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Judge Blocks Kentucky Medicaid Work Requirement

[UPDATED at 5:30 p.m. ET]

A federal judge on Friday struck down a Trump administration decision allowing states to force low-income adults to work to qualify for Medicaid.

The 60-page ruling, which is likely to be appealed, was hailed by advocates for the poor. But it could limit the number of states expanding Medicaid under the Affordable Care Act.

“The Secretary never adequately considered whether [the work requirement] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid,” wrote Judge James Boasberg. “This signal omission renders his determination arbitrary and capricious.”

Boasberg also noted that “the Secretary never provided a bottom-line estimate of how many people would lose Medicaid with Kentucky HEALTH in place. This oversight is glaring, especially given that the risk of lost coverage was ‘factually substantiated in the record.’”

The case has been closely watched because work has never been a condition for receiving health coverage through Medicaid.

“Today’s decision is disappointing,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “States are the laboratories of democracy and numerous administrations have looked to them to develop and test reforms that have advanced the objectives of the Medicaid program. The Trump administration is no different.”

The administration is now reviewing its legal options, she said.

The ruling by the U.S. District Court immediately blocks Kentucky from moving ahead with implementing its work requirement, which was scheduled to begin its rollout Sunday.

“Even a temporary implementation of Kentucky HEALTH could cause serious harm,” Boasberg wrote in his decision.

Critics of the work requirement applauded the court’s finding, saying that it reinforced and emphasized Medicaid’s mission.

“Medicaid is about health insurance. Period,” said Frederick Isasi, executive director of Families USA, a consumer advocacy group that supported the health law. “And policies that make it harder for people to get health insurance run counter to the program’s purpose.”

Judy Solomon, vice president of the left-leaning Center on Budget and Policy Priorities, agreed, calling the decision “a big victory.” She said this work requirement rejection should apply to the other states looking to implement it.

Those on the other side of the issue took a different view.

“It’s a setback, but I would not call it a blow,” said Angela Rachidi, a research fellow with the conservative American Enterprise Institute. She said she believes that the ruling will affect only Kentucky and that other states will move forward with the same provision, which could illicit other lawsuits.

“Today’s decision is clearly erroneous and should be reversed swiftly,” said Jonathan Ingram, vice president of research at the Foundation for Government Accountability, which favored the work requirements and opposes the health law.

Kentucky Gov. Matt Bevin, a Republican, had threatened to scale back the health program if the courts rejected the mandate, a move that could leave hundreds of thousands of low-income adults without coverage.

Kentucky was the first of four states that won federal approval this year to advance a work requirement, a historic change in the federal-state program’s 53-year history. The others are Arkansas, Indiana and New Hampshire. It’s unclear if this federal court ruling invalidates the other states’ work requirement plans.

“This is a big roadblock for the four states looking to implement these already approved waivers,” said Matt Salo, executive director of the National Association of Medicaid Directors. “The court decision acknowledged that there will be appeals, and I suspect this may well end up at the Supreme Court eventually.”

Seven more states have applications pending with the federal government: Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin.

Kentucky’s program would have required nondisabled adults each month to participate in 80 hours of work, job training, education or other volunteer service to remain covered. Those failing to meet the requirement can regain coverage the month after they complete 80 hours of community engagement in a 30-day period or by taking a state-approved health literacy or financial literacy course.

Those exempted include pregnant women, full-time students, primary caregivers of a dependent and beneficiaries who are considered medically frail or have an acute medical condition that would prevent them from complying.

State officials estimate about 200,000 adults would have to comply with the new work requirements by year’s end.

Critics say the work requirement would lead many low-income people to lose their health coverage, and with it their access to care. They note Kentucky’s own projections show that 95,000 Medicaid enrollees would fall from the rolls within five years. They fear such a directive could have a chilling effect on people signing up for Medicaid or make it harder for people to qualify.

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About 500,000 adults were added to Medicaid in Kentucky after the state in 2014 expanded coverage to everyone with incomes below 138 percent of the federal poverty level, or about $16,700 for a single adult.

Adding a work requirement has been seen in some states as a way to give political cover to Republicans, who after initially resisting the expansion decided to pursue it.

The Republican-controlled Virginia legislature in May approved expanding Medicaid contingent on such a policy. Trump administration officials said the work requirement gives low-income adults an incentive to enter the workforce. Proponents argue that working or doing community service would improve enrollees’ health.

States that are implementing the policy have exempted large swaths of people, such as those who are pregnant, going to school, getting treatment for opioid addiction, taking care of a sick relative or suffering from a medical condition that prevents them from working.

Critics argue that people need Medicaid to get healthy so they can work. The work requirement, they add, was unnecessary because the large majority of Medicaid enrollees already work or go to school or care for a relative.

A Kaiser Family Foundation report estimated just 6 percent of adult Medicaid enrollees would be affected because they either already work or meet one of many exemptions. (Kaiser Health News is an editorially independent program of the foundation.)

But the idea has strong public backing. About 70 percent of Americans said they support states imposing a work requirement on nondisabled adults, according to a Kaiser Family Foundation poll last year.

Advocacy groups filed the lawsuit against the federal government and Bevin on behalf of 16 Kentucky Medicaid recipients. They claim the work requirement violates the 1965 law establishing Medicaid because it would reduce low-income people’s access to health care.

The decision also overturned the entire Kentucky Medicaid waiver approved by the Trump administration in January, saying that “preserving the status quo — including plaintiffs’ continuity of coverage — is appropriate.”

Under Kentucky’s plan, premiums would range from $1 a month for people with little or no income and up to $37.50 a month.

Those above the poverty line who fail to pay would be locked out of coverage for six months and must pay past-due premiums to regain coverage.

Those below the poverty line who don’t pay would have their reward accounts for receiving vision and dental benefits docked.

Heather Hahn, a senior fellow at the nonpartisan Urban Institute, said the ruling was important because it focused attention on the purpose of Medicaid, but she warned this was only the first battle in the legal war over the future of the program.

“There is a lot of momentum for work requirements, and I would expect people to try other avenues to move them forward,” she said.

Gov. Bevin filed a countersuit against those same 16 Medicaid recipients in a federal court in Frankfort, Ky., to uphold the work requirements and other provisions.

The Kentucky Hospital Association and the Kentucky Association of Health Plans filed briefs supporting Bevin in Frankfort while dozens of scholars representing some of the nation’s most prestigious schools of public health are backing the Medicaid recipients in the Washington case.

A decision is pending in the Frankfort lawsuit.


Trump’s Next High Court Pick Likely To Target Abortion. Is That What The Public Wants?

Kaiser Health News:States - June 29, 2018

President Donald Trump has vowed that his nominees to the Supreme Court will vote to overturn Roe v. Wade, the landmark 1973 ruling that legalized abortion nationwide.

He seems to have made good on this promise with the appointment to the high court of Neil Gorsuch, whom experts expect to rule that way if given the chance.

Trump will now get another opportunity to reshape the bench with this week’s retirement announcement by Justice Anthony Kennedy.

But a Kaiser Family Foundation poll out early Friday suggests that’s not what most of the public wants.

The foundation’s June tracking poll found that Americans oppose overturning Roe V. Wade by 38 percentage points — 67 vs. 29 percent.

Among Democrats and independents, support for keeping the ruling intact is even stronger, 81 percent and 73 percent respectively, according to the poll.

But the opposition does not hold across party lines.

A majority of Republicans — 53 percent — said they want the case reversed. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

Respondents to the poll also opposed recent Trump administration efforts to restrict federal funding for Planned Parenthood on the grounds that it uses non-federal funds to perform abortions.

A total of 57 percent opposed the new rules, including 67 percent of Democrats and 55 percent of independents. Even a plurality of Republicans opposed the rules — 48 percent, compared with 46 percent who expressed support.

Those findings are in line with a recent deep dive into public opinion on abortion by Gallup.

Gallup, which has been asking Americans about abortion since 1962 — more than a decade before Roe v. Wade was decided — found that unlike other social issues, for which public opinions have changed over time, abortion views have stayed relatively stable. And the public is equally divided between those who call themselves “pro-choice” (48 percent) and “pro-life” (48 percent).

Still, Gallup found that within those percentages, the public remains muddled, and generally in favor of restrictions, such as how long into a pregnancy an abortion can be performed or the reasons a woman is seeking the abortion. Just under 30 percent said abortion should be legal under any circumstances, while only 18 percent said it should be illegal under any circumstances. Fifty percent say it should be legal “only under certain circumstances.”

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Like the Kaiser Family Foundation, Gallup found strong support for Planned Parenthood, with 62 percent saying they hold a “favorable opinion” of the reproductive health group.

Republicans were the only major demographic group with an unfavorable opinion of Planned Parenthood (63 percent) along with those who identify themselves as “pro-life” (59 percent).

But even in those groups more than a third of respondents approved of Planned Parenthood. Large majorities of Democrats, independents, men, women and people of all age groups have a favorable opinion of the organization, despite recent attacks on it by Trump and congressional Republicans.

Gallup said that support has remained relatively consistent since 2015, although margins have grown narrower since the 1990s.

The Kaiser Family Foundation poll was conducted June 11-20 among 1,492 adults. The margin of error is +/-3 percentage points for the full sample.

Gallup’s findings on abortion attitudes are based on its annual Values and Beliefs poll, conducted May 1-10.  It has a margin of error of +/-4 percentage points. Its Planned Parenthood poll was done in June and has a margin of error of +/-3 percentage points.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Top Policy Expert’s Ties To Giant Drugmaker Often Go Unstated

When Dr. Mark McClellan sat for an in-depth 30-minute question-and-answer session at an April health policy forum, the audience was filled with top researchers, advocates and Capitol Hill staffers eager to hear what insight the former head of the Food and Drug Administration would dispense.

He did not disappoint.

In response to a question about how competition might drive down the cost of new drugs made from living cells, McClellan said, “That is a great example of where more clarity from FDA about what exactly is required could potentially open up more biosimilar competition.”

McClellan is director of the Margolis Center for Health Policy at Duke University, the academic position by which he’s commonly identified. But he frequently has not disclosed another position he’s held since late 2013: He earned $285,000 last year on the board of pharmaceutical giant Johnson & Johnson, a company accused of blocking the sale of Pfizer’s Inflectra biosimilar, which competes against J&J’s blockbuster Remicade, a rheumatoid arthritis drug.

According to corporate financial filings, McClellan has been compensated with more than $1 million in cash and stock awards since taking that post.

McClellan also receives compensation as a member of the advisory board of privately held Alignment Healthcare, which employs doctors and provides chronic-care management for Medicare Advantage plans in three states. Alignment Healthcare declined to disclose his compensation.

The issue of conflicts of interest has become more pressing in recent years as drug prices soar and health care companies reach out to the academic and policy community for advice — often with generous payments attached, ethics experts say.

Sen. Claire McCaskill (D-Mo.) introduced a bill in June that would require drugmakers to report payments to patient advocacy groups and professional societies. If passed, it would toughen the Sunshine Act, which requires pharmaceutical companies to report payments to teaching hospitals and physicians, detailing how much was paid annually to doctors for travel, speaking and food.

As a board member to these for-profit health care companies, McClellan has a fiduciary obligation “not to injure them” when writing articles and speaking, said Stephen Bainbridge, law professor at UCLA.

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And while there is no legal requirement to disclose board memberships when writing for journals or speaking, Bainbridge and other experts agreed there is an ethical obligation.

“There’s certainly a potential conflict of interest there,” Bainbridge said, adding that while serving on the board of Johnson & Johnson “you are dealing with an enormous company that has fingers in a lot of different pies.”

McClellan said in an emailed statement that he provides specific disclosures on topics on which his interests might give the appearance of conflict, including in medical journals and at speaking engagements.

“My board memberships are public information and are broadly known within the field, and I stand by the independence and integrity of all my work,” McClellan said.

Ellen de Graffenreid, director of communications at the Duke-Margolis Center, said it was “clear that Dr. McClellan disclosed his position on the Johnson & Johnson Board when a potential conflict of interest existed — that is, when the publication mentions drugs or devices that may intersect with J&J’s business.” She said that while he serves on the J&J board, he “does not advocate for any positions on behalf the company.”

McClellan is a prolific writer and speaker about how the U.S. health care system operates. He left his work at the Brookings Institution to become the founding director of Duke-Margolis in 2015. He ran the FDA from 2002 to 2004 and served as administrator of the U.S. Centers for Medicare & Medicaid Services from 2004 to 2006 before joining Brookings.

In a majority of the articles McClellan wrote for the Journal of the American Medical Association, he did not disclose his corporate connections when he filled out forms concerning potential conflicts of interest. Of 15 papers he wrote since 2013, McClellan disclosed his relationship with Johnson & Johnson three times.

Johnson & Johnson is a Fortune 500 health care giant, with more than $76 billion in annual sales and a range of products including pharmaceuticals, medical devices and consumer products that include brand names Aveeno, Tylenol and Neutrogena.

“I don’t think there’s any reason to cover up or ignore those [corporate] relationships,” said Arthur Caplan, a professor of bioethics at New York University School of Medicine. “In general … I would say disclose more.”

Journals, conferences and policy forums generally ask contributors to list their potential conflicts of interest — financial relationships that might in some way sway their opinion or color the audience’s perception of information they relay. But the experts themselves decide which connections to list.

At the April forum addressing high drug prices, which was hosted by Kaiser Permanente’s Institute for Health Policy, neither the forum’s agenda, nor the speaker’s introduction at the event mentioned McClellan’s Johnson & Johnson role. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Kaiser Permanente’s John Nelson said speakers at the forums typically have extensive backgrounds and “thus we only provide abbreviated biographies when introducing them.” Kaiser Permanente declined to say whether they knew of McClellan’s corporate roles.

Dr. Jerry Avorn, a professor of medicine at Harvard Medical School, said he favors disclosure of corporate roles and thinks “many [people] would argue that it should be for the reader and not the author” to determine whether there is a conflict of interest.

The question of when to disclose industry or nonprofit funding has been debated for decades, said Dr. Sandro Galea, who wrote about conflicts of interest and schools of public health last year in JAMA.

“There are public and private actors and both importantly shape the environment in which we are in,” Galea said, adding that it has been “relatively standard practice” for those in academia to determine for themselves whether there is a conflict to disclose.

Bioethics professor Caplan said he could understand why some authors would choose not to disclose a board membership in every article, particularly if the article wasn’t directly related to the company or its products. Caplan serves as an unpaid chair of a compassionate use advisory committee based at New York University and funded by Janssen, which is a division of Johnson & Johnson.

“Just because you have a connection to a company, in my opinion, you don’t necessarily generate a conflict for everything that you do,” Caplan said. “We have to get more sophisticated” about conflicts of interest, though he advocates personally for full disclosure.

Elite medical journals, including JAMA and the New England Journal of Medicine, have streamlined the conflicts of interest question by using a standard disclosure form created by the International Committee of Medical Journal Editors.

JAMA media relations manager Deanna Bellandi declined to release McClellan’s ICMJE forms and said, “We publish what authors provide.”

The New England Journal of Medicine publishes the ICMJE forms with its manuscripts. McClellan disclosed his role at Johnson & Johnson in a 2015 letter to NEJM about the 21st Century Cures Act, a sweeping law that increases funding for disease research and alters the regulatory system for drugs and medical devices. But he did not disclose any corporate roles in two recent articles for NEJM Catalyst, a separate publication that requires authors to fill out a separate disclosure form. Those 2017 articles focused on payment reform and private-sector entrepreneurship in health care.

When completing the standard ICMJE disclosure form, an author fills out a series of sections. Section 3 notes: “You should disclose interactions with ANY entity that could be considered broadly relevant to the work.” And it tells the author to report “all sources of revenue paid (or promised to be paid) directly to you or your institution on your behalf over the 36 months prior to submission of the work.”

The Duke-Margolis Center and McClellan have been at the forefront of discussions on the merits of using real-world evidence, a somewhat controversial topic that could alter the way drugs are regulated and approved. The idea is that once a drug is on the market, the patients’ experience might in part supplant rigorous and expensive clinical trials.

Johnson & Johnson, whose executives are open proponents of the use of real-world evidence, did not respond to requests for comment.

McClellan did not disclose his J&J board membership in a 2017 white paper about real-world evidence, which was funded in part by the FDA. In September 2017, McClellan’s role at J&J was not disclosed during a public event done in coordination with the FDA. In December, Duke-Margolis announced a Real-World Evidence Collaborative, which is funded by pharmaceutical companies including Johnson & Johnson.

In May, a $4.2 million FDA grant was reposted for bids after concerns that Duke-Margolis was the sole bidder listed on the grant. The grant focuses on the drug approval process and research initiatives in the 21st Century Cures Act, including the potential benefits of using real-world evidence to analyze whether a drug works instead of rigorous and expensive clinical trials.

“Billions of dollars ride on the evidence that the FDA will accept for whether or not a drug is safe and effective,” said Avorn, whose center does similar research on drug pricing.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Readers And Tweeters Let Loose Over Kids Being Detained At The Border — And More

Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity and require full names.

Kaiser Health News’ June 20 scoop on the exact number of children under age 13 who had been detained at the border under the Trump administration’s “zero tolerance” immigration policy got wide attention, including from investigative news outlet ProPublica and Hollywood legend Mia Farrow:

What about the 2322 children under 12 years old, who are currently being detained by Trump administration? When will they be united with their parents? What is the process?

— Mia Farrow (@MiaFarrow) June 20, 2018

In walking back into the past, we are now in the year 1941!

— Andrej Mrevlje (@andrejmrevlje) June 21, 2018

— Andrej Mrevlje, founder and editor of Yonder, Washington, D.C.

‘Pain Pills’ Or Intoxicants?

A thought on Julie Appleby’s article about opioid duration (“Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass,” June 22): Our words form our ideas. A “pain pill” stops pain from occurring. Opioids do not do this. Intoxicants stop us from perceiving pain. Opioid meds do this.

What would happen if we called opioids “intoxicants”?

There are times when an intoxicant is appropriate. I had knee surgery, and it’s best to be intoxicated to endure that. Afterward, I took half a narcotic. Of course, my knee hurt. But the pain had meaning: that I was healing and things would get better.

I have been an ER doctor for 33 years, since before the so-called opioid epidemic began. I now tell patients to whom I’m giving opioids that I’m giving them permission to be drunk when that is what they need — and not when they don’t.

— Dr. Tom Benzoni, Des Moines

A Kentucky surgeon voices his concern that the patients’ needs could get lost amid prescriptive formulas for how many opioids are needed post-surgery.

“no one should be given more than five or 10 opioid tablets after a cesarean section.” Seriously? This "research" is beneath the level expected of @HopkinsMedicine -Someone should tell these surgeons that they treat patients – not procedures. @AAPSonline

— Confluential Truth (@jamespmurphymd) June 25, 2018

— Dr. James Murphy, Louisville

One D.C. source hopes to put readers wise to the teenage black market of pain pills following wisdom teeth extractions.

I know teens who get a 10 day supply for wisdom teeth. Then they stash about 50% of them (day 5) for distribution later to friends.

— Lucia Savage (@SavageLucia) June 22, 2018

— Lucia Savage, Washington, D.C.

Extra Pointer On Poison Ivy

Very good article on poison ivy (“Poison Ivy, A ‘Familiar Stranger’ That Could Ruin Your Summer,” June 11). Something you might want to add in future discussions, though, is that the sap of the tropical mango tree has the same oil that causes a reaction from poison ivy contact. Few people realize this, but even when buying fresh mangoes in the store, this sticky sap that is around the broken stem can give the same kind of painful rash as poison ivy does.

— Keith Cheshire, East Palatka, Fla.

Opening Up About Stigma

I wish Kate Spade’s family would come forth and share their true experiences surrounding her illness (“Kate Spade’s Death Ignites Concern About Rising Suicide Rate,” June 7). Substance abuse and mental illness need to be openly discussed to take away the stigma, so those who need help aren’t judged and receive proper care.

— Debbie Strobl, St. Louis

Concerning bipolar disorder, otherwise known as manic-depressive illness: Bipolar II is not “milder” than bipolar I. It’s different. The degree of mania is less extreme, but the periods of depression tend to be much longer. Misdiagnosis as merely depression is likely, which can lead to ineffective medication. The point I would have liked Liz Szabo’s story to emphasize about Ms. Spade is that while her treatment did not prevent her suicide, it may well have delayed it. Treatment is not always successful, but not treating serious mental illness guarantees poor outcomes.

— Candy Clouston, Plainfield, Ill.

My Own Private ‘A-Ha’ Moment

Your reporting on Montana’s state health plan (‘Holy Cow’ Moment Changes How Montana’s State Health Plan Does Business,” June 20) is right-on … kinda sorta. A long time ago, I worked for six different small to medium rural hospitals in several states and sections of the country from the late 1970s until 2008. What Montana has done is crude but useful.

I had often thought that Medicare’s “cost-based” system needed improvement. The introduction of the diagnosis-based reimbursement was a step in the right direction: rewarding hospitals able to provide specific services economically (comparatively) without subsidy for other services that cannot be provided at a reasonable cost. I thought that paying average costs was a way to shift funds away from the most expensive hospitals to small and rural hospitals, which have much lower costs. But, alas, these strategies were bastardized and manipulated.

I finally quit financial management of hospitals when I realized I had reached a point where I had to cut back on nursing to be able to pay for clerks and systems to maximize coding of the billing. I applaud Montana for its relatively simple system. But I reserve my enthusiasm for the fact that a smarter man than most, W. Edwards Deming, described the health care system as the most complex industry in the U.S.

I think his 60-year-old observation holds up. My belief is that there is no really good method of health care financial design. But, obviously, all others are better than what we have in this country.

— Mike Thomas, Kalama, Wash.

Back-And-Forth On Nursing Homes

As a former nursing home administrator and an attorney representing skilled nursing facilities, I found that this article (“Neglect Unchecked: Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients,” June 13) incorrectly argued that skilled nursing facilities are financially incentivized to transfer patients to the hospital and that financial considerations increase transfer rates.

First, the examples of financial burdens are incorrect: Physicians directly bill the residents’ insurance for examinations and “stat” lab tests are simply not a significant cost much less one that would be alleviated by a hospital transfer. Second, Medicaid residents do not usually return with up to 100 days of higher Medicare reimbursement because: (1) residents don’t often stay in the hospital long enough for the three-midnight qualifying stay; (2) residents may have already used their 100 days; and (3) long-term residents may not meet Medicare’s criteria to be a “skilled” patient (e.g. making enough progress with physical therapy).

The issue of hospital readmission requires a balancing act of minimizing unnecessary transfers to the hospital without creating a chilling effect that would discourage appropriate transfers.  However, the tendency to sensationalize articles about skilled nursing facilities with unrelated allegations of poor patient care leaves little room for a discussion regarding hospital readmissions or other important topics involving skilled nursing facilities and/or the provision of care to elderly patients with complex, chronic and progressive diseases.

— Tara Murray, Sausalito, Calif.

Father’s And Son’s Injuries Lead To The Mother Of All Therapy Bills

Angel Dean Lopez is a Hollywood television writer and father who enjoys doing projects with his three kids. Every fall, he helps them transform 7-inch-long blocks of wood into whimsical race cars for the neighborhood’s annual Pinewood Derby in the Los Feliz area of Los Angeles.

“So you have to take your block of wood, shape it, sand it, paint it, use your imagination,” Lopez said, pointing to some favorites from derbies past that sit on a shelf in his home office — cars in the shape of an ice cream cone, a penguin and an Altoids peppermint box.

But one derby project lives in infamy: an S. Pellegrino bottle on wheels. It was the brainchild of his son Theo, then 9, in the fall of 2016, a time when Lopez recalls he was frantically busy at work.

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“I was in a hurry and I did a horrible thing,” he said, recalling how his hand slipped as he was using a handheld power tool called a router with a fast-spinning, blade that shaves and shapes wood. He had flipped the machine over to try to save time. Improvising was a bad idea.

After surgery and a two-day hospital stay, Lopez returned home with his pinkie finger sewn together at an odd angle and his right hand immobilized in a cast.

Then, about a week later, it was déjà vu — Theo seriously injured his hand carving a Halloween pumpkin.

“My knife got stuck and my fingers slipped down the blade,” Theo recalled. He cut down to the tendon of his pinkie finger and required a complex surgical repair. Surprisingly, he said it didn’t hurt.

Following their surgeries, doctors ordered father and son to undertake numerous rounds of occupational therapy to help them regain full use of their hands.

Theo Lopez, 11, seriously injured his right hand and fingers while carving Halloween pumpkins at age 9. (Heidi de Marco/KHN)

Angel Dean Lopez holds the power tool that sliced his finger. (Heidi de Marco/KHN)

For Theo, therapy lasted about a year. For Lopez, it was several months and then repeated after follow-up surgery. The healing went well for both, and Lopez was pleased. Lopez has insurance through the Writers Guild of America, and has always been happy with its low premiums and deductibles. He wasn’t worried about coverage for this specialized occupational therapy that both father and son clearly needed.

And then the bills came.

Patients: Angel Dean Lopez, a television writer, Los Angeles. Theo Lopez, 11, student, Los Angeles.

Total bill: $10,190 for occupational therapy for two patients, father and son. Of that total, the Lopez family paid $8,561 — $4,836 for son Theo and $3,725 for dad Angel.

Service providers: Children’s Hospital Los Angeles for Theo Lopez; Cedars-Sinai Medical Center Hand Therapy Clinic for Angel Dean Lopez.

Medical procedures: Angel had reconstructive plastic surgery on three fingers as well as a second surgery to remove a pin stabilizing his fourth finger; he was in a cast for two months. Theo also had reconstructive plastic surgery to repair his tendon.

After such injuries, patients typically need sessions of occupational therapy where specialists use techniques such as massage, strengthening and stretching exercises to regain normal function and movement. Both father and son needed custom splints made and tweaked by the therapists throughout the healing.

Lopez said if it weren’t for the odd coincidence of two family members requiring the same medical care at the same time, he may have let all this slide. But the financial double whammy has left him facing thousands in out-of-pocket costs that he wasn’t expecting.

What Gives: Lopez’s Writers Guild of America insurance covers and paid $60 for each occupational therapy visit. The providers charge a list price of over $500 per session, an amount that was reduced to about $325 when billed to the insurer because of its negotiated discounts.

The proper rate for occupational (and physical) therapy is a bone of contention between insurers and therapists. And the Lopez family is caught in the middle, in need of treatments to regain full use of their hands so Angel can again type his television scripts and Theo can again play bluegrass music on his fiddle.

The union’s payment of a flat fee of $60 “is lower than any private insurer we’ve seen,” said Randall Steward, vice president of enterprise contracting and payor relations at Children’s Hospital Los Angeles. But rates insurers pay for occupational or physical therapy are highly variable.

Medicare would pay $124 per 45-minute session for occupational therapy — more than double what Lopez’s insurer paid. Healthcare Bluebook, a company that analyzes claims data for consumers and hospitals, pegs the fair range in Los Angeles between $204 and $252 per 45-minute session.

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The Writers Guild declined to comment for this article, but one reason its rate is so low is that it classifies occupational and physical therapy not as ancillary medical services but as alternative treatment, on par with acupuncture and chiropractic care, according to insurance policy documents provided by Lopez.

“This is not typical. I’ve worked for payors and hospitals now for close to 25 years,” Steward said. “I’ve never seen an insurance plan categorize occupational and physical therapy, as this plan does, as an alternative treatment.”

Also, because of that categorization in Lopez’s plan, the amount not covered by insurance that Lopez has to pay out-of-pocket does not even count toward the family’s “out-of-pocket maximum” — that’s when the sum of deductibles, premiums and other charges reaches a threshold that triggers the insurer to pick up the remainder of the tab.

Sharmila Sandhu, who is counsel and director of regulatory affairs for the American Occupational Therapy Association, said that insurers are using various techniques to limit payouts, leaving patients on the hook for bigger bills. “We are finding that insurance companies are increasing the copayment amounts for occupational therapy services or identifying other ways to limit the frequency or duration of visits a client can access,” Sandhu said.

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The Resolution: Lopez appealed the decision in a four-page letter to the Writers Guild of America claims department. The Writers Guild health policy denied the appeal. Lopez said a representative for the union told him it would be reviewing its reimbursement policy for occupational therapy.

The Takeaway: Remember that occupational and physical therapy rates vary considerably and health insurers vary greatly in their coverage. Out-of-pocket payments can really add up since almost all patients need a number of sessions.

Ask questions about how your insurance will cover those services as they are prescribed by your doctor. If you feel it is inadequate, negotiate with both the insurer and the provider. If the costs are unaffordable, ask your prescribing doctor if a more limited course of therapy would do the trick.

This is a monthly feature from Kaiser Health News and NPR that dissects and explains real medical bills in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize? Submit it here and tell us the story behind it.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

KHN’s ‘What The Health?’ Podcast Turns 1. Justice Kennedy Retires. Now What?

Kaiser Health News:States - June 28, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Rebecca Adams

CQ Roll Call


Read Rebecca's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

The retirement of Supreme Court Justice Anthony Kennedy has triggered a political earthquake in Washington, as Republicans see a chance to cement a conservative majority and Democrats fear a potential overturn of abortion rights and anti-discrimination laws, and even — possibly — challenges to the Affordable Care Act. Kennedy has been the deciding vote in dozens of cases over his long career on the high court, mostly siding with conservatives but crossing ideological lines often enough that liberals see him as the last bulwark against challenges from the right to many policies.

The Supreme Court made other health news this week, ruling that California cannot require anti-abortion “crisis pregnancy centers” to post signs informing women of their right to an abortion and telling them that financial help is available.

And this is a special week for us. It’s our first anniversary. This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Kennedy’s retirement will put all eyes on the Senate, where Republicans have a slim majority but have also changed the rules to allow confirmation with only 51 votes instead of the usual 60.
  • The fight over Kennedy’s replacement is likely to galvanize both Republicans and Democrats, but also put in the hot seat the two Republican female senators who have supported abortion rights — Susan Collins of Maine and Lisa Murkowski of Alaska.
  • This week’s primaries again put the spotlight on Democratic support of single-payer health proposals, as Alexandria Ocasio-Cortez upset the fourth-ranking Democrat in the House in New York and former NAACP head Ben Jealous won the Democratic nomination for governor in Maryland. But while Democrats have made clear that health is their top issue for the coming campaign, they have so far managed to paper over their intraparty differences on incremental versus wholesale change.
  • The California legislature could vote on a measure as soon as Thursday that would gut efforts by municipalities to put in place soda taxes. If it passes, it will mark a change in momentum away from the success of these measures across the country. The soda industry took a page from the tobacco companies in executing this plan.
  • The controversy surrounding the Trump administration’s immigration policy that separates children from their parents at the border continued to be a flashpoint this week. Health and Human Services Secretary Alex Azar was questioned about it on Capitol Hill during a hearing about drug pricing. Congressional Republicans find themselves in a difficult position. Many don’t want to defend the administration, but there doesn’t seem to be an avenue by which to move forward either.

To hear all our podcasts, click here.

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

Podcast: KHN’s ‘What The Health?’ Justice Kennedy Retires. Now What?

Julie Rovner

Kaiser Health News


Read Julie's Stories Rebecca Adams

CQ Roll Call


Read Rebecca's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

The retirement of Supreme Court Justice Anthony Kennedy has triggered a political earthquake in Washington, as Republicans see a chance to cement a conservative majority and Democrats fear a potential overturn of abortion rights and anti-discrimination laws, and even — possibly — challenges to the Affordable Care Act. Kennedy has been the deciding vote in dozens of cases over his long career on the high court, mostly siding with conservatives but crossing ideological lines often enough that liberals see him as the last bulwark against challenges from the right to many policies.

The Supreme Court made other health news this week, ruling that California cannot require anti-abortion “crisis pregnancy centers” to post signs informing women of their right to an abortion and telling them that financial help is available.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Kennedy’s retirement will put all eyes on the Senate, where Republicans have a slim majority but have also changed the rules to allow confirmation with only 51 votes instead of the usual 60.
  • The fight over Kennedy’s replacement is likely to galvanize both Republicans and Democrats, but also put in the hot seat the two Republican female senators who have supported abortion rights — Susan Collins of Maine and Lisa Murkowski of Alaska.
  • This week’s primaries again put the spotlight on Democratic support of single-payer health proposals, as Alexandria Ocasio-Cortez upset the fourth-ranking Democrat in the House in New York and former NAACP head Ben Jealous won the Democratic nomination for governor in Maryland. But while Democrats have made clear that health is their top issue for the coming campaign, they have so far managed to paper over their intraparty differences on incremental versus wholesale change.
  • The California legislature could vote on a measure as soon as Thursday that would gut efforts by municipalities to put in place soda taxes. If it passes, it will mark a change in momentum away from the success of these measures across the country. The soda industry took a page from the tobacco companies in executing this plan.
  • The controversy surrounding the Trump administration’s immigration policy that separates children from their parents at the border continued to be a flashpoint this week. Health and Human Services Secretary Alex Azar was questioned about it on Capitol Hill during a hearing about drug pricing. Congressional Republicans find themselves in a difficult position. Many don’t want to defend the administration, but there doesn’t seem to be an avenue by which to move forward either.

To hear all our podcasts, click here.

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

ACA Protections For Sick Patients Still Popular Despite GOP’s Efforts To End Them

Even as many Republicans continue to back a repeal of the Affordable Care Act, a majority of GOP voters want to retain a core consumer protection of the law that prohibits insurers from denying care or charging more to people with histories of health problems, according to a poll released Wednesday.

The requirement that insurers treat people with preexisting conditions the same as those with pristine health histories allowed the law to expand coverage to millions of previously uninsurable people starting in 2014.

But the Trump administration has refused to defend it in a legal challenge against the law brought by 20 Republican state attorneys general. The administration called for the protections guaranteeing coverage to be nullified.

The poll from the Kaiser Family Foundation showed 7 in 10 people think insurance companies should not be permitted to deny coverage because of a person’s medical history or charge them higher rates. Support for the preexisting conditions provision included 58 percent of Republicans. (Kaiser Health News is an editorially independent program of the foundation.)

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As the 2018 congressional elections near, Democratic and independent voters identify health care as “the most important issue” for candidates to discuss. Support for the provision is especially strong among households where someone has a preexisting condition. But it remains a second-tier priority for Republican voters, according to the poll, nearly tied with immigration and behind the economy and jobs. Nearly 6 in 10 Republican voters place a priority on a candidate’s support for repealing the health law.

There is more partisan agreement on President Donald Trump’s proposal to require that drugmakers publish list prices for their drugs in television commercials. Three-fourths of the public support the idea.

Those drug ads are ubiquitous on TV, and 14 percent of people who said they saw an ad said they had talked with a doctor about the specific medicine, the poll found. More than half said the physician gave them the drug and 48 percent said they discussed the cost of the medicine with the doctor.

The poll was conducted June 11-20 among 1,492 adults. The margin of error is +/-3 percentage points for the full sample.

‘You Can’t Have Perfection’: Lawmakers Who Forged ACA Look Back

Former Sens. Max Baucus (D-Mont.) and Chris Dodd (D-Conn.) and former Reps. Henry Waxman (D-Calif.) and George Miller (D-Calif.) and retiring Rep. Sander Levin (D-Mich.) led the five key committees that pushed the Affordable Care Act toward its passage in 2010.

They joined Kaiser Health News’ Julie Rovner during a session at the annual Aspen Ideas Festival in Colorado to discuss the partisan battles over the ACA, how their efforts in Congress differed from an earlier effort by the Clinton administration to revamp health care, and the problems that arose because they couldn’t get a bill through Congress to make corrections to the ACA.

They note the high price their party paid for implementing the law and the deep disagreement it sparked in the country about the role of government.

The former lawmakers agreed that they don’t think the law is perfect or meets all their hopes. While the bill generated intense opposition from conservatives during its initial debate, they said, they felt they could not give up. Their efforts to revamp health care were the foundation that future generations can build on, they said.

Thinking About An Association Health Plan? Read The Fine Print

If you own a restaurant, plumbing company or other small business, you may be intrigued by the expected expansion of association health plans under a new rule that got a stamp of approval from the Trump administration last week.

Will they meet your needs? Save you money?

Those are important questions for small businesses and self-employed people who struggle to buy affordable insurance for themselves and their workers.

Federal officials said the new rule would help level the playing field for these businesses, giving the kind of flexibility on benefits and leverage to negotiate with providers that large companies may have.

When announcing the policy on June 19, President Donald Trump said it would “result in very low prices, much more choice, much more freedom, including in many cases new opportunities to purchase health insurance. You’ll be able to do this across state lines.”

But detractors say the plans may not provide the full protection that workers need, plus the changes likely will drive up costs in the regular individual and small-group markets, where people who need comprehensive coverage would be forced to seek insurance.

Critics also point to “the long history of fraud and scams and insolvencies” for these plans, said Timothy Jost, emeritus professor of law at Washington and Lee University in Virginia.

“I think consumers are going to be in for a pretty wild ride,” Jost said.

Here are some details about what association health plans could mean for you.

Q: What are association health plans and what did the administration change?

Association health plans (sometimes called AHPs) allow small businesses to band together to buy insurance. Some plans have been in place for years, and those plans can continue to operate after the new rule takes effect. But the Trump administration’s regulation loosens the rules for additional plans to enter the market, allowing more small businesses, including individuals who work for themselves, to join these plans.

In contrast to earlier AHPs that generally required the association’s members to share an economic or other common purpose beyond enrolling in health insurance, new AHP members can be connected by geography alone or by business and professional interests. And under the new rule, providing members with insurance can be the main purpose of the association health plans.

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Q: When will the plans be available?

The new rule will be phased in starting in September. It’s uncertain how soon after that date plans will be offered.

Q: The ACA added some popular protections, including requiring plans to cover preventive care without charging consumers anything out-of-pocket and allowing people to keep their kids on their plan until they reach age 26. How will these provisions be handled under association health plans? 

Those provisions still apply to association health plans.

Q: How are preexisting medical conditions handled in the new rule?

Association health plans that are established under the new rule won’t be allowed to discriminate against individuals if they’re sick. But that doesn’t necessarily mean that people with preexisting medical conditions won’t encounter roadblocks in finding affordable, comprehensive coverage.

In the final rule, the administration lays out a variety of circumstances that could affect affordability. For example, an association plan could charge companies that employ construction workers higher premiums than firms that are in the hospitality business. The rule also allows plans to charge different rates based on gender, age and location.

Q: Will the plans cover a broad range of benefits?

It’s unclear. Association health plans are intended to make health insurance more affordable for small businesses in part by giving them the same kind of flexibility that large companies have in choosing which benefits they offer.

Flexibility may have a downside, though. AHP insurers don’t have to include the 10 “essential health benefits” that are required under the health law for plans in the individual and small-group market, typically companies with fewer than 50 employees. They might exclude coverage for prescription drugs or rehab services, for example.

Even though they’re not required to, large companies typically provide comprehensive benefits to compete for top talent. Smaller companies with fewer resources may find it tougher to afford generous employee perks.

Association health plans that cover employers with at least 15 employees will have to offer maternity coverage — one of the ACA’s essential health benefits — under the new rule. But smaller employers could skip that requirement.

The plans have to abide by the annual maximum out-of-pocket spending limit for the essential health benefits they decide to cover, and they can’t impose annual or lifetime limits on coverage of those benefits.

But since plans don’t have to cover all the essential health benefits, those protections aren’t as meaningful, some say.

“It waters down the out-of-pocket cap protection if you don’t have essential health benefit coverage requirements,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Q: How could premiums be affected?

The new rule allows health insurers to use several factors that may provide clues that people are likely to be expensive to insure, including gender, age, industry and geography, when setting rates for employers. A company with older workers who are more likely to have chronic conditions, for example, could face higher rates — as might one that employs lots of women, who might rack up charges for maternity care. In addition, individuals within a company could be charged different premiums based on their occupation or other factors not related to their health status if the employer chooses to do so, Jost said.

Q: Who’s likely to benefit under the rule? 

Companies that have relatively young, healthy employees could fare well.

“For young men in certain low-risk industries, who are currently healthy, they’re likely to encounter a relatively low premium,” said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms.

The Blue Cross Blue Shield Association, when filing comments on the proposed rule, said association health plan premiums for women in their early 30s might be more than 30 percent higher than rates under regular individual and small-group rules. It also estimated that rates for young men of a similar age could be more than 40 percent lower than ACA rates.

Similarly, companies in some industries could see lower premiums than others, according to BCBS. Rates for engineering companies could be about 9 percent lower than what insurers would charge on the individual and small-group market, for example, while those for the taxicab industry could be nearly 15 percent higher.

Q: What if an employer offers a really skimpy plan? Are workers stuck with it?

That depends. If an employer offers coverage that doesn’t meet minimum standards, workers can shop for subsidized health insurance on the marketplace, and the employer may face penalties. (Companies with fewer than 50 workers are exempt from penalties, however.) In 2018, that means that single coverage can’t cost workers more than 9.56 percent of their entire household income and plans have to pay at least 60 percent of the cost of covered benefits. The same rules apply if an employer offers coverage through an association health plan.

Some policy experts say they’re worried that people who work for small businesses may get burned if their companies, which do not offer any plans now, start offering coverage through an association health plan. The new plan may be skimpier and more expensive than the comprehensive coverage they’ve been getting on the ACA exchange.

“Even though the AHP coverage might be skimpy, employees would no longer be eligible for subsidized coverage on the exchange,” said Katie Keith, a health policy consultant who writes frequently about health law.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

Gawande’s Goal Is Providing The ‘Right’ Health Care In New Venture By 3 Firms

Dr. Atul Gawande, the famed surgeon-writer-researcher chosen to lead a joint health venture by three prominent employers to bring down health costs, said his biggest goal is to help professionals “make it simpler to do the right thing” in delivering care to patients.

His comments at the Aspen Ideas Festival came just days after being named chief executive of a health care partnership unveiled earlier this year by Amazon, Berkshire Hathaway and JP Morgan Chase & Co. The new enterprise will oversee health coverage for about 1.2 million employees of the companies and their families. Gawande said he will focus on the same behaviors by doctors and hospitals that he studies at his Boston-based think tank Ariadne Labs.

One of the biggest problems in health care is that “doing the right thing is incredibly complicated” and that one of the biggest sources of waste in the system is that patients are given “the wrong care in the wrong way at the wrong time,” he said

He said he hopes to find specific ways to make health care more efficient and the solutions exportable.

“The opportunities are as long as my arm,” he said. “So all we have to do in this new venture is pick a few of them and try to bat them out of the park.”

For example, he said, even in countries where everyone is covered by insurance only about half of those with high blood pressure have it controlled. In the U.S. that percentage is closer to 40 percent. And while Americans spend “tons more money” to treat low back pain, he said, “the level of disability and pain has changed not at all.”

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Gawande, 52, was purposely vague about his new job — which he will add to his long list of activities, including teaching at Harvard and operating on patients at a university-affiliated hospital in Boston, writing for The New Yorker and serving as chairman of Ariadne Labs.

“We are going to come up with a name, it’s one of my first jobs,” he joked to interviewer Judy Woodruff of “PBS NewsHour” during a session at Aspen on Saturday. On Monday, at another session, he told The New York Times’ David Leonhardt that he “had no idea” how many employees would eventually come to work for the organization, although it will be a stand-alone, not-for-profit entity. He declined a separate interview.

But Gawande did talk at length in both appearances about his approach to the new initiative.

“The largest concept here is I get to have a million patients that I as a doctor get to add to my responsibility,” he said Saturday. “And my job to them is to figure out ways that we are going to drive better outcomes, better satisfaction with care and better cost efficiency with new models that can be incubated for all.”

That is essentially what Ariadne already does — tests ways to make care more effective and efficient and spreading those practices in the U.S. and abroad.

As an example, he talked about his mother’s recent knee replacement. A total of 66 health workers saw her in the hospital — he counted — and often provided conflicting advice about whether she should be up or in bed or exactly what she should be doing.

“And you just want to say, ‘Is anybody in charge?’” he said. “That’s the broken system.” The system is moving “from individual delivery of stuff … to team delivery of outcomes. And that’s a radically different place.” He wants to help make that transition more effective.

Gawande said his research has also shown that “the right care” can’t just be dictated. He developed a now-famous surgical checklist that was later mandated for doctors in Canada. But he pointed out in his discussion Saturday that the requirement showed no reduction in surgery-related mortality. Yet in Scotland, where the implementation was more gradual and more data-driven, he said, “in the first three years we saw a more than 25 percent reduction in deaths.”

Gawande said that although he is going to work for companies that provide insurance to their workers, “employer-based care is broken,” with the vast majority of new jobs lackinghealth insurance.

And even those workers who are offered job-based health insurance are increasingly priced out of care. Some people he grew up with in Ohio, he said Monday, “are paying half their income in taxes and health care premiums and going bankrupt because of health care costs.”

When workers have deductibles that are multiples larger than their bank accounts, they stop treating their chronic conditions. “And it has enormous harm for the future,” he said.

Still, he was optimistic about the possibilities of making health care both better and less expensive.

“It’s feasible to do these things,” he said Monday. “But it’s not sexy.”

Fearing Deportation, Immigrant Parents Are Opting Out Of Health Benefits For Kids

Kaiser Health News:States - June 25, 2018

The fear of family separation is nothing new for many immigrants already living in the U.S. In fact, that fear, heightened in recent weeks, has been forcing a tough decision for a while. Advocates say a growing number of American children are dropping out of Medicaid and other government programs because their parents are not citizens.

Marlene is an undocumented resident of Texas and has two children who are U.S. citizens who qualify for Medicaid, the federal-state program for low-income people. (Kaiser Health News is not using Marlene’s last name because of her immigration status.) One of her children has some disabilities.

“My son is receiving speech therapy,” she said in Spanish. “But it’s been difficult.”

It was a long journey to get the right evaluations and diagnoses, and her son is finally making progress, Marlene said. But she braces for a day when he might have to do without this therapy and others that are paid for through Medicaid. Because she’s undocumented, she’s extremely nervous about filling out applications for government programs like this.

Already, she has decided to stop receiving food stamps, now known as SNAP, which her children, as citizens, are entitled to based on the family’s income.

She dropped it because the application to receive those benefits changed, she said.

“They are asking a lot of questions,” she said. “They are investigating one’s life from head to toe.”

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Marlene said she was nervous, in particular, about being asked to provide years of pay stubs and other eligibility requirements she had not experienced before. Marlene said the application alone made her “sick from stress.”

Repeated calls and emails to Texas health officials to ask about the changes in the benefits application process went unanswered.

Marlene’s son has Medicaid for the next several months. But she is worried how that application will change, too, next time she has to apply.

Health care groups say they’ve observed other immigrant families making similar choices, and they think it will accelerate if a proposed change to green card eligibility becomes law. Under the proposed change, if family members receive government services — even if those family members are citizens — it would ding the applicants’ chances of approval for permanent residency.

“We are seeing families having to make this impossible choice,” said Maria Hernandez, the founder of Vela, a nonprofit in Austin that helps parents who have children with disabilities.

Hernandez instructs parents how to advocate for their children and how to find the appropriate health care and therapies for their kids, and helps them find community support, among other things.

She conducts many of these classes in what used to be an elementary school on the east side of Austin, known as one of the most diverse areas of the city. She said about seven in 10 of the families she works with are immigrants — mostly from Mexico.

“We are working with families who the parents are immigrants but the children are born here,” Hernandez said.

Parents tell Hernandez they feel like they can’t risk any attention from the government, even if that means losing badly needed benefits for their kids.

In the first year of the Trump administration, Central Texas experienced an uptick in immigration raids and deportations. Since then, Hernandez said, a lot of people in the immigrant community have been making critical choices out of fear.

“It’s out of fear of deportation,” she said. “It’s out of fear of having their children being penalized in some way and potentially losing a parent that until this point has been their fierce advocate.”

In Texas, this is a decision that is bound to affect a significant number of children, said Anne Dunkelberg with the Center for Public Policy Priorities in Austin. Dunkelberg has been closely watching various immigration proposals and their effect on access to government services.

“A quarter of Texas children have at least one parent who is not a U.S. citizen,” she said. “Now, I am sure that not a hundred percent of those kids — and it’s about 1.8 million kids — not a hundred percent of them are using a public benefit, but a very high percentage will be.”

Dunkelberg said families opting out of Medicaid could further raise the number of uninsured in Texas, which is already the highest in the nation.

Hernandez said parents who have children with disabilities have told her that without Medicaid they’ll rely on emergency rooms “as needed.”

“We know that that is not a good plan for kids that for forever have been followed by a neurologist because they have seizures or have been going to occupational therapy for years and are finally making progress,” she said.

Approximately 10 million citizen children in the U.S. have at least one non-citizen parent.

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Rx: Zucchini, Brown Rice, Turkey Soup. Medicaid Plan Offers Food As Medicine
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PHILADELPHIA — Feliciano Pagan stood at his front door when the MANNA food truck pulled up to his two-story brick row home.

Pagan, 48, greeted the driver with a smile as he carried in two large bags filled with frozen dinners and fresh fruit that would last a week. Among the goods were chicken fajitas with brown rice and zucchini; chicken dumplings, carrots and beets; and sweet-and-sour pork chops with turkey noodle soup.

These medically tailored meals — all with limited salt and carbohydrates — are designed to keep Pagan, who has congestive heart failure, out of the hospital. Health Partners Plans, the nonprofit company that runs the Medicaid health plan Pagan belongs to, is betting on it.

Feliciano Pagan, a Medicaid recipient in Philadelphia, looks over his medically tailored meals made at the kitchens of the nonprofit MANNA and paid for by Health Partners Plans, his Medicaid health plan. (Phil Galewitz/Kaiser Health News)

Since 2015, Health Partners has joined a small group of insurers around the country to offer some members specially designed meals to improve their health. The company paid the full cost for 560,000 meals to be delivered to more than 2,100 of its members with various conditions such as diabetes, heart disease and kidney failure.

The Metropolitan Area Neighborhood Nutrition Alliance (MANNA), a Philadelphia-based nonprofit organization that provides medically appropriate food for people with serious illnesses, prepares and delivers the meals.

The service covers three meals a day and typically lasts six weeks, although members can renew for two additional six-week cycles. It also provides nutritional counseling. MANNA provides the meals to everyone in the household to help family members support patients who need to change bad diets. Health Partners, which serves Philadelphia and nearby counties, said its investment is paying off.

With the kick-start that comes from receiving these free meals and continued counseling to shop better and prepare healthy meals, the members are better able to control their diabetes, use the hospital less and reduce their medical costs, according to the health plan.

“We wanted to see how this would work out and we are quite pleased that with the cooperation of our members we did see a dramatic reduction in their costs … and improved outcomes,” said William George, CEO of Health Partners.

George would not disclose how much his health plan pays for meals, although one industry expert said it costs less than $15 a day per member.

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The growing number of “food as medicine” programs nationally are aimed at improving nutrition among adults with serious illnesses to help them heal, recover from medical procedures and control chronic diseases.

Aetna and two other insurers also have added the benefit for their Medicaid enrollees in the Philadelphia area.

California’s Medicaid program in May began a three-year pilot project to provide meals to several thousand adults with chronic diseases. In New York, the nonprofit group God’s Love We Deliver provides medically tailored meals to two dozen Medicaid managed long-term care plans.

An example of one of MANNA’s meals. (Phil Galewitz/Kaiser Health News)

Despite the success of these food programs, they are not standard benefits in Medicare — the federal health program for seniors and disabled people — or Medicaid — the state-federal health program for low-income people. Advocates say efforts to expand the programs are stymied by concerns about the cost and public resistance to a government health program providing free food.

But private Medicaid and Medicare plans have discretion to spend their government funding on services outside direct medical care. Proponents of these meal services are trying to persuade more of the private plans to adopt the programs.

Karen Pearl, CEO of God’s Love We Deliver, said while it may seem obvious that giving people healthy meals will help them get well, it’s still a huge change for plans focused on paying for doctor visits, hospital care and drug benefits.

“For plans trying to care for high-cost members, sometimes it’s hard to carve out money from the medical model, as nutrition has not always been front of mind,” she said.

A recent shift among government and private insurers to pay doctors and hospitals to keep people out of the hospital could give this approach a boost, according to experts.

A study published in Health Affairs in April found providing tailored meals for at least six months in a Massachusetts Medicaid health plan reduced ER visits, hospital admissions and health spending compared with adults who did not receive an intervention.

Another study, published this month in the American Journal of Managed Care, found that when the Maine Medical Center offered specially tailored meals to 622 high-risk Medicare patients, the hospital’s readmission rates dropped by 38 percent over two years, compared with patients without the intervention. The cost savings were more than $200,000, according to the research.

“Telling someone to go to the gym and eat healthy does not work anymore,” George said. People either don’t know how to eat nutritious meals, don’t have easy access to healthy food or can’t afford it, he said.

That was the case with Pagan, whose blue-collar neighborhood has fast-food restaurants but lacks a larger grocery store with a broad array of fruits and vegetables.

Pagan has had heart valve surgery and may soon need a heart transplant. His doctors have told him to cut back on greasy food, but he said he didn’t know how until Health Partners offered him the special meals.

“It’s hard not knowing what foods to eat,” Pagan said during an interview in May just after he received his latest meals from MANNA.

Waynetta Faust, a volunteer at MANNA, prepares sweet-potato-and-crab soup. (Phil Galewitz/Kaiser Health News)

A MANNA delivery man walks up the steps of Feliciano Pagan’s home in northeast Philadelphia. (Phil Galewitz/Kaiser Health News)

MANNA uses a team of chefs and hundreds of volunteers to prepare the meals from scratch at its headquarters in downtown Philadelphia. Meals are tagged with a colored sticker depending on which of 11 types of diet they meet — such as low-calorie, high-protein or low-salt.

Unlike the popular Meals on Wheels America service, which provides meals to seniors across the country on a sliding fee scale, these specialized meals vary based on each person’s health status.

“It’s taken awhile for the concept to catch on that medically tailored meals are more than just food or a meal but high-tech specialty health care service for people living with complex medical needs,” said Robert Greenwald, faculty director of Harvard Law School’s Center for Health Law and Policy Innovation.

MANNA CEO Sue Daugherty said getting insurers to cover the cost of meals is vital to expanding her group’s reach, which otherwise relies on philanthropic support. About 375 of its 1,300 clients are now covered by Medicaid health plans.

It has been challenging to get insurers to look at the meals as a way to save money, Daugherty said.

“We think of food as medicine and want folks to have access to their prescribed diet just like they do for a prescribed medication,” she said.

For example, she added, cancer patients undergoing chemotherapy often have little appetite, so getting them meals rich in calories and protein is important to keep up their strength.

Sue Daugherty, CEO of MANNA, holds medically tailored meals in the nonprofit’s kitchen in Philadelphia. (Phil Galewitz/Kaiser Health News)

George said another key is nutritional counseling so members can learn to make better choices in the supermarket and prepare healthy meals themselves.

“We don’t have the resources to feed everyone forever,” he said.

There’s little research on how people’s health fares after they stop getting the medically tailored meals, said Seth Berkowitz, an assistant professor of medicine at the University of North Carolina, who co-authored the Health Affairs study. While there’s little controversy that giving people nutritious meals is good for their health, more research is needed to determine who are the best candidates for these programs and how long they should last, he said.

Marina Rangel, 53, of Philadelphia, credited the meals she received in 2016 through Health Partners for getting her back on the road to health.

At the time, she weighed 400 pounds and could barely move around her home. After five months of receiving meals and counseling, she lost 45 pounds, which encouraged her doctors to give her a hip replacement. Today, her weight is down to 245, her diabetes is under control, and she works at home selling antiques on eBay.

“It’s been amazing, lifesaving for me to be in the program,” she said.

This story is part of a collaboration between WHYY’s The Pulse, The Philadelphia Inquirer and Kaiser Health News.

Zero-Tolerance Prosecution and Family Reunification

HHS Gov News - June 24, 2018

The Department of Homeland Security (DHS) and Health and Human Services (HHS) have a process established to ensure that family members know the location of their children and have regular communication after separation to ensure that those adults who are subject to removal are reunited with their children for the purposes of removal. The United States government knows the location of all children in its custody and is working to reunite them with their families.

As part of the apprehension, detention and prosecution process, illegal aliens, adults and children, are initially detained by U.S. Customs and Border Protection (CBP) before the children are sent to HHS’ Office of Refugee Resettlement (ORR) and parents to Immigration and Customs Enforcement (ICE) custody. Each entity plays a role in reunification.  This process is well coordinated.

U.S. Customs and Border Protection

  • CBP has reunited 522 Unaccompanied Alien Children (UAC) in their custody who were separated from adults as part of the Zero Tolerance initiative.  The reunions of an additional 16 UAC who were scheduled to be reunited on June 22, 2018 were delayed due to weather affecting travel and we expect they will all be reunited with their parents within the next 24 hours.  There will be a small number of children who were separated for reasons other than zero tolerance that will remain separated: generally only if the familial relationship cannot be confirmed, we believe the adult is a threat to the safety of the child, or the adult is a criminal alien.
  • Because of the speed in which adults completed their criminal proceedings, some children were still present at a United States Border Patrol (USBP) station at the time their parent(s) returned from court proceedings.  In these cases, the USBP reunited the family and transferred them, together, to ICE custody as a family unit.

U.S. Immigration and Customs Enforcement

  • ICE has dedicated the Port Isabel Service Processing Center as the primary family reunification and removal center for adults in their custody.
  • A parent who is ordered removed from the U.S. may request that his or her minor child accompany them. It should be noted that in the past many parents have elected to be removed without their children.
  • ICE has posted information in all of its facilities advising detained parents who are trying to locate, and/or communicate with, a child in the custody of HHS to call the Detention Reporting and Information Line for assistance, which is staffed by live operators Monday through Friday from 8 AM to 8 PM.
  • The information provided by these parents to the call operators will be forwarded to HHS for action. ICE and HHS will coordinate a review of their custodial data to identify where each child is located, verify the parent/child relationship, and set up regular communication and removal coordination, if necessary.
  • Each ICE Field Office has Juvenile Coordinators who manage these cases throughout the immigration court proceedings.
  • Further, ICE maintains a publicly available online detainee locator which can be used to locate adults detained by ICE. This site can be accessed at:

ICE has completed the following steps toward reunification:

  • Implemented an identification mechanism to ensure on-going tracking of linked family members throughout the detention and removal process;
  • Designated detention locations for separated parents and will enhance current processes to ensure communication with children in HHS custody;
  • Worked closely with foreign consulates to ensure that travel documents are issued for both the parent and child at time of removal; and
  • Coordinated with HHS for the reuniting of the child prior to the parents’ departure from the United States.

U.S. Health and Human Services Office of Refugee Resettlement

  • Minors come into HHS custody with information provided by DHS regarding how they illegally entered the country and whether or not they were with a parent or adult and, to the extent possible, the parent(s) or guardian(s) information and location. There is a central database which HHS and DHS can access and update when a parent(s) or minor(s) location information changes.
  • As of June 20th HHS has 2,053 separated minors being cared for in HHS funded facilities, and is working with relevant agency partners to foster communications and work towards reuniting every minor and every parent or guardian via well-established reunification processes. Currently only 17% of minors in HHS funded facilities were placed there as a result of Zero Tolerance enforcement, and the remaining 83% percent arrived to the United States without a parent or guardian.
  • Parent(s) or guardian(s) attempting to determine if their child is in the custody of the Office of Refugee Resettlement (ORR) in HHS Administration for Children and Families should contact the ORR National Call Center ( at 1-800-203-7001, or via email Information will be collected and sent to HHS funded facility where minor is located. The ORR National Call Center has numerous resources available for children, parent(s), guardian(s) and sponsors.
  • Within 24 hours of arriving at an HHS funded facility minors are given the opportunity to communicate with a vetted parent, guardian or relative. While in HHS funded facilities’ care, every effort is made to ensure minors are able to communicate (either telephonic or video depending on the circumstances) with their parent or guardian (at least twice per week). However, reasonable safety precautions are in place to ensure that an adult wishing to communicate with a minor is in fact that minor’s parent or guardian.
  • Minors in HHS funded facilities are permitted to call both family members and/or sponsors living in the United States and abroad. Attorneys representing minors have unlimited telephone access and the minor may speak to other appropriate stakeholders, such as their consulate, the case coordinator, or child advocate. Additional information on telephone calls, visitation, and mail policies are available in the policy guide.
  • Under HHS’ publicly available policy guide for Unaccompanied Alien Children, the Office of Refugee Resettlement (ORR) releases minors to sponsors in the following order of preference: parent; legal guardian; an adult relative (brother, sister, aunt, uncle, grandparent or first cousin); an adult individual or entity designated by the parent or legal guardian (through a signed declaration or other document that ORR determines is sufficient to establish the signatory’s parental/guardian relationship); a licensed program willing to accept legal custody; or an adult individual or entity seeking custody when it appears that there is no other likely alternative to long term ORR care and custody.

Podcast: KHN’s ‘What The Health?’ Live from Aspen!

Julie Rovner

Kaiser Health News


Read Julie's Stories Joanne Kenen



Read Joanne's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

With President Donald Trump and Republicans in Congress stymied in their efforts to change the nation’s health care system, individual states are wrangling with public ire over price and coverage.

Two guests this week, Democratic Govs. John Hickenlooper of Colorado and Steve Bullock of Montana, have made health a priority in their states and are among the governors who have signed on to bipartisan efforts to shore up parts of the Affordable Care Act that are not working. Both governors are also among the long list of Democrats mentioned as possible presidential candidates in 2020.

Meanwhile, actions in Washington, including this week’s regulation expanding the availability of association health plans, often leave states scrambling to figure out what it will mean for their own health insurance markets.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Both governors said they think health care will be a dominant voting issue in 2018 and 2020. They say governors are among the few who are able to work on the issue on a bipartisan basis.
  • The conservative health plan unveiled this week as a replacement for the Affordable Care Act would give states more flexibility. It also would likely pose an enormous challenge because, over time, it would reduce the amount of federal health care dollars and wouldn’t give states much time to implement their programs.
  • If a federal court in Washington, D.C., opts to throw out Kentucky’s Medicaid work requirement for nondisabled adults, expansion plans in a number of states could be thrown into disarray. Some of them, like Kentucky, say they will not keep the expansion without the work requirement.
  • Montana offered a somewhat different path to work for people who are covered under the Medicaid expansion. Eighty percent of them are working already. Instead of being punitive, Bullock said, the state made a number of support services and employment training options available and, in turn, that raised the number of those working by 9 percent.
  • Hickenlooper said that in Colorado, because the unemployment rate is below 3 percent, most of the nondisabled adults who were covered under Medicaid expansion and not working are instead caring for their children or elder family members.

To hear all our podcasts, click here.

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

Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass

What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?

That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.

The answer isn’t clear-cut.

Surgeon Marty Makary wondered why and what could be done.

So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.

After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.

Even Makary admitted that for most of his career he “gave [painkillers] out like candy.”

In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?”

The answer was illuminating.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, says Dr. Marty Makary, who’s leading an effort to curb overprescribing by offering procedure-specific guidelines for opioid painkillers. (Courtesy of Johns Hopkins Medicine)

“The head of the hospital’s pain services said, ‘You’re the surgeon, what do you think?’” recalled Makary.

Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.

“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”

After a quick couple of weeks of intense discussion, Makary’s group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.

“We’re in a crisis,” said Makary, explaining why the group didn’t go a more traditional route and publish its findings in a medical journal first, which could take months.

Sometimes the right number of opioids is zero, concluded the group.

Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.

For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.

Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.

Oh, and for cardiac bypass surgery? No more than 30 pills.

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But What About The Pain?

Tens of thousands of Americans are dependent upon opioid medications. An increasing number are dying from overdoses, both from prescription medication and street drugs.

Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine.

After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found that persistent use of opioids was “one of the most common complications after elective surgery.”

In that study, University of Michigan researchers found that 6 percent of people who had never taken opioids but received them after surgery were still taking the medications three to six months later.

With about 50 million surgeries that occur in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.

Smokers, and those diagnosed with certain conditions such as depression, anxiety or chronic pain before their operations, were most at risk of long-term use.

Each refill or additional week of use makes for a greater risk of misuse, other studies have shown.

Additional research points to another reason for concern. If patients don’t take all the pills they are prescribed following an operation, those pills can be stolen or diverted to other people, who then run the risk of becoming dependent.

Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.

For one thing, some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture.

“Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. “Could you put a lidocaine patch over the wound or is there a better way to immobilize a joint?”

Studies have shown that sometimes a combination of ibuprofen and acetaminophen can be just as good as or better than opioids.

Alternatives should always be considered first, agreed Makary.

Another concern is that guidelines for prescribing relief — even those aimed at short-duration, acute pain, such as that following surgery — have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits have made it difficult for chronic pain patients to get the medications they need.

Some people even apply these concerns to recommendations about the treatment of acute pain.

“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine. “It’s challenging to lump all patients into one basket.”

A Different Focus: Duration

Lawmakers — desperate to address overdose problems that are destroying families and communities — have gone where they usually don’t: setting specific rules for doctors.

Legislatures in more than a dozen states, including New Jersey, Massachusetts and New York, have set restrictions, often on the number of days’ worth of pills prescribed for acute pain.

“States said that since physicians haven’t self-regulated, we’re going to do it for them,” said Nelson at Rutgers.

Congress, too, is getting involved, holding a flurry of hearings this spring, and considering legislation that would, among other things, set limits on prescribing opioids for acute pain. The recently passed federal spending bill includes $3 billion in new funding to help states and local governments with opioid prevention, treatment and law enforcement efforts.

To be sure, the medical profession has also responded to the crisis — with medical societies and other expert groups offering a growing number of standards for prescribing opioids.

Some are fairly generic, recommending the lowest dose for the shortest period of time for acute pain. Some are more prescriptive.

None is meant to address the needs of chronic pain patients or those with cancer.

And state rules vary. New Jersey’s, for example, says patients with acute pain should, initially, get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time.

The Centers for Disease Control and Prevention recommends three days.

Makary and some other experts say that, while well-intentioned, such durational rules are too blunt.

A day’s worth of pills can vary, depending on how often the doctor instructs patients to take them. Under many of the state rules, patients could still head home with more than 50 pills.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, said Makary.

Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take their rules a step further.

“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.

Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.

That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and lead to more informed patients among those who need a longer supply.

Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules — like those adopted by the states — can be effective.

“I personally think three days is enough,” said Nelson. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”

That said, Nelson called the Hopkins’ approach an “excellent idea” and one he has tried to do. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

To get around overprescribing — or setting one-size-fits-all guidelines — physicians at Dartmouth-Hitchcock Medical Center have a developed their own data-based approach.

Dr. Richard Barth, the chief of general surgery at Dartmouth, and colleagues studied 333 patients discharged from the hospital following six common surgeries that included bariatric procedures; operations on the stomach, liver, colon and pancreas; and hernia repair.

Surveying the patients, they asked how many opioid pills they went home with, how many they actually took, how many went unused and how much pain they experienced.

The data helped them land on a way to recommend a specific number of pills. “If they took none the day before discharge, then over 85 percent of patients did not take any when they went home,” said Barth.

Dartmouth-Hitchcock now uses that data as a recommended starting point for physicians.

Under the guidelines, patients taking no opioid pain pills the day before discharge go home with none. Those who take one to three pills get 15, an amount Barth’s study found satisfied 85 percent of patients, and those who took four or more get 30 pills.

“We came out with a very easy to implement and remember guideline,” said Barth. “We actually called patients and asked them how many [pills] they used. That’s what differentiates us from other places.”

Brummett, at Michigan, says the Opioid Prescribing Engagement Network, a collaboration of hospitals, insurers, physicians and others in his state, has used similar data methods to come up with procedure-specific guidelines.

“We’ve taken a data-driven approach,” he said. “We believe patient-reported outcomes are a better way to guide than expert consensus.”

For his part, Makary admitted it is harder to develop guidelines like those at Hopkins and Dartmouth, but he said the effort is vital.

“It’s mind-boggling to me” that so many opioid-prescribing guidelines do not specify the procedure, said Makary. “An ingrown toenail is not the same as cardiac bypass surgery.”

‘Holy Cow’ Moment Changes How Montana’s State Health Plan Does Business

Marilyn Bartlett, the director administrator of Montana’s Health Care and Benefits Division, recalls thinking “holy cow” when she got an urgent directive from state legislators in late 2014: “You have to get these costs under control, or else.”

Increasing health care costs in the state workers’ health plan were helping hold down workers’ wages. The plan’s financial reserves were dwindling, heading for negative territory.

So began Barlett’s high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head.

Instead of starting with the hospital’s list price and negotiating down for discounts, the state began telling these facilities how much it was willing to pay — a “reference price” — for each type of hospitalization. State officials used generally conservative Medicare rates as a baseline and starting point for the discussion.

Before the plan took effect, hospital charges for state employees for the same service had varied widely, with some hospitals charging three to six times the Medicare rate for some services.

To even out the disparities and save money, the state decided it would pay an average of 234 percent of Medicare rates — a level of payment that hospitals indicated they would accept and an amount the state calculated would allow an efficient hospital to deliver high-quality care and still profit.

While other states and some private employers have set prices they are willing to pay for some standardized procedures — such as a colonoscopies or hip replacements — Montana’s experiment is more sweeping, covering all hospital services, and it uses Medicare as a common yardstick.

Two years in, the state calls the effort a success, saving $15.6 million this year over the estimate of what it would have paid without the change. Meanwhile, its reserve fund has grown and is so healthy the state dipped into it for other needs.

Did The State Get The Payments Right?

“A centralized price-setting model has danger. It can overpay or underpay,” said Glenn Melnick, director of the Center for Health Policy and Management at the University of Southern California.

Lawmakers directed Marilyn Bartlett, the director administrator of Montana’s Health Care and Benefits Division, to get employee health costs under control, so she changed the way the state pays hospitals.(Courtesy of Marilyn Bartlett)

Like some other cost-control efforts, the Montana approach might lead to smaller numbers of hospitals that agree to participate in the state plan, he noted.

So far, there’s been no sign of that, said Bartlett: “No hospital has gone broke.”

But resistance is natural, said Damon Haycock, head of Nevada’s public employees’ benefits plan, because, ultimately, money saved for state workers is money hospitals don’t get.

There could be a ripple effect, as others in the community will want parity.

“If a state takes a hard line and says, we’re not paying more than X, then cities and counties and large employers would want the same deal,” he said. “And that becomes a massive political hurdle.”

To get buy-in, the state settled on the 234 percent, which many economists consider a relatively generous mark-up from standard Medicare payments.

Medicare doesn’t negotiate prices with hospitals or use hospital-set charges in its calculations. Instead, Medicare sets reimbursement through a complex formula that includes the cost of providing the service and the type of diagnoses. By its calculations, the government program pays hospitals enough to cover their services as well as a small profit.

Hospital officials, including many of those in Montana, disagree.

“When you look at total costs, Medicare probably pays 75 to 80 percent,” said Jay Doyle, president of St. James Healthcare in Butte. The facility, part of the SCL Health system, reported losing $9 million on its Medicare patients in 2016, the latest data available.

But economists say the prices are adequate if the hospitals spend the money wisely.

“Hospitals will say Medicare pays 90 cents on the dollar,” said Zack Cooper, an assistant professor of health policy and economics at Yale, which makes their argument sympathetic “for the first 15 seconds.”

In fact, for most hospitals, Medicare covers their costs, he added.

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Reaching Out To The Holdouts

The Montana effort took aim at hospital-set prices, often called “chargemaster rates,” which to Bartlett were seemingly “going up and up.” She and the third-party administrator the state hired gathered data and dove into the new negotiations.

At some hospitals, Montana was shelling out more than three times what Medicare paid for inpatient care. Outpatient services showed an even wider range. Some hospitals were paid more than six times the Medicare rates.

When Bartlett’s team settled on paying an average of 234 percent of Medicare for inpatient and outpatient care, the decision involved a delicate balance: Set the bar too high and some hospitals would raise prices; too low, and some could cut back services or refuse to sign on.

As the July 1, 2016, deadline approached, five hospitals were holding out — and the state didn’t want huge gaps in its hospital network.

“I was absolutely freaking,” said Bartlett.

Four of the five remaining agreed before the deadline. The last major holdout was Benefis Health System in Great Falls, which argued that it was already one of the lower-cost hospitals in the state and that it should save its biggest discounts for its biggest customers.

Benefis declined requests for an interview.

At the time, state workers and their unions began a classic public relations arm-twisting campaign. Workers were told they might get hit with out-of-network bills from Benefis if it did not sign on. Such bills represent the balance between what the state pays and what hospitals charge.

Employee unions urged members and other interested groups to call or write Benefis, urging it to get on board.

The hospital is “kind of a monopoly, used to calling their own tune,” because it is the only major hospital within 90 miles, recalls Keith Leathers, an investigator with Montana’s Department of Public Health and Human Services. He was among those employees who picked up the phone, left messages and wrote notes.

By the end of July, Benefis finally signed on.

Will Others Follow Suit?

“A lot of states could learn from Montana,” said William Kramer, executive director for National Health Policy with the Pacific Business Group on Health, a coalition of employers. Within the state, companies and cities in the state are watching the experiment as well.

There are discussions underway about expanding Montana’s program beyond 35,000 state workers to cover city, county and university employees.

“If you want to get at pricing abuse by hospitals, why wouldn’t every single employer do that,” said Francois de Brantes, an independent benefits consultant and former director of the Center for Payment Innovation at Altarum, a Washington, D.C.-based nonprofit research and consulting firm.

That, of course, makes hospitals nervous since they have traditionally compensated for low reimbursement from some insurers by charging others more.

“If [that] happened, it would have huge economic impact,” including layoffs at his hospital, said Doyle of St. James Healthcare.

But Cooper, the Yale economist, suggested that hospitals paid based on multiples of Medicare will be fine if they deploy their earning wisely rather than on duplicative services, additional MRI machines or gleaming, marble-filled lobbies.

For many, he said, “it’s a function of investment decisions, not that Medicare doesn’t pay enough.”

Secretary Azar Praises Trump Administration Expansion of Health Insurance Options

HHS Gov News - June 20, 2018

HHS Secretary Alex Azar issued the following statement regarding the Department of Labor’s release of a final rule on the regulation of Association/Small Business Health Plans:

“This action by the Trump Administration will give more Americans access to affordable, high-quality health insurance coverage. Allowing small businesses and individuals to band together to offer new options is especially important because access to health insurance for employees of small businesses has narrowed over the years, including under the Affordable Care Act. We look forward to leading continued work across the Trump Administration to open up more options for affordable, accessible, private health coverage.”

Read more about the Department of Labor’s action here:

Administration Eases Way For Small Businesses To Buy Insurance In Bulk

Small employers will more easily be able to band together to buy health insurance under rules issued Tuesday by the Trump administration, but the change could raise premiums for plans sold through the Affordable Care Act’s online marketplaces, analysts say.

The move loosens restrictions on so-called association health plans, allowing more businesses, including sole proprietors, to join forces to buy health coverage in bulk for their workers.

By effectively shifting small-business coverage into the large-group market, it exempts such plans from ACA requirements for 10 “essential” health benefits, such as mental health care and prescription drug coverage, prompting warnings of “junk insurance” from consumer advocates.

Supporters say the new Labor Department rules, which the government estimated could create health plans covering as many as 11 million people, will lead to more affordable choices for some employers.

When it comes to health insurance, “the regulatory burden on small businesses should certainly not be more than that on large companies,” Labor Secretary Alexander Acosta told reporters Tuesday.

Existing rules limit association plans to groups of employers in the same industry in the same region.

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The new regulations eliminate the geographical restriction for similar employers, allowing, for example, family-owned auto-repair shops in multiple states to offer one big health plan, said Christopher Condeluci, a health benefits lawyer and former Senate Finance Committee aide.

The rules, to be implemented in stages into next year, also allow companies in different industries in the same region to form a group to offer coverage — even if the only reason is to provide health insurance.

Like other coverage under the ACA, association insurance plans will still be required to cover preexisting illnesses.

Analysts warn that because these changes will likely siphon away employers with relatively healthy consumers from ACA coverage into less-expensive trade-association plans, the result could be higher costs in the online marketplaces.

“If you have a group that is healthier than average, you might get a better rate from one of these plans, and your broker is going to come and say, ‘Hey, I can get you a better deal,’” said Dan Mendelson, president of Avalere Health, a consulting firm.

That would mean that, on balance, consumers insured through ACA small-group and individual plans could be older, sicker and more expensive, adding to years of erosion of the ACA marketplaces engineered by Republicans hostile to the law.

Loosening rules for association plans would lead to 3.2 million people leaving the ACA plans by 2022 and raising premiums for those remaining in individual markets by 3.5 percent, Avalere calculated this year.

America’s Health Insurance Plans, the largest medical insurance trade group, issued a statement saying the regulation “may lead to higher premiums” in ACA insurance and “could result in fewer insured Americans.”

Unlike ACA plans, association coverage does not have to include benefits across the broad “essential” categories, including hospitalization and emergency care.

The National Association of Insurance Commissioners previously warned that such plans “threaten the stability of the small group market” and “provide inadequate benefits and insufficient protection to consumers.”

The American Academy of Actuaries has expressed similar concerns.

Business groups praised the change, proposed in draft form earlier this year.

“We’ve been advocating for association health plans for almost 20 years, and we’re pleased to see the department moving aggressively forward,” said David French, senior vice president of government relations for the National Retail Federation.

Association plans have been around for decades, although enrollment has been more limited since the ACA’s passage. While some of the plans have worked well for their members, others have a checkered history.

In April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.8 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.

The coverage “was sold across state lines and was issued through a third-party association,” according to a release from the Massachusetts attorney general’s office.

If You’ve Got Hep C, Spitting Can Be A Felony

Kaiser Health News:States - June 19, 2018

Last week, an Ohio man who has the hepatitis C virus was sentenced to 18 months in prison for spitting at Cleveland police and medics.

Matthew Wenzler, 27, was reportedly lying on a Cleveland street across from a downtown casino in January. When police and emergency medical technicians tried to put him on a stretcher to take him to a hospital, he spit saliva mixed with blood repeatedly at them, hitting an officer in the eye.

In Ohio, it’s a felony for people who know they have HIV, viral hepatitis or tuberculosis to intentionally expose another person to their blood, semen, urine, feces or other bodily substances such as saliva with the intent to harass or threaten the person.

Advocates for people living with diseases like hepatitis C and HIV say these laws add to the stigma that patients already face and studies suggest the laws are not effective at stopping the spread of disease.

“This person is now facing a year and a half of incarceration for something that didn’t harm anyone and didn’t pose a risk of harm to anyone,” said Kate Boulton, a staff attorney at the Center for HIV Law and Policy.

Roughly two-thirds of states, according to the Center for HIV Law and Policy, have laws that make it a crime to knowingly expose others to HIV, the virus that causes AIDS. Many of these laws were passed in the 1980s and 1990s when fear and stigma about HIV were high and contracting the disease was considered a death sentence.

In recent years, about a dozen states have added hepatitis C to the list of medical conditions for which people can face criminal prosecution if they knowingly expose others by engaging in certain activities like sex without disclosure, needle-sharing or organ donation.

Public health officials say these provisions, which are sometimes tacked on to existing HIV laws, are likely to be ineffective at stemming transmission of the disease. They may even exacerbate the problem.

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“If you have to let people know that you are infected with HIV or hepatitis C before you have sex with them, why would anyone in their right mind get themselves tested and begin treatment?” said Dr. Anne Spaulding, an epidemiologist and associate professor at Emory University’s public health school. She has worked as a medical director in correction systems and published research on hepatitis C among prisoners.

Yet, among some lawmakers there is still interest in criminalizing actions they view as spreading the disease. The increasing awareness of the opioid epidemic, which is linked to the spread of hepatitis C through the use of dirty needles, may play a role, some experts say.

“We’re seeing this massive surge in opioid addiction,” said Boulton. “Whereas hepatitis maybe wasn’t on the radar in the past, now it is.”

An estimated 3.5 million people have hepatitis C, a viral infection that causes inflammation of the liver that can lead to scarring, liver cancer and death. It is typically passed from person to person through blood. Today that happens often through sharing needles to inject drugs, and, more rarely, through sex. But many older cases were caused by blood transfusions before testing for the virus existed.

The virus isn’t transmitted through urine, feces, semen or saliva, Spaulding said, noting that although there have been some cases of the disease being spread through blood hitting the eye, it is very rare and requires a great deal of blood.

In 2016, the most recent figures available, nearly 3,000 cases were reported to the federal Centers for Disease Control and Prevention, a 22 percent increase from the previous year. But many cases go unreported, in part because people don’t realize they carry the virus. The CDC estimates that the full number of new cases in 2016 was 41,200.

“Hepatitis C is still a very dangerous disease to contract,” said South Dakota Republican State Sen. Stace Nelson, who sponsored a bill this year that would have made it a felony for people who have been diagnosed with hepatitis C to expose someone else to the disease. “These circumstances where someone knows that they have it and intentionally or negligently infects someone else … it’s a threat to society.”

Advocates have been working to reform state laws that make it a crime to expose people to HIV. In the process, they are increasingly working to head off efforts to criminalize hepatitis C, including supporting local advocates to help stop a bill in Michigan in recent years, said Sean Strub, who in 1994 founded POZ magazine, which is dedicated to issues about HIV. He is also executive director of the Sero Project, an education and advocacy group that, among other things, is working to end criminal penalties for exposing others to HIV.

“Now we have this very robust and active movement combatting HIV criminalization,” Strub said. “But we’re really combatting a whole range of conditions.”

Sometimes, however, HIV reform has had negative consequences for people living with hepatitis C.

Take for example Iowa, which passed a law in 1998 that said people who were found guilty of knowingly exposing others to HIV faced up to 25 years in prison and had to register as sex offenders, even if they used a condom and didn’t infect anyone. The burden of proof was on the accused to show that they had disclosed their HIV status to their partner.

Advocates successfully pushed to replace that with a law reducing the penalties and eliminating the sex offender registration requirement. But one of their goals also was to reduce stigma by no longer singling out HIV.

So they added hepatitis, meningococcal disease and tuberculosis to the medical conditions that people could be prosecuted for if they exposed others to it.

People who worked for the replacement law say they realized from the start that it wasn’t an ideal solution.

But outright repeal wasn’t an option politically, said Tami Haught, a community organizer in Iowa who works as the training and organizing coordinator for the Sero Project.

“It was a tough decision that had to be made,” said Haught, who is HIV positive. She noted that in some states without disease-specific exposure laws, prosecutors have found a way to charge people under other general criminal laws in any case.

On balance, she said she believes it was the right way to go.