Seeking to Grow Market Share?

Get a FREE assessment of your CDH products —
a $3,000 value.
LEARN HOW >

Podcast: KHN’s ‘What The Health?’ States Race To Reverse ‘Roe’

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-90971607017c5fc1cdce4ca58c77b28f') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-90971607017c5fc1cdce4ca58c77b28f' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

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

Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Alice Miranda Ollstein

Politico

@AliceOllstein

Read Alice's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

Alabama is the latest in a growing list of states passing bans on abortion in an attempt to get the Supreme Court to weaken or overturn Roe v. Wade, the 1973 ruling that legalized abortion nationwide. Unlike most of the other state laws that have passed this year, however, the Alabama law would completely ban abortion except when the woman’s life was in danger from the pregnancy.

On Capitol Hill, separate bipartisan groups in the House and Senate unveiled draft proposals to address “surprise” medical bills that patients get when they inadvertently receive care outside their insurance network. The bills take different approaches, however, so it’s not clear where a compromise might lie.

And in Washington state, the legislature has approved a new “public option” health insurance plan — to be run by private insurers — that will become available for consumers who purchase their own insurance.

This week’s panelists are Julie Rovner from Kaiser Health News, Margot Sanger-Katz of The New York Times, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The high court’s justices can pick and choose which cases they take, and many observers think that they are more inclined to deal with abortion on an incremental basis rather than through a radical change like Alabama’s law. A law from Indiana that bans abortions for particular reasons, including gender selection and disability, has been before the court for months.
  • It’s not yet clear if the current spate of state bills will have an impact on the presidential election in 2020, but they could play a role in Senate races in Alabama, Georgia and Maine, among other states.
  • As the effort on surprise medical bills works its way forward, keep an eye on Sen. Lamar Alexander (R-Tenn.), who chairs the committee that handles these measures. He has suggested that he will have another bill to offer on the subject.
  • House Democrats have packed some popular bills to fight rising drug prices with measures to bolster the Affordable Care Act, and Republicans are crying foul. Once again, Sen. Alexander may be a critical player, because he is trying to pull together a measure that deals with drug pricing, surprise medical bills, the cost of health care and the Obamacare marketplaces.
  • Washington has become the first state to embrace a public option insurance plan for its ACA marketplace. But the plan will be run by insurance companies and it’s unclear how that would lead to lower premium prices for consumers.

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

Julie Rovner: The Atlantic’s “Why the Government Pays Billions to People Who Claim Injury by Vaccines,” by James Hamblin

Margot Sanger-Katz: Journal of the American Medical Association’s “Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting,” by Christina A. Roberto, Hannah G. Lawman, Michael T. LeVasseur and others

Alice Miranda Ollstein: The New York Times’ “Why Politics Should Be Kept Out of Miscarriages,” by Aaron E. Carroll

Anna Edney: Kaiser Health News’ “No Mercy: Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?” by Sarah Jane Tribble

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle Play or Spotify.

Trump’s Talk On Preexisting Conditions Doesn’t Match His Administration’s Actions

“We will always protect patients with preexisting conditions, very importantly.”

President Donald Trump on May 9, 2019 in comments delivered during a White House event on surprise medical bills

Delivering remarks on surprise medical billing, which is a concern that has drawn bipartisan interest, President Donald Trump waded into another high-profile health issue: making sure insurance protects people who have preexisting health conditions.

This fact check was produced in partnership with PolitiFact.

This story can be republished for free (details). “We will always protect patients with preexisting conditions, very importantly,” Trump said on May 9.

It’s natural Trump would want to make this claim.

Polling from the Kaiser Family Foundation suggests that such protections, which prohibit individual insurance plans from charging people more based on their medical history, are a top priority for Americans and among the most popular provisions of the Affordable Care Act. (KHN is an editorially independent program of the foundation.)

With that context, we decided to put a microscope to the president’s claim.

We asked White House staff to point us to the policies or proposals on which Trump’s statement was based. They declined to provide specifics but reiterated the president’s assertion.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Texas V. Azar, And A Health Policy Vacuum

Interviews with four separate experts, though, suggested that the administration’s stance on a pending lawsuit that seeks to overturn the Affordable Care Act runs counter to Trump’s claim.

The case, known as Texas v. Azar, comes from a group of Republican attorneys general who argue that the entire health law should be struck because the 2017 tax bill gutted Obamacare’s requirement to have insurance, often called the individual mandate. In December, a Texas judge agreed.

The case is now before the 5th Circuit Court of Appeals. And, most relevant here, the Department of Justice — that is, the Trump administration’s legal arm — has refused to defend the ACA in these proceedings.

It’s highly unusual for an administration to decline to defend a federal law in court.

“This is a case when the department can make strong arguments in defense of the statute. Refusing to defend in those circumstances is almost unprecedented,” said Nicholas Bagley, a law professor at the University of Michigan.

Sources:

President Donald Trump, White House comments, May 9, 2019.

Congressional Budget Office, “How CBO and JCT Analyzed Coverage Effects of New Rules for Association Health Plans and Short-Term Plans,” Jan. 31, 2019.

Kaiser Health News, “Trump Administration Loosens Restrictions On Short-Term Health Plans,” Aug. 1, 2018.

Kaiser Health News, “Trump Administration And Democrats Return Health Law To Political Center Stage,” March 26, 2019.

Kaiser Health News, “A Texas Lawsuit Being Heard This Week Could Mean Life Or Death For The ACA,” Sept. 4, 2018.

Kaiser Health News, “Judge Strikes Down ACA Putting Law In Legal Peril — Again,” Dec. 14, 2018.

Kaiser Family Foundation, “KFF Health Tracking Poll — April 2019: Surprise Medical Bills and Public’s View of the Supreme Court and Continuing Protections for People With Pre-Existing Conditions,” April 24, 2019.

Kaiser Family Foundation, “Poll: The ACA’s Pre-Existing Condition Protections Remain Popular with the Public, including Republicans, As Legal Challenge Looms This Week,” Sept. 5, 2018.

Kaiser Family Foundation, “Why Do Short-Term Health Insurance Plans Have Lower Premiums Than Plans That Comply with the ACA?” Oct. 31, 2018.

Email interview with Jonathan Adler, Johan Verheij Memorial Professor of Law at Case Western Reserve University, May 14, 2019.

Email interview with Wendy Epstein, professor of law and faculty director at the Mary and Michael Jaharis Health Law Institute of DePaul University College of Law, May 14, 2019.

Telephone interview with Sabrina Corlette, professor at Georgetown University’s Health Policy Institute, May 14, 2019.

Telephone interview with Nicholas Bagley, professor at University of Michigan Law School, May 14, 2019.

The New York Times, “Trump Retreats on Health Care After McConnell Warns It Won’t Happen,” April 2, 2019.

The New York Times, “What the Lawless Obamacare Ruling Means,” Dec. 15, 2018.

PolitiFact, “Pre-Existing Conditions: Does Any GOP Proposal Match The ACA?” Oct. 17, 2018.

Urban Institute, “Updated Estimates of the Potential Impact of Short-Term, Limited Duration Policies,” August 2018.

U.S. Department of Justice, “Re: Texas v. United States,” March 25, 2019.

U.S. Senate, “H.R. 1628,” Nov. 24, 2018.

The White House Office of Management and Budget, “Budget for a Better America,” March 11, 2019.

Initially, the Trump administration’s position on the lawsuit focused on the individual mandate, arguing that without it the ACA’s preexisting condition protections should be struck down, too. In filing a brief to the appellate court, though, the DOJ joined the plaintiffs to argue the law should be scrapped entirely. This outcome would also eliminate the law’s protections for people with preexisting health conditions.

In that context, “there is real cause for skepticism” about Trump’s assertion, said Wendy Netter Epstein, a law professor at DePaul University.

The most generous assessment came from Jonathan Adler, a health law expert at Case Western Reserve University. Adler has supported previous Obamacare challenges, but he argued that this one is legally unsound.

He agreed that the White House’s actual actions are “at odds with the president’s promise.”

But, Adler said, the structure of Trump’s claim — promising what his administration “will” do, rather than commenting on what it has done — leaves open the possibility of taking other steps to keep preexisting condition protections in place.

That’s true, other experts acknowledged. So far, the White House has postponed a legislative push until after the 2020 election — leaving a vacuum if the courts do wipe out the health law.

And, the GOP bills the White House has supported to date — including the so-called Graham-Cassidy legislation first proposed in 2017, which the administration again endorsed in its 2019 budget proposal — would fall short, multiple experts said.

Unlike the ACA, Graham-Cassidy allows states to redefine which core benefits — a list that includes protections for people with health problems — insurance plans must cover, which would make those specific protections optional. (For more on Graham-Cassidy, here’s another PolitiFact check from last fall.)

Plus, experts said, even if the White House had a plan, the odds of it gaining passage are slim with a divided Congress.

That makes safeguarding the ACA in court “the only show in town” if the administration is serious about protecting consumers who have preexisting conditions, Bagley said.

There’s one loophole that conservatives — the White House included — might lean on, suggested Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute. It relies on what people mean when they talk about “protections.”

Some experts also point out that the administration has issued regulations that run contrary to Trump’s claim. In particular, it recently issued a rule loosening restrictions on the length of so-called short-term health plans, which supporters said would bring a more affordable option to the individual insurance market. But these plans, which, because of the rule change, can last a year instead of three months, are considered bare-bones and are not required to provide preexisting condition protections.

Our Ruling

Trump said his administration will “always protect patients with preexisting conditions.”

But the White House’s policy trajectory does exactly the opposite. The DOJ’s stance, which reflects a policy in place at the same moment the president made this claim, would eliminate the only law guaranteeing that people with preexisting conditions both receive health coverage and do not have to pay more for it.

And on the regulatory front, the administration has advanced a health insurance option that is not required to include these protections.

Furthermore, the administration has not put forth any plan that might keep those guarantees in place. Every replacement health bill it has endorsed has offered protections less generous than those offered by the ACA. And it has taken further steps that could make it harder for people with preexisting conditions to get affordable coverage.

This statement is not accurate and makes a claim in direct opposition to what’s actually happening. We rate it False.

Listen: Abortion Laws Could Have Unexpected Consequences

Kaiser Health News:States - May 15, 2019
( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-5c7b4f07b12d75c52061d68856b4a6b7') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-5c7b4f07b12d75c52061d68856b4a6b7' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Julie Rovner, Kaiser Health News’ chief Washington correspondent, talks with Robin Young on “Here and Now” about the possible ramifications of strict abortion limits passed by Alabama’s legislature or other laws recently enacted in certain conservative states. The Alabama bill would outlaw all abortions except those to save a woman’s life and would establish long prison terms for doctors who violate it. Georgia and other states have passed laws that would make an abortion illegal after a heartbeat is detected, which typically comes after about six weeks. Women’s health advocates warn that such measures could affect a wide variety of reproductive health measures, including IVF procedures for couples with infertility problems; care for women who have experienced miscarriages; and the use and possible bans of some contraceptives. Listen to the conversation here.

Walmart Charts New Course By Steering Workers To High-Quality Imaging Centers

Walmart Inc., the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out not to need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy — not price, said employer health experts.

“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”

Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

“There’s no question that there are a lot of errors that occur,” said Dr. Vijay Rao, chairwoman of radiology at the Thomas Jefferson University Hospital in Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Rao said. The average radiologist typically has only seconds to read each image, she said. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use free-standing outpatient centers rather than those based in hospitals, which tend to be more expensive.

Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.

Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants and certain cancers.

As part of its “Centers of Excellence” program, the Bentonville, Ark.-based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.

Sampling Imaging Centers’ Work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.

“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.

Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images — like those of the brain or bones — and sometimes radiologists read images from exams they have less experience with, he said.

Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.

Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.

Few Guides For Consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

“We would love to have more robust … measurements” about the outcomes of patient care than what is currently available, said Dr. Geraldine McGinty, chair of the college’s board of chancellors.

Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly two years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles-based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”

Woods said that even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.

Listen: A Blitz Of Health Care Bills

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-75d92cb3ea602ce03a9edcc1d187fa94') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-75d92cb3ea602ce03a9edcc1d187fa94' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Julie Rovner, Kaiser Health News’ chief Washington correspondent, talks with Robin Young on “Here and Now” about Democrats’ plans to push a package of health care bills through the House this week. The measure will give lawmakers a talking point about their efforts to bolster the Affordable Care Act after the Trump administration has sought to weaken it. The package, however, includes several bills with bipartisan support to get generics on the market sooner. So, voting against the package will prove tough for Republicans. Rovner and Young also discuss bipartisan efforts on Capitol Hill to eliminate surprise medical bills that patients get when their doctors or hospitals are outside their insurance network and the administration’s new requirement for drugmakers to add medications’ list prices in TV ads. You can listen to the discussion here.

HHS Establishing Interdepartmental Substance Use Disorders Coordinating Committee, Seeking Member Nominations

HHS Gov News - May 14, 2019

Adm. Brett P. Giroir, M.D., Health and Human Services Assistant Secretary for Health and Senior Advisor to the Secretary for Opioid Policy, announced today the creation of a new committee to identify areas for improved coordination related to substance use disorder (SUD) research, services, supports and prevention activities across all relevant federal agencies.

HHS, in coordination with the Office of National Drug Control Policy (ONDCP), is seeking members for the Interdepartmental Substance Use Disorders Coordinating Committee, which was authorized by the SUPPORT for Patients and Communities Act Public Law 115-271.

Per the statute, the committee will be composed of both federal and nonfederal members. In addition to members from HHS and ONDCP, the federal members will include representatives from the Departments of Education, Housing and Urban Development, Justice, Labor, Social Security, Veteran Affairs and “other federal agencies that support or conduct activities or programs related to substance use disorders, as determined appropriate by the Secretary.”

Non-Federal members, who will be appointed by the HHS Secretary, will include:

  • Individuals who have received treatment for a diagnosis of SUD;
  • Directors of state substance use agencies;
  • Representatives of leading research, advocacy or service organizations for adults with SUDs;
  • Physicians, licensed mental health professionals, advance practice registered nurses, or physician assistants with experience in treating individuals with SUDs;
  • SUD treatment professionals who provide treatment services at certified opioid treatment programs;
  • SUD treatment professionals who have research or clinical experience in working with racial and ethnic minority populations;
  • SUD treatment professionals who have research or clinical mental health experience in working with medically underserved populations;
  • State-certified SUD peer support specialist;
  • Drug court judge or judge with experience in adjudicating cases related to SUD;
  • Public safety officer with extensive experience in interacting with adults with a SUD; and
  • Individuals with experience providing services for homeless individuals with a SUD.

Information about how to nominate individuals to serve on this committee is available in the Federal Register. Applications are due June 14, 2019.

Dealing With Hospital Closure, Pioneer Kansas Town Asks: What Comes Next?

Kaiser Health News:States - May 14, 2019

FORT SCOTT, Kan. — A slight drizzle had begun in the gray December sky outside Community Christian Church as Reta Baker, president of the local hospital, stepped through the doors to join a weekly morning coffee organized by Fort Scott’s chamber of commerce.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-f81df2f29b7dccd8d36e3b5a47990f9e') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-f81df2f29b7dccd8d36e3b5a47990f9e' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

The town manager was there, along with the franchisee of the local McDonald’s, an insurance agency owner and the receptionist from the big auto sales lot. Baker, who grew up on a farm south of town, knew them all.

About 'No Mercy'

KHN’s year-long series, No Mercy, follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium.

Still, she paused in the doorway with her chin up to take in the scene. Then, lowering her voice, she admitted: “Nobody talked to me after the announcement.”

Just a few months before, Baker — joining with the hospital’s owner, St. Louis-based Mercy — announced the 132-year-old hospital would close. Baker carefully orchestrated face-to-face meetings with doctors, nurses, city leaders and staff members in the final days of September and on Oct. 1. Afterward, she sent written notices to the staff and local newspaper.

For the 7,800 people of Fort Scott, about 90 miles south of Kansas City, the hospital’s closure was a loss they never imagined possible, sparking anger and fear.

Reta Baker, president of Mercy Hospital, began as a staff nurse in 1981 and “has been here ever since.” The hospital closed at the end of 2018.(Christopher Smith for KHN)

“Babies are going to be dying,” said longtime resident Darlene Doherty, who was at the coffee. “This is a disaster.”

Bourbon County Sheriff Bill Martin stopped before leaving the gathering to say the closure has “a dark side.” And Dusty Drake, the lead minister at Community Christian Church, diplomatically said people have “lots of questions,” adding that members of his congregation will lose their jobs.

Yet, even as this town deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small communities like this one need a traditional hospital at all? And, if not, what health care do they need?

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Sisters of Mercy nuns first opened Fort Scott’s 10-bed frontier hospital in 1886 — a time when traveling 30 miles to see a doctor was unfathomable and when most medical treatments were so primitive they could be dispensed almost anywhere.

Now, driving the four-lane highway north to Kansas City or crossing the state line to Joplin, Mo., is a day trip that includes shopping and a stop at your favorite restaurant. The bigger hospitals there offer the latest sophisticated treatments and equipment.

Visitors to Mercy Hospital Fort Scott would pass a tall white cross as they drove down a winding driveway before arriving at the front door. Sisters of Mercy nuns founded the hospital in 1886, and the newest building, constructed in 2002, honors that Roman Catholic faith with various fixtures and stained-glass windows.(Christopher Smith for KHN)

Mercy flew its flags at half-staff in December in honor of former President George H.W. Bush, who died Nov. 30. (Christopher Smith for KHN)

And when patients here get sick, many simply go elsewhere. An average of nine patients stayed in Mercy Hospital Fort Scott’s more than 40 beds each day from July 2017 through June 2018. And these numbers are not uncommon: Forty-five Kansas hospitals report an average daily census of fewer than two patients.

James Cosgrove, who directed a recent U.S. Government Accountability Office study about rural hospital closures, said the nation needs a better understanding of what the closures mean to the health of people in rural America, where the burden of disease — from diabetes to cancer — is often greater than in urban areas.

What happens when a 70-year-old grandfather falls on ice and must choose between staying home and driving to the closest emergency department, 30 miles away? Where does the sheriff’s deputy who picks up an injured suspect take his charge for medical clearance before going to jail? And how does a young mother whose toddler fell against the coffee table and now has a gaping head wound cope?

There is also the economic question of how the hospital closure will affect the town’s demographic makeup since, as is often the case in rural America, Fort Scott’s hospital is a primary source of well-paying jobs and attracts professionals to the community.

No Mercy Facebook Group

As Fort Scott deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small, rural communities need a traditional hospital at all? And if not, how will they get the health care they need?

Join The Facebook Group

The GAO plans to complete a follow-up study later this year on the fallout from rural hospital closures. “We want to know more,” Cosgrove said. The report was originally requested in 2017 by then-Sen. Claire McCaskill (D-Mo.) and then-Rep. Tim Walz (D-Minn.), and has been picked up by Sen. Gary Peters (D-Mich.). Here in Fort Scott, the questions are being answered — painfully — in real time.

At the end of December, Mercy closed Fort Scott’s hospital but decided to keep the building open to lease portions to house an emergency department, outpatient clinic and other services.

Mercy Hospital Fort Scott joined a growing list of more than 100 rural hospitals that have closed nationwide since 2010, according to data from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. How the town copes is a window into what comes next.

An empty operating room at the closed hospital(Christopher Smith for KHN)

Unused hospital equipment is stored for shipment to other hospitals in the nonprofit Mercy health system.(Christopher Smith for KHN)

While some parts of the building are still in use, vast, empty halls and workstations abound at Mercy’s closed Fort Scott hospital. (Christopher Smith for KHN)

‘We Were Naive’

Over time, Mercy became so much a part of the community that parents expected to see the hospital’s ambulance standing guard at the high school’s Friday night football games.

Mercy’s name was seemingly everywhere, actively promoting population health initiatives by working with the school district to lower children’s obesity rates as well as local employers on diabetes prevention and healthy eating programs — worthy but, often, not revenue generators for the hospital.

“You cannot take for granted that your hospital is as committed to your community as you are,” said Fort Scott City Manager Dave Martin. “We were naive.”

Indeed, in 2002 when Mercy decided to build the then-69-bed hospital, residents raised $1 million out of their own pockets for construction. Another million was given by residents to the hospital’s foundation for upgrading and replacing the hospital’s equipment.

“Nobody donated to Mercy just for it to be Mercy’s,” said Bill Brittain, a former city and county commissioner. The point was to have a hospital for Fort Scott.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-7ab61e3b321a6678470b0aa41420b4e1') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-7ab61e3b321a6678470b0aa41420b4e1' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Today Mercy is a major health care conglomerate, with more than 40 acute care and specialty hospitals, as well as 900 physician practices and outpatient facilities. Fort Scott is the second Kansas hospital Mercy has closed.

Tom Mathews, vice president of finance for Mercy’s southwestern Missouri and Kansas region, said Fort Scott’s steady decline in patients, combined with lack of reimbursement — as well as the increasing cost of expenses such as drugs and salaries — “created an unsustainable situation for the ministry.”

But Fort Scott is a place that needs health care: One out of every four children in Bourbon County live in poverty. People die much younger here than the rest of the state and rates for teen births, adult smoking, unemployment and violent crime are all higher in Bourbon County than the state average, according to data collected by the Kansas Health Institute and the Robert Wood Johnson Foundation. Ten percent of Bourbon County’s more than 14,000 residents, about half of whom live in Fort Scott, lack health insurance. Kansas is one of 14 states that have not expanded Medicaid under the Affordable Care Act and, while many factors cause a rural closing, the GAO report found states that had expanded Medicaid had fewer closures.

Dr. Katrina Burke checks Randall Phillips during an exam at Mercy Hospital in Fort Scott, Kan., in December. “Up in the city, a lot of doctors don’t do everything like we do,” Burke says of the variety of patients she sees as a family practice doctor who also delivers babies. (Christopher Smith for KHN)

Burke, a family practice physician, also delivered babies at Mercy Hospital before it closed. “A lot of my moms are single moms … they don’t have good resources to even get to their OB appointment,” says Burke, who adds that she’s worried about how her patients will get to another hospital 30 miles away when it’s time for the baby to come. Burke delivered 85 babies last year. (Christopher Smith for KHN)

The GAO report also found that residents of rural areas generally have lower household incomes than their counterparts in bigger cities, and are more likely to have limitations because of chronic health conditions, like high blood pressure, diabetes or obesity, that affect their daily activities.

The county’s premature birth rate is also higher than the 9.9% nationwide, a number that worries Dr. Katrina Burke, a local family care doctor who also delivers babies. “Some of my patients don’t have cars,” she said, “or they have one car and their husband or boyfriend is out working with the car.”

By nearly any social and economic measure, southeastern Kansas is “arguably the most troubled part of the entire state,” said Dr. Gianfranco Pezzino, senior fellow at the Kansas Health Institute. While the health needs are great, it’s not clear how to pay for them.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-9948fc087ae1cdae03e2d26f5885f0e1') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-9948fc087ae1cdae03e2d26f5885f0e1' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Health Care’s ‘Very Startling’ Evolution

Reta Baker describes the farm she grew up on, south of town, as “a little wide place in the road.” She applied to the Mercy school of nursing in 1974, left after getting married and came back in 1981 to take a job as staff nurse at the hospital. She has been here ever since,” 37 years — the past decade as the hospital president.

It has been “very startling” to watch the way health care has evolved, Baker said. Patients once stayed in the hospital for weeks after surgery and now, she said, “they come in and they have their gallbladder out and go home the same day.”

With that, payments and reimbursement practices from government and health insurers changed too, valuing procedures rather than time spent in the hospital. Rural hospitals nationwide have struggled under that formula, the GAO report found.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-210397ec20eb885a303e9e944b3e3a6d') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-210397ec20eb885a303e9e944b3e3a6d' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Acknowledging the challenge, the federal government established some programs to help hospitals that serve poorer populations survive: Through a program called 340B, some hospitals get reduced prices on expensive drugs. Rural hospitals that qualified for a “critical access” designation because of their remote locations got higher payments for some long stays. About 3,000 hospitals nationwide get federal “disproportionate share payments” to reflect the fact that their patients tend to have poor or no insurance.

Fort Scott took part in the 340B discount drug program as well as the disproportionate share payments. But, though Baker tried, it could not gain critical access status.

When Medicare reimbursement dropped 2% because of sequestration after the Budget Control Act of 2011, it proved traumatic, since the federal insurer was a major source of income and, for many rural hospitals, the best payer.

Then, in 2013, when the federal government began financially penalizing most hospitals for having too many patients returning within 30 days, hospitals like Fort Scott’s lost thousands of dollars in one year. It contributed to Fort Scott’s “financial fall,” Baker said.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-74a2c07714a30ff91f613d6a0bea6611') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-74a2c07714a30ff91f613d6a0bea6611' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Baker did her best to set things right. To reduce the number of bounce-back admissions, patients would get a call from the physician’s office within 72 hours of their hospital stay to schedule an office visit within two weeks. “We worked really, really hard,” Baker said. Five years ago, the number of patients returning to Fort Scott’s hospital was 21%; in 2018 it was 5.5%.

Meanwhile, patients were also “out-migrating” and choosing to go to Ascension Via Christi in Pittsburg — which is two times larger than Fort Scott — because it offered cardiology and orthopedic services, Baker said. Patients also frequently drove 90 miles north to the Kansas City area for specialty care and the children’s hospital.

“Anybody who is having a big surgery done, a bowel resection or a mastectomy, they want to go where people do it all the time,” Baker said. Mercy’s Fort Scott hospital had no cardiologists and only two surgeons doing less complicated procedures, such as hernia repair or removing an appendix.

Last year, only 13% of the people in Bourbon County and the surrounding area who needed hospital care chose to stay in Fort Scott, according to industry data shared by Baker.

There were no patients in the hospital’s beds during one weekend in December, Baker said, adding: “I look at the report every day. It bounces between zero and seven.” The hospital employed 500 to 600 people a decade ago, but by the time the closure was announced fewer than 300 were left.

Fort Scott City Manager Dave Martin stands in the middle of the city’s historical main street, which connects to one of the first military outposts built in the United States. Martin, who feels angry at Mercy for abandoning the community, says, “We really thought that we had a relationship.”(Christopher Smith for KHN)

That logic — the financial need — for the closing didn’t sit well with residents, and Mercy executives knew it. They knew in June they would be closing Fort Scott but waited until October to announce it to the staff and the city. City Manager Martin responded by quickly assembling a health task force, insisting it was “critical” to send the right message about the closure.

Relations between Mercy and the city grew so tense that attorneys were needed just to talk to Mercy. In all, Fort Scott had spent more than $7,500 on Mercy Closure Project legal fees by the end of 2018, according to city records.

Will Fort Scott Sink With No Mercy?

When Darlene Doherty graduated from Fort Scott High School in 1962, there were two things to do in town: “Work at Mercy or work at Western Insurance.” The insurance company, though, was sold in the 1980s, and the employer disappeared, along with nearly a thousand jobs.

Yet, even as the community’s population slowly declined, Martin and other community leaders have kept Fort Scott vibrant. There’s the new Smallville CrossFit studio, which Martin attends; a new microbrewery; two new gas stations; a Sleep Inn hotel, an assisted living center; and a Dairy Queen franchise. And the McDonald’s that opened in 2012 just completed renovation.

The town’s largest employer, Peerless Architectural Windows and Doors, which provides about 400 jobs, bought 25 more acres and plans to expand. There’s state money promised to expand local highways, and Fort Scott has applied for federal grants to expand its airport.

Baker and some of the physicians on Mercy’s staff have been busy trying to ensure that essential health care services survive, too.

Baker found buyers for the hospital’s hospice, home health services and primary care clinics so they could continue operating.

Burke, the family care doctor, signed on to be part of the Community Health Center of Southeast Kansas, a federally qualified nonprofit that is taking over four health clinics operated by Mercy Hospital Fort Scott. She will have to deliver babies in Pittsburg, which is nearly 30 miles away on a mostly two-lane highway that has construction workers slowing traffic as they work to expand it to four lanes.

Burke said her practice is full, and she wants her patients to be taken care of: “If we don’t do it, who’s going to?”

Mercy donated its ambulances and transferred emergency medical staff to the county and city.

And, in a tense, last-minute save, Baker negotiated a two-year deal with Ascension Via Christi hospital in Pittsburg to operate the emergency department — which was closed for two weeks in February before reopening under the new management.

But she knows that too may be just a patch. If no buyer is found, Mercy will close the building by 2021.

This is the first installment in KHN’s year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium.

Eric Swalwell’s Tweet About Georgia’s New Abortion Restriction Only Slightly Off-Key

Kaiser Health News:States - May 14, 2019

“The so-called ‘heartbeat’ law outlaws abortion before most women even know that they’re pregnant. This is one of the most restrictive anti-abortion laws in our country.”

Eric Swalwell on May 8, 2019, in a tweet.

Georgia Gov. Brian Kemp signed into law Tuesday the state’s latest abortion restriction. Political reaction to the measure, which prohibits the procedure once a doctor can detect a fetal heartbeat — usually at about the six-week mark — was swift.

This fact check was produced in partnership with PolitiFact.

This story can be republished for free (details). Abortion opponents applauded the measure, which puts Georgia in the company of Ohio, Kentucky, Mississippi, North Dakota and Iowa. (Courts have blocked the Iowa and North Dakota laws.) Reproductive rights activists are widely expected to challenge the Georgia law, which many legal experts say violates the abortion standard set by the Supreme Court in its landmark Roe v. Wade decision.

Rep. Eric Swalwell (D-Calif.), a 2020 Democratic presidential candidate, was among the critics who weighed in.

“The so-called ‘heartbeat’ law outlaws abortion before most women even know that they’re pregnant,” Swalwell posted on Twitter. “This is one of the most restrictive anti-abortion laws in our country.”

Swalwell’s claim is an argument we’ve heard often about the six-week abortion ban. We emailed his press team, who redirected us to an article in The Atlanta Journal-Constitution, describing the law’s passage. But we wanted to dig deeper.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

‘Most Women’?

Swalwell’s claim has two components: First, he said the law bans abortion “before most women even know that they’re pregnant.”

This is a tricky one. We contacted four reproductive-law experts, along with the American College of Obstetricians and Gynecologists. We also looked at information from the Guttmacher Institute, a reproductive health research and policy organization that supports abortion rights but whose research is widely cited.

None of those sources could point us to data showing when “most women” know they’re pregnant.

Maggie McEvoy, an ACOG spokeswoman, said the organization doesn’t track that information, and it isn’t clear anyone does.

And about Swalwell’s statement:

“Is it empirically true? I don’t know that the medical literature supports that,” said Katherine Kraschel, who runs the Solomon Center for Health Law and Policy at Yale Law School.

Rep. Eric Swalwell (D-Calif.)

But even without that data, experts said, it is abundantly clear that women who are not trying to conceive are much less likely to be aware of a pregnancy until well after six weeks.

That’s because “six weeks” really means “six weeks after a woman’s last menstrual cycle.” Typically, a cycle is about 28 days, or four weeks, long. But many women are accustomed to having irregular periods, and delays can be exacerbated by everyday factors such as stress and fatigue, which could stretch a cycle to 30 or 40 days. At this point, though a woman may not yet be aware that she is pregnant or be experiencing any symptoms, a physician may be able to discern a fetal heartbeat.

Most women don’t realize they’re pregnant until missing at least one period, said Dr. Kristyn Brandi, an OB-GYN at Rutgers Medical School. Often, it takes two.

Sources:

Rep. Eric Swalwell (D-Calif.), Twitter post, May 8, 2019.

The Atlanta Journal-Constitution, “Kemp Signs Anti-Abortion ‘Heartbeat’ Legislation, Sets Up Legal Fight,” May 7, 2019.

Guttmacher Institute, “A Surge in Bans on Abortion as Early as Six Weeks, Before Most People Know They Are Pregnant,” updated May 7, 2019.

Guttmacher Institute, “Induced Abortion in the United States,” January 2018.

Guttmacher Institute, “Radical Attempts to Ban Abortion Dominate State Policy Trends in the First Quarter of 2019,” April 3, 2019.

The New York Times, “Georgia Governor Signs ‘Fetal Heartbeat’ Abortion Law,” May 7, 2019.

The New York Times, “Georgia Is Latest State to Pass Fetal Heartbeat Bill as Part of Growing Trend,” March 30, 2019.

NPR, Amid Chaos, Alabama Senate Postpones Vote on Nation’s Strictest Abortion Ban,” May 10, 2019.

Telephone Interview with Katherine Kraschel, May 9, executive director of the Solomon Center at Yale Law School, May 9, 2019.

Telephone Interview with Melissa Murray, professor of law at New York University, May 8, 2019.

Telephone Interview with Kristyn Brandi, assistant professor of obstetrics and gynecology at Rutgers-New Jersey Medical School, May 9, 2010.

Telephone Interview with Megan Christin, director of media relations and communications at American College of Obstetricians and Gynecologists, May 9, 2010.

Email Interview with I. Glenn Cohen, professor of law at Harvard University, May 8, 2019.

Email Interview with Kimberly Mutcherson, professor of law at Rutgers Law School, May 8, 2019.

Email Interview with Maggie McEvoy, senior manager of media relations and communications at the American College of Obstetricians and Gynecologists, May 9, 2010.

Generally, medical experts say, women who are actively trying to conceive tend to track their cycles very closely and know much sooner if they are pregnant. But for women whose pregnancies are unintended, and who may be more likely to contemplate an abortion, Swalwell’s statement is more accurate.

About two-thirds of women seeking abortions usually come in around eight weeks since their last menstrual period, per the most recent Guttmacher statistics.

In other words, the six-week restriction would cut off access to abortion at a point in the pregnancy when “there’s a high level of women who might not know,” Kraschel said.

‘One Of The Most Restrictive’

The second half of Swalwell’s claim is easier to verify.

He said this is “one of the most restrictive anti-abortion laws” in the country, a characterization experts say is certainly accurate. The phrase “one of” is a crucial distinction. The Georgia ban is no more stringent than those approved in the five other states that have passed heartbeat laws.

In Alabama, lawmakers are considering a bill that would effectively criminalize all abortions — treating physicians who perform the procedures as felons. If it were to become law, Alabama’s would be the most stringent in the nation. But voting in the state Senate on that legislation was postponed after a debate erupted over whether to include an exemption for rape or incest.

Legal experts also suspect that, as conservatives pursue new abortion legislation, heartbeat restrictions are among the likeliest to end up in front of the Supreme Court. Conservatives believe the judicial makeup favors a ruling that could overturn or scale back the abortion protections outlined in Roe v. Wade.

Our Ruling

Swalwell runs into data obstacles with the first half of his claim. He says a six-week ban prohibits abortion before “most women” know that they are pregnant, but there isn’t any research that conclusively says that’s correct.

Some clarification would help him here.

Most women who aren’t trying to conceive are less likely to know this early that they are pregnant. They probably aren’t taking pregnancy tests or closely monitoring their periods. And women seeking abortions are generally coming in after six weeks.

To be fair to Swalwell, his broader point here is true: The women more likely to seek abortions are, six weeks from their last period, less likely to realize they are pregnant.

The second half of this claim is unequivocally correct. Georgia’s law is indeed among the nation’s strictest.

This claim is correct but could use more context and clarification. We rate it Mostly True.

Newsom Changes Course On Plan To Pay For Immigrant Health Coverage

Gov. Gavin Newsom’s administration Friday reversed course on his plan to divert public health dollars from several counties to help provide health coverage to young adults who are in the country illegally.

The administration heeded the alarm sounded by Sacramento, Placer, Santa Barbara and Stanislaus counties, which had warned that the governor’s plan would compromise their ability to cope with surging rates of sexually transmitted diseases and, in some cases, measles outbreaks.

“The Administration has subsequently reevaluated this proposal due to the potential negative impacts to public health activities in these counties,” Vivek Viswanathan, chief deputy director of the state Department of Finance, wrote in a letter Friday to the chairs of the state Assembly and Senate Budget Committees.

Sacramento County, for example, estimates it would have lost roughly $7.5 million  that goes toward operating its STD clinic and paying communicable disease investigators. It warned that without the money, it would have to close the STD clinic and cut its own health services for undocumented immigrants of all ages.

“The public health dollars being restored make a big difference particularly at a time we have measles,” Dr. Peter Beilenson, Sacramento County Health Services Director, told California Healthline Friday. “We’re thrilled. It’s a great thing for the patients that we’re serving.”

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

This year, there have been 44 confirmed cases of measles in California as of May 8, three of them in Sacramento County. Public health officials also are struggling to address record rates of sexually transmitted diseases, with more than 300,000 cases of gonorrhea, chlamydia and syphilis reported in California in 2017.

On Thursday, when Newsom unveiled his revised budget — one that still included the plan to divert money from the four counties — he announced it would cost less to cover young adult unauthorized immigrants next year than previously estimated.

Because the state would have to delay the implementation date by six months to address IT issues, he said, it would cost $98 million to cover them in 2019-20, a significant drop from his original forecast of $260 million. The number of people expected to enroll also has dropped from 138,000 to 106,000.

The lower cost estimate means the administration won’t need to divert money from those four counties. What it does need, it will take from a special state budget reserve fund, said Department of Finance spokesman H.D. Palmer.

Newsom still plans to divert state money from 35 mostly small and rural counties, funds that currently pay for health services for uninsured residents, including undocumented immigrants, Palmer said.

Those counties participate in something called the County Medical Services Program, which has a $300 million budget surplus, Newsom noted at his budget briefing Thursday.

“That’s more than enough to address their issues,” Newsom said.

He also noted that his budget includes $40 million to combat infectious diseases.

Legislators are crafting their own budget proposals and have held dozens of hearings examining Newsom’s plan. The governor and lawmakers have until June 15 to negotiate a final budget, so it’s not yet clear which proposals will be included.

Placer County, which has reported three measles cases this year, praised Newsom’s change of heart.

“I appreciate the governor listening to some of the potential impacts it could have on public health and realizing that, in this time in California, we need to be making investments,” said Jeff Brown, director of Placer County’s Health and Human Services Department.

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

How Obamacare, Medicare And ‘Medicare For All’ Muddy The Campaign Trail

The health care debate has Democrats on Capitol Hill and the presidential campaign trail facing renewed pressure to make clear where they stand: Are they for “Medicare for All”? Or will they take up the push to protect the Affordable Care Act?

Obamacare advocates have found a powerful ally in House Speaker Nancy Pelosi, who in a recent “60 Minutes” appearance said that concentrating on the health law is preferable to Medicare for All. She argued that since the ACA’s “benefits are better” than those of the existing Medicare program, implementing Medicare for All would mean changing major provisions of current Medicare, which covers people 65 and up as well as those with disabilities.

This talking point — one Pelosi has used before — seems tailor-made for the party’s establishment. It’s politically palatable among moderates who believe that defending the ACA’s popular provisions, such as protecting coverage for those with preexisting conditions, fueled the Democrats’ House takeover in 2018.

Progressive Democrats argue that the time has come to advance a far more disruptive policy, one that guarantees health care to all Americans. Those dynamics were on full display on Capitol Hill, as recently as an April 30 Medicare for All hearing.

But this binary view — Medicare (and, for argument’s sake, Medicare for All) versus Obamacare — oversimplifies the issues and distracts from the policy proposals.

“It’s sort of a silly argument,” said Robert Berenson, a health policy analyst at the Urban Institute, of Pelosi’s talking point. “She’s trying to argue the Affordable Care Act needs to be defended, and Medicare for All is a diversion.”

As the debate continues, one point should be clear: Medicare for All would not look like the ACA or like Medicare today. Instead, it — or any other single-payer system — would drastically change how Americans get health care.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

 

Analyzing Medicare Isn’t That Helpful In Understanding ‘Medicare For All’ Proposals.

Medicare for All is complicated, analysts noted, and the phrase is often deployed to mean different things, depending on who is speaking.

What’s clear is that the “Medicare” described in Sen. Bernie Sanders’ (I-Vt.) legislation — the flagship Medicare for All proposal — would create a health program far more generous than traditional Medicare’s current benefit, or even the vast majority of health plans made available through the ACA.

Sanders relied heavily on this concept during his 2016 Democratic presidential primary run and recently introduced an updated version in the Senate.

To be fair, though, Sanders also sometimes blurs the lines between the programs. In a May 5 appearance on ABC’s “This Week with George Stephanopoulos,” he used existing Medicare as part of his sales pitch: “Medicare right now is the most popular health insurance program in the country,” he said. “But it only applies to people 65 years of age or older. All that I want to do is expand Medicare over a four-year period to cover every man, woman and child in this country.”

As counterintuitive as it sounds, understanding Medicare as it works today isn’t helpful in envisioning a Medicare for All plan. Unlike with existing Medicare, the proposed health plan would cover things like nursing home care, vision care and dental services. It would get rid of cost sharing — meaning no premiums, deductibles or copays. (Sanders has acknowledged that financing the program would mean raising taxes.)

“It’s not Medicare. It’s something different,” said Ellen Meara, a health economist at the Dartmouth Institute for Health Policy and Clinical Practice.

But voters may not grasp the differences between the existing Medicare program for seniors and the hypothetical one being discussed. Pelosi’s comments may add to that confusion. Pelosi’s office did not respond to a request for comment.

Prioritizing efforts to bolster the ACA based on Medicare’s current benefit package “is convenient and not necessarily compelling,” Berenson said, adding: “No one is proposing the Medicare benefit package would be taken and applied nationally.”

That said, many of the presidential candidates have advanced far less sweeping health care options that would lower the Medicare age to 55 or allow people to buy in to the current Medicare program — an approach often referred to as a “public option.” Those would keep the program essentially structured as it is today.

The Democratic Health Care Debate Is More Complicated Than These Familiar Words Suggest.

Every analyst interviewed for this story floated some kind of concern regarding a Medicare for All system. There’s the issue of how people would respond to losing the option of private insurance — a likely consequence of Sanders’ proposal — and the question of what level of tax hikes would be necessary to finance such a system, particularly if it covers a big-ticket item such as long-term care. There are also concerns about the financial impact for hospitals, often large employers in a community, or for the private insurance industry jobs that would likely disappear.

Focusing on current Medicare benefits misses the point, suggested Sherry Glied, a health economist and dean at New York University. When debating the merits of the ACA versus Medicare for All, Medicare’s current generosity is kind of a red herring, she said.

Plus, making Obamacare or Medicare for All an either-or debate ignores a sizable political bloc: Democrats who say they support the ACA and see single-payer as a next step. That tension is at play with presidential candidates like Kamala Harris, who frame Medicare for All as an ultimate goal, while also backing incremental reforms.

Comparing Medicare To Obamacare Is Difficult Since Each Offers Different Benefits To Different People.

The problem is that both Medicare and Obamacare are vast programs. Depending on your income, health needs and the version you sign up for, either one could prove the better choice.

“It’s impossible to say the ACA as a concept has more or less generous benefits,” Berenson said.

Broadly, the ACA has protections in place that traditional Medicare doesn’t. It caps how much patients pay out-of-pocket, and it has more generous coverage of mental health care and substance abuse treatment. But, in practice, those benefits have proved elusive for many since Medicare generally has a more robust network of participating physicians than many of the ACA’s cheaper plans, which restrict patients to a narrower coverage network.

Also, most beneficiaries don’t solely have traditional Medicare.

About a third use Medicare Advantage, in which private insurance companies construct Medicare plans with benefits and protections based on factors like company, tier and geography. They, too, are often restricted to narrower networks.

More than 1 in 5 traditional Medicare beneficiaries also receive Medicaid coverage, according to figures kept by the Kaiser Family Foundation, and about a third of them buy so-called Medigap plans, which are sold by private insurance and are meant to supplement gaps in coverage.

The ACA also encompasses an array of coverage options. Which plans are available in an area and whether earnings qualify a consumer for a government subsidy— a tax break meant to make an ACA plan more affordable — make a significant difference in evaluating whether Medicare or an ACA plan offers better benefits for a particular person or family.

Suggesting that one is clearly better than the other, Meara said, is a “gross oversimplification.”

But that kind of oversimplification may be hard to avoid, especially in a primary season where health care is a top issue.

“The Affordable Care Act is also not one thing, the way Medicare is not one thing,” said Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago. “So much of health care is more complicated than we can explain in a sound bite.”

‘John Doe’ Patients Sometimes Force Hospital Staff To Play Detective

Kaiser Health News:States - May 13, 2019

The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: no wallet, no cellphone, not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. And they strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” said Jan Crary, supervising clinical social worker at L.A. County+USC, whose team is frequently called on to identify unidentified patients.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At L.A. County+USC, social workers pick through personal bags and clothing, scroll through cellphones that are not password-protected for names and numbers of family or friends, and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings, and even try to track down dental records. It’s more difficult to check fingerprints, because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary said.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, said Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the past three years, the number of patients who arrived unidentified at L.A. County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, the staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary said.

Jan Crary, supervising clinical social worker at Los Angeles County+USC Medical Center, leads a team who increasingly must play detective when patients cannot be identified.((Heidi de Marco/KHN))

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” said Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals who sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs. On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands. Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, said Lake. But it was a struggle, especially for smaller hospitals, he said.

The Health Insurance Portability and Accountability Act (HIPAA), a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

Police and family members inquired about him at the hospital several times but were told he was not there. After a week — during which hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing persons from police or family members. The guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing persons.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

Lenh Vuong, a clinical social worker at Los Angeles County+USC Medical Center, checks on a former John Doe patient who was recently identified. (Heidi de Marco/KHN)

Maria Torres visits Felipe Luna, her brother. Luna ended up at Los Angeles County+USC Medical Center after he was hit by a car and suffered head injuries. “The only thing he had on him was a bank card and a receipt,” Torres says. “I think that was a good thing he had that in his pocket, but that's not an ID.” (Heidi de Marco/KHN)

At L.A. County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary said.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays at L.A. County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary said she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, delirious with what was later diagnosed as encephalitis and unable to speak.

Acting on a gut instinct that the well-groomed man must have a loved one who had reported him missing, Crary checked with police stations in the area. She learned instead that this John Doe was wanted in several states for sexual assault.

“He was done in by a mosquito,” Crary mused.

“It is a case that I will never forget,” she added. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification rather than finding a felon.”

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

Trump Administration Secures Historic Donation of Billions of Dollars in HIV Prevention Drugs

HHS Gov News - May 10, 2019

Health and Human Services Secretary Alex M. Azar II announced today that, as a result of discussions between the Trump Administration and Gilead Sciences, Inc., the pharmaceutical company has agreed to donate pre-exposure prophylaxis (PrEP) medication for up to 200,000 individuals each year for up to 11 years.  PrEP is used to reduce the risk of HIV infection in individuals who are at higher risk for HIV. It has been shown to reduce the risk of new infection by up to 97 percent when taken consistently.

The agreement between the U.S. Department of Health and Human Services and Gilead will last until at least December 31, 2025 and possibly through December 31, 2030, and will provide medication to treat individuals who are at risk for HIV and who are uninsured. This donation will deliver Gilead’s PrEP medication Truvada, which currently carries a list price of more than $20,000 per patient per year, to up to 200,000 people per year, including in the states and counties identified as priority areas in the Trump Administration plan to end the HIV epidemic in America.

Gilead will donate Truvada until its second-generation HIV preventative medication, Descovy, becomes available.  At that time, Gilead will donate Descovy.  The agreement would end after 11 years, or when a generic version of Descovy becomes commercially available, whichever comes first. The government has agreed to cover costs associated with distributing the drugs.

Secretary Azar issued the following statement regarding the finalized agreement:

“Securing this commitment is a major step in the Trump Administration’s efforts to use the prevention and treatment tools we have to end the HIV epidemic in America by 2030. Under President Trump’s leadership, HHS worked with Gilead to secure preventative medication for individuals who might otherwise not be able to access or afford this important treatment. The majority of Americans who are at risk and who could protect themselves with PrEP are still not receiving the medication. This agreement will help close that gap substantially and deliver on President Trump’s promise to end the HIV epidemic in America.”

Additional Background:

In his State of the Union Address on February 5, 2019, President Donald J. Trump announced his Administration’s goal to end the HIV epidemic in the United States within 10 years. To achieve this goal and address the ongoing public health crisis of HIV, the initiative Ending the HIV Epidemic: A Plan for America will leverage the powerful data and tools now available to reduce new HIV infections in the United States by 75 percent in five years and by 90 percent by 2030. In his FY 2020 Budget, President Trump proposed historic new funding dedicated specifically to this initiative.

To read the HHS’s statement on FY2020 Budget proposal for ending the HIV epidemic In America, please visit:
https://www.hhs.gov/about/news/2019/03/11/statement-on-fy2020-budget-proposal-for-ending-the-hiv-epidemic-in-america.html

For more information, please visit:
https://www.hiv.gov/

Secretary Azar Statement on Trump Administration Surprise Billing Principles

HHS Gov News - May 10, 2019

Health and Human Services Secretary Alex Azar released the following statement regarding President Trump’s announcement of principles for legislation addressing surprise medical billing:

“Laying out principles for Congress to address surprise billing is another major step in President Trump’s efforts to deliver on this commitment: You, as the American patient, have the right to know what a prescription drug or healthcare service costs before you receive it. We aim to address surprise billing in a way that will protect American patients from this abusive practice and lay a foundation for a system where the patient is put at ease and in control. Today’s announcement follows our announcement yesterday that we have finalized the new requirement that drug companies include their list prices in television ads, which was one more step toward delivering American patients the affordability they need, the options and control they want, and the quality they deserve.”

To read about the administration’s announcement on drug prices in TV ads, visit: https://www.hhs.gov/about/news/2019/05/08/cms-drug-pricing-transparency-fact-sheet.html

Listen: Trump’s Plan To End ‘Unpleasant Surprise’ Bills

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-e4cf6d654eca74a5b079aeceec932aa5') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-e4cf6d654eca74a5b079aeceec932aa5' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )(); Related

President Donald Trump called for an end to the “unpleasant surprise” of certain medical bills on Thursday. Specifically, he outlined a plan that would forbid bills beyond in-network insurance rates in emergencies. For elective procedures, patients would have to consent in advance to receiving care from an out-of-network provider — and get only one bill after a surgery. NPR reporter Selena Simmons-Duffin covered the White House announcement, which featured two patients from the KHN-NPR “Bill of the Month” series.

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

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

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

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

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

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

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

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

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

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

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

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

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

Related

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

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

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

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

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

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

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

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

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

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

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

Hospitals don’t like it, either.

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

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

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

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

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

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

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

KHN senior correspondent Fred Schulte contributed to this report. 

State Bans Pesticide Linked To Developmental Problems

Kaiser Health News:States - May 09, 2019

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

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

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

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

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

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

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

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

Corteva Agriscience did not respond to requests for comment.

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

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

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

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

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

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

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

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

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

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

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-1f893b112bcb69f18a79b2688917c160') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-1f893b112bcb69f18a79b2688917c160' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )(); Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Jennifer Haberkorn

Los Angeles Times

@jenhab

Read Jennifer's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Alice Miranda Ollstein

Politico

@AliceOllstein

Read Alice's Stories

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

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

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

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

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

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

Among the takeaways from this week’s podcast:

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

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

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

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

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

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle Play or Spotify.

Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers

Private health insurance plans in 2017 paid more than twice what Medicare would have for those same health care services, says a sweeping new study from Rand Corp., a respected research organization.

Its study, which examines payment rates by private insurers in 25 states to 1,600 hospitals, shines light into a black box of the health industry: what hospitals and other medical providers charge. It is among the first studies to examine on such a wide level just how much more privately insured people pay for health care.

The finding: a whole lot. The difference varies dramatically across the country. And as national health expenses climb, this growing gap poses a serious challenge for lawmakers. The Rand data suggests a need for market changes, which could come in the form of changes in industry behavior or government regulation, in order to bring down hospital prices in the private sector. “If we want to reduce health care spending,” said Christopher Whaley, a Rand economist and one of the paper’s two authors, “we have to do something about higher hospital prices.”

Put another way, if, between 2015 and 2017, hospitals would have charged these health plans the same rates as Medicare, it would have reduced health spending by $7.7 billion.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

The national discrepancy is staggering on its own. But the data fluctuated even more when examined on a state-by-state level.

In Indiana, private health plans paid on average more than three times what Medicare did. In Michigan, the most efficient of the states studied, the factor is closer to 1.5 — the result, the study authors said, of uniquely strong negotiating of the powerful UAW union, historically made up of autoworkers.

The difference between Medicare and private coverage rates matters substantially for the approximately 156 million Americans under age 65 who get insurance through work-sponsored health plans, researchers said. For them, higher hospital prices aren’t an abstraction. Those charges ultimately translate to individuals paying more for medical services or monthly premiums.

That’s especially true for the increasing number of people who are covered by “high-deductible” health plans and have to pay more of their health care costs out-of-pocket, said Paul Ginsburg, a health economist at the Brookings Institute. He was not associated with this study.

The gap between Medicare and private plans — and how it plays out across the country — underscores a key point in how American health care is priced. Often, it has little to do with what it costs hospitals or doctors to provide medical care.

“It’s about how much they can charge, how much the market can take,” said Ge Bai, an associate professor at the Johns Hopkins University Carey Business School who studies hospital prices but was not affiliated with the study.

The paper’s authors suggest that publishing this pricing data — which they collected from state databases, health plans and self-insured employers — could empower employers to demand lower prices, effectively correcting how the market functions.

But, they acknowledged, there’s no guarantee that would, in fact, yield better prices.

One issue is that individual hospitals or health systems often have sizable influence in a particular community or state, especially if they are the area’s main health care provider. Another factor: If they are the only facility in the market area to offer a particularly complex service, like neonatal intensive care or specialized cardiac care, they have an upper hand in negotiating the price tag. In those situations, even if an employer is made aware that Medicare pays less, it doesn’t necessarily have the ability to negotiate a lower price.

“Employers and health plans in a lot of cases are really at the mercy of big, must-have systems. If you can’t legitimately threaten to cut a provider or system out of the network, it’s game over,” said Chapin White, a Rand policy researcher and Whaley’s co-author. “That’s when you come up against the limits of market-based approach.”

It wasn’t always this way, said Gerard Anderson, a Johns Hopkins health policy professor and expert in hospital pricing, who was also not involved with the study. Anderson began comparing Medicare prices to that of private insurance in the 1990s, when they paid virtually the same amount for individual services.

Since then, private health plans have lost the ability to negotiate at that same level, in part because many hospital systems have merged, giving the hospitals greater leverage. “Most large, self-insured corporations do not have the market power in their communities to take on the hospitals even if they wanted to do so,” Anderson said.

The RAND findings come as Democrats campaigning for 2020 are reopening the health care reform debate. Single-payer advocates argue, among other points, that covering everyone through a Medicare-like system could bring lower prices and increase efficiency to the rest of the country, or at least give the government leverage to negotiate a better price.

That’s certainly possible, but it isn’t guaranteed. Under single-payer, Anderson said, the challenge would be to make sure Medicare doesn’t simply end up paying more, or that cuts aren’t so dramatic that hospitals and doctors go out of business.

And there’s the political calculus, Ginsburg of Brookings noted. Hospitals, doctors and other health care industries are all influential lobbies and could successfully ward off any efforts to lower prices.

“It’s one thing to have regulatory control of prices. It’s another to set them low enough to make a difference,” he said.

Other strategies, such as a “public option” — which would allow people to opt into a government-provided plan but preserve multiple health care payers — could also make a difference, he said. Lawmakers on the state or federal level could limit what hospitals are allowed to charge for certain medical services, as Maryland does.

Some states have taken smaller-scale approaches, too, by tying their payment rates to a percentage of Medicare, rather than negotiating case by case. In Montana, state employees get coverage that pays about 230% of the Medicare rate on average — an arrangement that saved the state more than $15 million over two years.

For its part, the American Hospital Association, an industry trade group, points to the importance of lowering the cost of prescription drugs or reducing overuse, among other things.

Policy fixes are debatable, White said. But the data makes one point clear: From an efficiency standpoint, the current system isn’t working.

“There are right now the secret negotiations between health plans and hospitals,” and the system is “dysfunctional,” he said.

Pain Management Task Force to vote on final recommendations to improve treatment of pain

HHS Gov News - May 09, 2019

The Pain Management Best Practices Inter-Agency Task Force, a federal advisory committee, will be voting on final recommendations for pain management best practices at its May 9-10 meeting to be held at the Hubert H. Humphrey Building, 200 Independence Avenue, SW, Washington, D.C.

The Task Force, which was established by the Comprehensive Addiction and Recovery Act of 2016, will also vote on final recommendations to address gaps or inconsistencies for managing chronic and acute pain.

The draft final recommendations are posted on the Task Force website and the final report is expected to post there by May 30.

The Task Force draft final recommendations emphasize the importance of providing balanced, individualized, patient-centered pain management to ensure better clinical outcomes for pain that improve quality of life and functionality for patients, and endorse a broad framework of approaches for treating acute and chronic pain.

The draft final recommendations also advocate for tools to provide better pain management, and identify cross-cutting initiatives essential for implementing clinical best practices that focus on risk assessment, education, access to care, and addressing stigma. They support a multimodal approach for acute injury and perioperative pain, as well as a multidisciplinary approach for chronic pain patients with various underlying pain conditions, when clinically indicated, while also mitigating opioid exposure.

The Task Force has 28 members, representing federal and non-federal entities with diverse disciplines and views. It is overseen by the U.S. Department of Health and Human Services, in cooperation with the U.S. Departments of Veterans Affairs and Defense. The Task Force members have significant public- and private-sector experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, veteran health and minority health.

Members of the public may attend the meeting in person or via webcast. The meeting will occur on Thursday, May 9, 2019, from 10 a.m. to 5:30 p.m., and on Friday, May 10, 2019, from 9 a.m. to 12 p.m. ET. For more information, visit the Task Force’s meeting page.

Needle Exchanges Find New Champions Among Republicans

Kaiser Health News:States - May 09, 2019

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

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

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

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

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

Republicans have not always held this mindset.

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

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

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

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

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

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

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

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

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

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

Attitudes among Republicans on the federal level are also shifting.

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

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

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

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

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

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

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

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

Pages