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Updated: 21 hours 50 min ago

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:

CENTERS FOR DISEASE CONTROL AND PREVENTION

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.

NATIONAL INSTITUTES OF HEALTH

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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MEDICARE

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.

MEDICAID

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.

COMMUNITY HEALTH CENTERS

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.

ACA PREMIUM SUBSIDIES

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 healthcare.gov or state marketplaces will not be affected, according to HHS.

VETERANS AFFAIRS

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.

FOOD AND DRUG ADMINISTRATION

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.

NUTRITION SERVICES FOR SENIORS

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.

FOOD SAFETY

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.

Dangling A Carrot For Patients To Take Healthy Steps: Does It Work?

December 05, 2017

Patricia Alexander knew she needed a mammogram but just couldn’t find the time.

“Every time I made an appointment, something would come up,” said Alexander, 53, who lives in Moreno Valley, Calif.

Over the summer, her doctor’s office, part of Vantage Medical Group, promised her a $25 Target gift card if she got the exam. Alexander, who’s insured through Medi-Cal, California’s version of the Medicaid program for lower-income people, said that helped motivate her to make a new appointment — and keep it.

Health plans, medical practices and some Medicaid programs are increasingly offering financial incentives to motivate Medicaid patients to engage in more preventive care and make healthier lifestyle choices.

They are following the lead of private insurers and employers that have long rewarded people for healthy behavior such as quitting smoking or maintaining weight loss. Such changes in health-related behavior can lower the cost of care in the long run.

“We’ve seen incentive programs be quite popular in the insurance market, and now we are seeing those ramp up in the Medicaid space as well,” said Robert Saunders, research director at the Margolis Center for Health Policy at Duke University.

Medicaid patients who agree to be screened for cancer, attend health-related classes or complete health risk surveys can get gift cards, cash, gym memberships, pedometers or other rewards. They may also get discounts on their out-of-pocket health care costs or bonus benefits such as dental care.

Under the Affordable Care Act, 10 states received grants totaling $85 million to test the use of financial rewards as a way to reduce the risk of chronic disease among their Medicaid populations. During the five-year demonstration, states used the incentives to encourage people to enroll in diabetes prevention, weight management, smoking cessation and other preventive programs. The states participating were California, Connecticut, Hawaii, Minnesota, Montana, Nevada, New Hampshire, New York, Texas and Wisconsin.

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Medi-Cal, for example, offered gift cards and nicotine replacement therapy to people who called the state’s smoking cessation line. Minnesota’s Medicaid program handed out cash to people who attended a diabetes prevention class and completed bloodwork.

An evaluation of these programs, released in April, showed that incentives help persuade Medicaid beneficiaries to take part in such preventive activities. Participants said gift cards and other rewards also helped them achieve their health goals. But the evaluators weren’t able to show that the programs prevented chronic disease or saved Medicaid money. That’s in part because those benefits could take years to manifest, according to the evaluation.

Overall, research on the effectiveness of financial incentives for the Medicaid population has been mixed. A report this year by the Center on Budget and Policy Priorities found that they can induce people to keep an appointment or attend a class but are less likely to yield long-term behavior changes, such as weight loss. And in some cases, the report said, incentives are given to people to get exams they would have gotten anyway.

The center’s report also found that penalties, including ones that limit coverage for people who don’t engage in healthful behaviors, were not effective. Instead, they can result in increased use of emergency rooms by restricting access to other forms of care, the report said.

Some of the biggest factors preventing Medicaid patients from adopting healthful behaviors are related not to medical care but to their circumstances, said Charlene Wong, a pediatrician and health policy researcher at Duke University.

That makes administering incentive programs more complicated. Even recruiting and enrolling participants has been a challenge for some states that received grants through the Affordable Care Act.

“The thing that is most likely to help Medicaid beneficiaries utilize care appropriately is actually just giving them access to that care — and that includes providing transportation and child care,” said Hannah Katch, one of the authors of the report by the Center on Budget and Policy Priorities. Another barrier is being able to take time off work to go to the doctor.

But health plans are eager to offer patients financial incentives because it can bring their quality scores up and attract more enrollees. And medical groups, which may receive fixed payments per patient, know they can reduce their costs — and increase their profits — if their patients are healthier.

Providing incentives to plans and medical groups has created a business opportunity for some companies. Gift Card Partners has been selling gift cards to Medicaid health plans for about five years, said CEO Deb Merkin. She said health insurers that serve Medicaid patients want to improve their quality metrics, and they can do that by giving incentives and getting patients to the doctor.

“It is things like that that are so important to get them to do the right thing so that it saves money in the long run,” she said.

Agilon Health, based in Long Beach, Calif., runs incentive programs and other services for several California medical groups that care for Medi-Cal patients. The medical groups contract with the company, which provides gift cards to patients who get mammograms, cervical cancer exams or childhood immunizations. People with diabetes also receive gift cards if they get their eyes examined or blood sugar checked. And the company offers bonuses to doctors if their Medicaid patients embrace healthier behaviors.

The incentives for patients are “massively important for the Medicaid population, because the gaps in care are historically so prevalent,” said Ron Kuerbitz, CEO of Agilon. Those gaps are a big factor pushing up costs for Medicaid patients, because if they don’t get preventive services, they may be more likely to need costlier specialty care later, Kuerbitz said.

Emma Alcanter, who lives in Temecula, Calif., received a gift card from her doctor’s office after getting a mammogram late this summer. Alcanter, 56, had noticed a lump in her breast but waited about two years before getting it checked, despite reminders from her doctor’s office. “I was scared they were going to find cancer,” she said.

Alcanter finally decided to get screened after her first grandchild was born. The gift card was an added bonus, and Alcanter said it showed her doctors cared about her. Her mammogram revealed that the lump wasn’t cancer, and she plans to use the gift card to buy a present for her grandson.

The Storm Has Passed, But Puerto Rico’s Health Faces Prolonged Recovery

October 16, 2017

As President Donald Trump signals impatience to wind down emergency aid to Puerto Rico, the challenges wrought by Hurricane Maria to the health of Puerto Ricans and the island’s fragile health system are in many ways just beginning.

Three weeks after that direct hit, nearly four dozen deaths are associated with the storm. But the true toll on Puerto Rico’s 3.4 million residents is likely to involve sickness and loss of life that will only become apparent in the coming months and in indirect ways.

As victims continue to be found and stranded people reached, it will take time to assess the consequences of their missed care or undertreatment.

The situation in Puerto Rico’s health system is far more vulnerable than those in Texas or Florida, which also weathered hurricanes this fall — medically, economically and politically. A month after Hurricane Katrina in 2005, only about half of the final official fatalities had been tallied.

This KHN story also ran in Stat. It can be republished for free (details).

Puerto Rico has a higher rate of diabetes than any state, according to 2015 data from the U.S. Centers for Disease Control and Prevention. About half of the island’s population depends on Medicaid. And, unlike in the States, Puerto Rico’s Medicaid system receives a fixed amount to meet residents’ needs, a pot of money that could run dry next month, said Jenniffer González-Colón, Puerto Rico’s delegate to Congress.

“We’ve had a fiscal crisis, a Medicaid funding cliff, Hurricane Irma and Hurricane Maria —we are being hit from every angle,” she said.

Orlando Gutiérrez, an associate professor of nephrology at the University of Alabama-Birmingham and a board member of the American Kidney Fund, said Puerto Rico is the “perfect storm” for a disaster.

The Federal Emergency Management Agency has distributed food and water to help stave off disease or dehydration, relief workers have prioritized efforts to get hospitals and other health facilities operating again, and the Navy dispatched the hospital ship USNS Comfort, which has 250 beds.

Coordinated efforts to deliver fuel, water and medications to health facilities have allowed some to reopen. As of Oct. 12, federal emergency officials said nearly all Puerto Rican hospitals were open, although some are still dependent on generators. The Puerto Rican government said electricity has been restored to more than half of the hospitals. Nearly all of the dialysis centers are operating now, though many patients have missed treatments.

But Katia León, deputy director of primary care for the Association of Primary Care in Puerto Rico, said she believes the population’s health has worsened since the storm hit. Cases of diarrhea, pink eye and skin rashes are appearing in larger numbers, she said, and health officials are concerned about infections from contaminated water.

The potential for outbreaks means it is now more important than ever to keep clinics open, León said, even though the operating costs are likely to be high.

“We are talking about a situation that is going to continue in the long term … because this is a crisis without precedent,” she said.

Many residents are still unable to get to clinics or health centers for their chronic health conditions, such as diabetes or heart disease. Diabetes test strips and dialysis equipment have been in short supply since the storm. Patients went days or weeks without medication and treatment. Nutritious food and working refrigerators to store it in are scarce.

Some medicines are in tight supply or require arduous travel to secure.

Slow gains to provide electricity threaten patients on dialysis, who rely on power to filter their blood and survive. And mental trauma caused by the storm will linger long after buildings are reconstructed.

In addition, Puerto Rico was already facing a significant “brain drain,” as many young professionals, including doctors, moved to the U.S. mainland, said Andrew Schroeder, who works for DirectRelief, a private charity that has been coordinating shipments of medical supplies to the island. It will be an uphill battle to persuade these doctors and other health specialists to stay on the island now.

Hospitals and health clinics are working hard to get back to speed. Eddie Perez-Caban, the executive director of the Camuy Health Services clinic on the western side of Puerto Rico, said he was astonished after making the 25-minute commute through downed wires and fallen electric poles the day after Maria hit. He found a damaged roof, a broken air conditioning system and no electricity or running water — and about 75 of his employees ready to work. Five days later, the clinic opened with running water and AC and light powered by a generator.

“For so many people to show up — truthfully, it filled me with a lot of satisfaction to work with a group of people that have that commitment to the community and the patients we serve,” he said.

Republican leaders in the House of Representatives have proposed allotting an additional $1 billion for Puerto Rico’s Medicaid program to resupply its coffers as part of a bill that would extend the Children’s Health Insurance Program. But the legislation has been stalled in committee.

Puerto Rico’s program is different than those in the States. While states receive open-ended federal funding, Puerto Rico’s annual funding amount is capped — typically at more than $300 million. Nearly half of the island’s residents rely on the program for coverage. If the money runs out, as many as 900,000 beneficiaries could lose their health coverage, according to estimates from the Department of Health and Human Services under the Obama administration.

Another bill under consideration in Congress could offer Puerto Rico millions of dollars in disaster relief, an effort that has broad support. More than 6 in 10 Americans said Puerto Rico isn’t getting all the help it needs yet, and more than half said the emergency response has been too slow, with the federal government not doing enough to restore electricity and access to food and water, according to a poll released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

In Puerto Rico, most of the roughly four dozen dialysis centers are now seeing patients, though that service is dependent on getting shipments of fuel to power generators and water and dialysis solution for the treatments. Some clinics are shortening their hours and the time of treatment. Instead of four-hour treatments, patients are receiving only three hours of dialysis, which saves on staffing time, supplies and use of generators.

Mike Spigler, an official with the American Kidney Fund, who is handling some of the emergency response for kidney patients on the island, describes the situation as “tenuous.”

In the short term, patients can function without dialysis, or with limited treatments. But as time goes on, the risk of heart failure and stroke begins to climb.

Schroeder also said he is worried about mental health services, which often get lower priority than food and shelter after a storm. He said people are traumatized and, without counseling, anxiety and depression could become major public problems. Multiple news outlets report that two of the island’s 34 total deaths attributed to the hurricane were suicides.

Older residents of the island are particularly vulnerable to mental trauma in the aftermath of the storm, said José Acarón, the director of the Puerto Rican branch of AARP. Approximately 1.2 million people in Puerto Rico are 50 or older, Acarón said. Many of them live outside of traditional nursing homes or independent living facilities, making them harder to reach.

“We still have a lot of challenges to overcome before things can go back to normal,” said Acarón. “But a return to normal is not going back to where we were before the hurricane. It’s a new normal.”

Staff writer Phil Galewitz contributed to this article.

10 Ways Medicaid Affects Us All

October 05, 2017

Medicaid was created in 1965 as a program for the poor. Today, it helps 74 million people — more than 1 of every 5 people in the U.S. You or someone you know likely benefits.

Big School Booster

Medicaid paid for nearly $4 billion in school-based health care services in 2015.

Dependent Children

Medicaid aimed, at its start, to insure healthy children and pregnant women. Children are still the largest demographic group served. How Medicaid coverage breaks down:

Where The Money Goes

But a look at who benefits from Medicaid spending shows a different story.

Sustaining Livelihoods

About 60 percent of non-disabled Medicaid adult enrollees have a job.

Balance For Mental Health

Medicaid is the single-largest payer for mental health services in the U.S. and increasingly picks up the bill for substance abuse treatment.

Academic Achievement

Many adults under age 65 receiving Medicaid are well-educated.

Coverage Forecast

Most Medicaid enrollees churn in and out of the program every few years, depending on their circumstances. Odds are 1 in 4 you might need this safety net one day.

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