on Arkansas request to scale back its Medicaid decision. Deferring a decision on rolling back expansion could be a way of rejecting the application but in a less politically harsh way. Arkansas was one of the few Southern states to expand Medicaid under the ACA, a decision that brought hundreds of millions of federal dollars into the state.

Nine other states have requests pending with CMS to enact a Medicaid work requirement.

In Arkansas, enrollees who don’t work or volunteer at least 80 hours a month could lose coverage as early as September. The work requirement exempts many people such as those with opioid addiction and parents with dependent children.

Verma said the work requirement “is about helping people rise out of poverty to achieve the American dream.”

But advocates for the poor blasted the move, noting most Medicaid enrollees already work, go to school or are taking care of sick relatives.

“The Trump administration’s approval of Arkansas’ harsh work requirement in Medicaid will likely set back the state’s considerable progress under the Affordable Care Act in increasing coverage and improving access to care, health and financial stability for low-income Arkansans,” said Judith Solomon, vice president for health policy at the left-leaning Center on Budget and Policy Priorities.

Arkansas officials said they need the work requirement because without it many enrollees won’t seek out work or job training. Since January 2017, fewer than 5 percent of Medicaid enrollees who were referred to the state Department of Workforce Services to help with job training followed through and accessed services.

Upsurge Of Suburban Poor Discover Health Care’s Nowhere Land

February 09, 2018

The promise of cheaper housing brought Shari Castaneda to Palmdale, Calif., in northern Los Angeles County, about nine years ago.

The single mom with five kids had been struggling to pay the bills. “I kept hearing that the rent was a lot cheaper out here, so I moved,” she said.

But when she developed health problems — losing her balance and falling — Castaneda found fewer care options in her new town. Unable to find local specialty care, she traveled nearly 65 miles to a public hospital in Los Angeles, where doctors discovered a tumor on her spine.

Then she had to drive nearly 75 miles to the City of Hope cancer center in Duarte, Calif., for an operation to remove the growth. The procedure left her partially paralyzed. “I walked into the hospital and I never really walked again.”

Castaneda, 58, receives Social Security disability payments and is enrolled in Medi-Cal, the state’s Medicaid program for low-income people. “There are no doctors available here,” said Castaneda. “I called every single one of them in the book, and nobody takes Medi-Cal out here.” Instead, Castaneda now sees doctors nearly 50 miles away in Northridge.

Suburbs in the United States, often perceived as enclaves of the affluent, are home to nearly 17 million Americans who live in poverty — more than in cities or rural areas — and growing demand for care strains the capacity of suburban health services to provide for them, according to a recent study in Health Affairs. Suburban areas have historically received a fraction of health funding that cities have, leaving them with inadequate infrastructure and forcing people like Castaneda to scramble for the medical attention they need.

The Health Affairs study found that about a fifth of the suburban poor are uninsured, and many who do have health insurance — especially people on Medi-Cal — either can’t find providers or must travel far for appointments.

The Affordable Care Act cut California’s uninsured rate from 17 percent in 2013 to about 7 percent last year due largely to the Medicaid expansion, which added more than 3.7 million adults to the state’s Medi-Cal rolls. But that has not ensured access to health care for millions of suburbanites, said Alina Schnake-Mahl, a doctoral candidate at the Harvard T.H. Chan School of Public Health in Boston, who was lead author of the Health Affairs study.

“That really goes against the idea that everyone in the suburbs is insured because everyone has a white-collar job with coverage,” she said.

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Coverage doesn’t equate to care even for patients with Medi-Cal, as Castaneda can attest. Before the health law, they had trouble finding doctors who would see them because of Medi-Cal’s low payment rates. That problem intensified as millions more signed up for Medi-Cal, driving many enrollees to seek services at safety-net care facilities.

Health care services in the suburbs “are not robust enough to fill the needs” of a growing low-income population, said Charlie Gillig, supervising attorney at the Health Consumer Center of Neighborhood Legal Services of Los Angeles County, which has advised Castaneda about medical transportation services under Medi-Cal.

One-half of California’s 39 million residents live in suburbs, and rates of poverty among them range from nearly 25 percent around Bakersfield, in the Central Valley, to about 8 percent in the suburbs outside San Francisco, according to an analysis by Elizabeth Kneebone, research director at University of California-Berkeley’s Terner Center for Housing Innovation and a senior fellow at the Brookings Institution. The same analysis showed that 2.7 million suburban Californians lived below the poverty line in 2016, compared with 1.9 million in major cities.

Castaneda, who uses an oversized power wheelchair, says it’s difficult — “often impossible” — to arrange for a ride in a van. Getting to the doctor has become a long, painful ordeal.

And that’s if she can even schedule a visit, said Castaneda, noting that she also faces long wait times for her doctor in Northridge, a suburb that has seen an influx of patients from poorer areas. “You can’t get an appointment when you’re sick … so I’ve just been waiting and waiting,” she said. “They told me, ‘If you get sick enough, just go to the emergency room.’”

Of course, it can also be tough to get a clinic appointment or see a specialist in cities, but in the suburbs, Gillig said, “geography exacerbates an already existing problem.”

In his recent book on the changing geography of poverty, Scott Allard, a professor of public policy and governance at the University of Washington, showed that funding for human services was as much as eight times higher in urban areas than in the suburbs.

California’s metropolitan areas have had many decades to build up massive health care systems to serve the poor, including county hospitals, federally qualified health centers and community clinics. But the current scale of suburban poverty is a recent development.

Policymakers struggle to serve the health needs of cities in eastern Contra Costa County, about 50 miles from San Francisco. In Oakley, for example, business and community leaders lobbied hard for a new health center, which opened in 2011.

“There’s a huge need out here, especially for people who are undocumented or uninsured. They don’t have anywhere else to go,” said Leticia Cazares, regional manager for La Clinica, which operates the new health center. The clinic has two doctors and a nurse practitioner to serve 3,000 patients, most of whom are on Medi-Cal.

Many of the people who visit community clinics like the one in Oakley lack insurance, either because they are undocumented immigrants or because they make too much money to qualify for Medi-Cal — or subsidized coverage under Obamacare — and can’t afford it on their own.

Alex G.’s family fits both scenarios. Her husband, Edward, and 8-year-old son — also named Alex — are U.S. citizens, but she is an undocumented immigrant. The family lives in Brentwood, a town of about 60,000 in eastern Contra Costa County.

A 32-year-old community college student who declined to give her last name for fear of deportation, Alex has applied for permanent residency — a long process with an uncertain outcome.

Her husband has “a good job” as a programmer of industrial machines. He has employer-based insurance, but it covers only him. For Alex and her son to be covered, the family would have to pay $1,200 a month. Given California’s high cost of living, “we just can’t afford to pay that,” Alex said. Her husband’s salary of $70,000 is too high for Medi-Cal or Obamacare subsidies.

Alex recently experienced sharp stomach pains and had to wait several days for a mobile clinic that parks in front of a nearby community center once a week.

Whenever her son has an ear infection or a fever, Alex takes him to the free mobile clinic. “Not having insurance, I worry all the time about him getting sick,” she said.

Podcast: KHN’s ‘What The Health?’ The State Of The (Health) Union

January 31, 2018

In his first State of the Union Address, President Donald Trump told the American public that “one of my greatest priorities is to reduce the price of prescription drugs.” But that message could barely begin to sink in before other health news developed: The director of the Centers for Disease Control and Prevention was forced to resign Wednesday after conflict-of-interest reports.

Meanwhile, outside the federal government, Idaho is proposing to allow the sale of individual insurance policies that specifically violate portions of the Affordable Care Act. And three mega-companies — Amazon, Berkshire-Hathaway, and JPMorgan Chase — say they will partner to try to control costs and improve quality for their employees’ health care.

This week’s “What The Health?” panelists are Julie Rovner of Kaiser Health News, Alice Ollstein of Talking Points Memo and Julie Appleby and Sarah Jane Tribble of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Despite Trump’s strong rhetoric in the State of the Union Address, the president has taken few actions during his first year in office to reduce drug prices.
  • The president touted that Republicans had repealed the health law’s requirement that individuals get health insurance or pay a penalty. But that change in the law doesn’t go into effect until 2019, so his comments could be confusing to some taxpayers.
  • Idaho officials have announced that they are going to allow insurers to issue policies that don’t meet all the criteria of the federal health law. But it’s not clear that insurers are interested in participating in the experiment.
  • “Alexa, send me my Lipitor!” Can Amazon’s announcement that it and two other corporate behemoths are taking on employees’ health care create a new formula for keeping costs down and improving quality? Email Sign-Up

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

Julie Rovner: Kaiser Health News’ “No Car, No Care? Medicaid Transportation At Risk In Some States,” by JoNel Aleccia.

ALSO: JAMA’s “Are Medicaid Work Requirements Legal?” by Nicholas Bagley.

Alice Ollstein: Politico’s “Trump’s Top Health Official Traded Tobacco Stock While Leading Anti-Smoking Efforts,” by Sarah Karlin-Smith and Brianna Ehley.

Julie Appleby: The Atlantic’s “Why We Forget Most of the Books We Read,” by Julie Beck.

Sarah Jane Tribble: The New York Times’ “5-Year-Olds Work Farm Machinery, And Injuries Follow,” by Jack Healy.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

No Car, No Care? Medicaid Transportation At Risk In Some States

January 30, 2018

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

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EVERETT, Wash. — Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” said Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” said Holt. “Now that she’s older and more disabled, it’s crucial.”

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. The numbers have grown dramatically since the program expanded in 32 states plus the District of Columbia to cover prescription drugs, health screening for children, breast and cervical cancer treatment and nursing home care.

With a Republican administration vowing to trim Medicaid, Kaiser Health News is examining how the U.S. has evolved into a Medicaid Nation, where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid’s role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent, by Texas researchers.

Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

Already, states have wide leeway in how to provide and pay for the transportation.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn’t take place. She was sentenced to 30 days in jail and ordered to pay $21,500.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reversed the Affordable Care Act’s Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

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Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March letter to them.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, said Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman called the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

CMS released results of a 2014 survey of Medicaid users, which found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman said. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is cost-effective. For four of those conditions — prenatal care, asthma, heart disease and diabetes — medical transportation saved money when the total costs for both transportation and health care were tallied.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Most states rely on NEMT brokers or managed-care organizations to administer the transportation services. Other states run the service directly, paying providers on a per-ride basis, while some use local ride services and pay independent taxi firms to shuttle patients.

Meagan Holt wheels daughter Maddie outside for a ride to Seattle Children’s Hospital on Nov. 21, 2017. Holt doesn’t drive due to serious vision problems and can’t afford a car. (Heidi de Marco/KHN)

Dr. Molly Fuentes examines the mobility of Maddie Holt’s arms on Nov. 21, 2017. (Heidi de Marco/KHN)

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Still, Medicaid clients like Fallon Kunz, 29, of Mishawaka, Ind., are often stuck. Kunz, who has cerebral palsy, migraine headaches and chronic pain, uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she said.

Today, she lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she said. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The only way I can get rides to and from my doctor’s appointment is to ride the 2 miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she said. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she said on a December Tuesday. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she was shuttled to Seattle Children’s on a rainy Tuesday morning in a medical van driven by Donavan Dunn, a 47-year-old former big-rig trucker. He works for Northwest Transport, one of several regional brokers that manage NEMT services for Washington state.

Dunn said he received special training to transport patients like Maddie, who is loaded onto a motorized platform, wheelchair and all, into the van and then carefully strapped in.

“I have to drive different,” said Dunn. “I have to watch my corners, watch my starts, watch my stops. It’s always in the back of my mind that I have somebody on board that’s fragile.”

We’re talking about a lifesaving aspect of the Medicaid program. Eliot Fishman, senior director of health policy for Families USA

Dr. Molly Fuentes examines the mobility of Maddie Holt’s arms. (Heidi de Marco/KHN)

The transportation service can be used only for medical visits to the specialists who treat Maddie’s condition, which is caused by mutations in any one of at least 12 genes. If Meagan Holt needs to pick up prescriptions or get groceries, she leaves Maddie and a second daughter, Olivia, 3, at home with their dad and takes the bus or walks to her destinations.

Caring for a severely disabled child is not the life she expected, Meagan Holt said, but she cherishes time with Maddie, who has learned to communicate through tactile sign language spelled into her hand.

“She knows about 100 words. She knows the alphabet,” Meagan said. “She likes Disney princesses. She loves ‘Frozen.’”

Maddie is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” said Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick added. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients — and bad for the country.

In a 2016 Health Affairs essay, Verma noted that early analysis of the effects of curtailing NEMT in Indiana showed that more Medicaid patients with access to the program said transportation was a primary reason for missed appointments than did members without access.

“Moreover, 90 percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” she wrote.

But Marsha Simon, a Washington, D.C., health policy consultant who has tracked NEMT for years, said Medicaid is the option of last resort. People who are able to get rides on their own already do.

“If 90 percent can and 10 percent can’t, what about the 10 percent?” Simon said.

It’s a question that haunts Kunz every day.

“I’m a college student, I have a cat,” said Kunz, who is studying psychology online at Southern New Hampshire University. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

Death In The Family: An Uncle’s Overdose Spurs Medicaid Official To Change Course

January 29, 2018

Andrey Ostrovsky’s family did not discuss what killed his uncle. He was young, not quite two weeks past his 45th birthday, when he died, and he had lost touch with loved ones in his final months. Ostrovsky speculated he had committed suicide.

Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle died of a drug overdose.

His family knew the uncle’s life had been turbulent for a while before his death, watching as he divorced his wife and became estranged from his 4-year-old daughter and eventually lost his job as a furniture store manager. But Ostrovsky wanted to understand what happened to his uncle, his stepfather’s younger brother. So, last fall when he found himself in southeastern Florida, where his uncle died in 2015, he contacted one of his uncle’s friends for what he thought would be a quick cup of coffee.

Instead the friend “let loose,” revealing that they had been experimenting with a variety of drugs the night his uncle died — the tragic culmination of more than a decade of substance abuse much of his family knew nothing about. An autopsy showed there were opiates and cocaine in his system, Ostrovsky later learned.

The revelation shook Ostrovsky, a pediatrician appointed to the Centers for Medicare & Medicaid Services in 2016. He had championed better drug treatment programs for the 74 million people on Medicaid — an increasingly uphill battle after Republicans signaled they would trim the program under President Donald Trump.

Within his own agency, Ostrovsky already felt that he was something of a pariah. After he’d posted a tweet against a Republican plan to repeal and replace the Affordable Care Act, he was reprimanded and removed from his major projects. A conservative group known as America Rising filed a Freedom of Information Act request for his email correspondence, a move seen as an attempt to intimidate Ostrovsky.

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But that revelation over coffee in Florida made the drug crisis deeply personal for Ostrovsky and his family, prompting him to act. He realized that solutions were not just about money, but also about combating stigma, that stain he says prevented his uncle from getting help. So, he quit his government job last month and is speaking publicly about his family’s experience, to remove the shame of drug addiction.

“It’s not what killed him,” Ostrovsky says, referring to the stigma. “But that’s what killed him.”

Last fall, the Trump administration declared the opioid crisis a public health emergency, stopping short of allocating more funding for an “epidemic” that killed more than 42,000 in 2016 — more than any year on record, according to the Centers for Disease Control and Prevention. That declaration was extended last week. Early data indicate 2017 may have outpaced 2016 in drug deaths.

In one of the latest attempts to manage the crisis, Democratic Gov. Tom Wolf of Pennsylvania recently declared the opioid epidemic a statewide disaster emergency. For the first time, Pennsylvania officials will direct emergency resources toward a public health crisis in the same way they would a natural disaster.

The uncle’s story offers an intimate look at a crisis that has vexed officials on the local, state and national level, strained public health resources — and infiltrated not just America’s streets and drug dens, but also workplaces and successful middle-class families like Ostrovsky’s. KHN agreed not to disclose the uncle’s name out of respect for his family’s privacy.

The uncle immigrated to the United States from Azerbaijan when he was 16, seeking a brighter future than the one stretched before him in the crumbling Soviet Union, Ostrovsky recalled. His family settled in Baltimore, where he married and started his own family. When he wasn’t working, he grilled lamb kebabs and danced to music from his home country. He was a warm, welcoming host, insisting guests have at least a cup of tea.

“Even when he had nothing, he would take that last piece of bread and offer it to you,” Ostrovsky says.

Andrey Ostrovsky (Courtesy of Andrey Ostrovsky)

To Ostrovsky, he was the “cool uncle,” always bringing his nephew trinkets from his travels. When Ostrovsky was in seventh grade, his uncle returned from Jamaica with a shirt that read: “See no evil, hear no evil, speak no evil, s— happens mon.” Ostrovsky wore it to school — and happily suffered the inevitable punishment. “I love him for that and was proud to get in trouble,” he wrote in an email.

Sometime around the early 2000s, the uncle and his wife divorced. He began drinking more, a vice Ostrovsky attributed in part to his cultural heritage but that he suspects grew into alcoholism.

It is unclear to the family when, exactly, drugs came into his life, though his problems seem to have escalated in his 30s. His drug of choice was cocaine, Ostrovsky learned from his uncle’s friend, who frequently took drugs with him over the years.

His inability to function at work and other financial strains eventually drove him to crack cocaine, an especially addictive, cheaper form that produces an instant, intense high when smoked. Months before his death, he lost his job and grew depressed. He began using more heavily and trying new drugs. He dabbled in benzodiazepines, a class of psychoactive drugs like Xanax and Valium, and opioids.

Opioids, which broadly include both illegal drugs like heroin and prescription painkillers like OxyContin, are particularly perilous when misused because they suppress the ability to breathe. Those who use opioids also build up a tolerance over time, encouraging them to use more to achieve a high. These facts are especially problematic considering street drugs are often cut with more powerful opioids — such as fentanyl, a fast-acting painkiller — to create a more intense high.

Eventually, Ostrovsky’s uncle began living with his drug dealer. On the night of his death, he and his friend went through the dealer’s stash when he was out, trying pills and other drugs. When the dealer returned, after the friend had left, the uncle didn’t answer the door.

They found him on the couch, looking “at peace,” his friend recounted to Ostrovsky. They tried to resuscitate him and called for help. Sitting on the curb outside, his friend watched the paramedics carry him away.

The friend says he quit using drugs and is enrolled in a methadone program, a treatment option that uses another opioid to reduce withdrawal symptoms.

Hampered by political ideology from the White House that has spurred a focus on overhauling Medicaid benefits, for instance, Ostrovsky says his former agency, CMS, is “ill-equipped” right now to handle this problem. So, for now, he’s working outside the government.

This month, Ostrovsky announced he is joining Concerted Care Group, an addiction treatment program based in Baltimore whose patients are mostly covered by Medicaid, where he will serve as CEO as the organization looks to expand.

Ostrovsky first noticed Concerted Care Group when it was part of a CMS pilot program, a standout because it eschewed the surreptitious-feeling grab-and-go approach of most outpatient addiction centers. “This can’t be a methadone clinic,” Ostrovsky thought when he first heard about it.

It offered patients private spaces to take their medicine; security guards to ensure their safety; even coffee while they wait, preserving at least a modicum of patient dignity. In the same spirit, Ostrovsky hopes that sharing his personal story about his uncle will combat the stigma that makes patients and their loved ones ashamed to reach out for help.

“I think this is really important, that people hear about his story and talk,” he says, “and get over that feeling of not wanting to have that uncomfortable conversation with my family member who needs help.”

How The Shutdown Might Affect Your Health

January 19, 2018
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A government shutdown will have far-reaching effects for public health, including the nation’s response to the current, difficult flu season. It will also disrupt some federally supported health services, experts said Friday.

In all, the Department of Health and Human Services will send home — or furlough — about half of its employees, or nearly 41,000 people, according to an HHS shutdown contingency plan released Friday.

Here are some federal services and programs consumers might be wondering about:


According to the HHS plan, the CDC will suspend its flu-tracking program. That’s bad timing, given the country is at the height of a particularly bad flu season, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. Without the CDC’s updates, doctors could have a harder time diagnosing and treating patients quickly, he said.

Although states will still track flu cases, “they won’t be able to call CDC to verify samples or seek their expertise,” said Dr. Thomas Frieden, who was the director of the agency during the 2013 government shutdown.

A government shutdown will also affect the CDC’s involvement in key decisions about next year’s flu vaccine, which are scheduled to be made in coming weeks, said Dr. Arnold Monto, a professor of global public health at the University of Michigan.

Beyond the flu, the CDC will provide only “minimal support” to programs that investigate infectious-disease outbreaks. The Atlanta-based agency’s ability to test suspicious pathogens and maintain its 24-hour emergency operations center will be “significantly reduced,” according to the plan.

That could prevent the CDC from identifying clusters of symptoms and disease “that are the earliest indicators of outbreaks,” Frieden said.


Although the NIH will continue to treat patients at its clinical center in Bethesda, Md., the agency will not enroll new patients in clinical trials — which many people with life-threatening illnesses see as their last hope.

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Beneficiaries will be largely unaffected by a shutdown, especially if it is short. Patients will continue to receive their insurance coverage, and Medicare will continue to process reimbursement payments to medical providers. But those checks could be delayed if the shutdown is prolonged.


States already have their funding for Medicaid through the second quarter, so no shortfall in coverage for enrollees or payments to providers is expected. Enrolling new Medicaid applicants is a state function, so that process should not be affected.

States also handle much of the Children’s Health Insurance Program (CHIP), which provides coverage for lower-income children whose families earn too much to qualify for Medicaid. But federal funding for CHIP is running dry — its regular authorization expired on Oct. 1, and Congress has not agreed on a long-term funding solution. Federal officials announced Friday that the staff necessary to make payments to states running low on funds will continue to work during a shutdown.


According to the HHS plan, the Health Resources and Services Administration will continue to operate the nation’s 1,400 community health centers — clinics that serve about 27 million low-income people, providing preventive care, dentistry and other basic services. It will also continue the Maternal, Infant and Early Childhood Home Visiting Program, which targets low-income and at-risk families with house calls and lessons for healthy parenting. That program served about 160,000 families in fiscal year 2016.

But even those programs may not be at full speed. Funding for community health centers and the home visiting program was not renewed last fall — a casualty of Congress’ fight over the CHIP reauthorization — so, they are operating on left-over funds.


The shutdown will not affect some of the most politically charged health care programs, including ones created by the Affordable Care Act. Subsidies for people who get their health insurance through or state marketplaces will not be affected, according to HHS.


Staffing for the Department of Veterans Affairs will remain largely intact. “Even in the event that there is a shutdown, 95.5 percent of VA employees would come to work, and most aspects of VA’s operations would not be impacted,” said department press secretary Curtis Cashour in an email.

More than 99 percent of employees of the Veterans Health Administration, which runs the health care system, will continue working, according to the department’s contingency plan.

However, the Veterans Benefits Administration, responsible for overseeing benefits such as life insurance and disability checks, will face larger cutbacks. Over a third of its employees face furlough under a government shutdown.


In the short term, the crucial activities that protect consumers will get done, said Jill Hartzler Warner, who was the associate commissioner for special medical programs at the FDA during the 2013 shutdown.

Programs that are critical for the public safety will continue, as will positions paid for by user fees, including work under the Center for Tobacco Products, according to the HHS plan.

The hundreds of staff members who conduct sample analysis and review entry of products into the U.S. will continue to work. However, routine inspections and laboratory research will cease.

Warner, who left the agency in March 2017 and now works as an industry consultant, said grants for rare-disease drug development were determined in 2013 to not be necessary and were postponed.


The Administration for Community Living will not be able to fund federal senior nutrition programs during any shutdown, according to HHS officials. But it was not immediately clear how quickly clients would be affected.

A shutdown could delay federal reimbursements to independent Meals on Wheels programs, which serve more than 2.4 million seniors nationwide, according to Colleen Psomas, a spokeswoman for Meals on Wheels America. That could force programs to expand waiting lists for meals, reduce meals or delivery days, or suspend service, she said.

The magnitude of the effect could vary by the length of the shutdown and any final allocation. Some programs, however, could weather a shutdown, staffers said. In Portland, Ore., Meals on Wheel People spokeswoman Julie Piper Finley said meal delivery there will not be suspended. That agency receives about 35 percent of its funding through the Older Americans Act, but raises the rest of the money, ensuring that services are not disrupted.

Meanwhile, services connected to food and nutrition services for other needy populations are likely to keep operating with state partners who have funding through February and, in some cases, March, according to a Department of Agriculture spokesperson. Those programs include the Supplemental Nutrition Assistance Program, the Child Nutrition Programs and the Special Supplemental Nutrition Program for Women, Infants and Children.


The FDA’s food safety programs will cease, according to the HHS plan, but inspections conducted by Agriculture’s Food Safety and Inspection Service (FSIS) will continue.

Meat and poultry inspections are “such a critical, essential task, and the meat and poultry inspection acts require that inspectors be present continuously,” otherwise processing plants would have to close, said Brian Ronholm, former head of FSIS who now works for the law firm Arent Fox.

Ronholm added that many FSIS employees are “career folks” who have worked there through previous government shutdowns. “There was a lot of built-in knowledge of how to function during the [2013] shutdown,” he said, adding that this expertise would help the agency if there is another shutdown.

Staff writers JoNel Aleccia, Julie Appleby, Carmen Heredia Rodriguez, Shefali Luthra,  Jordan Rau, Stephanie Stapleton, Liz Szabo, Sarah Jane Tribble and Lydia Zuraw contributed to this report.

This article was updated on Jan. 20 to reflect that the deadline for government funding had passed without an agreement in Congress.