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Largest Study of Sepsis Cases among Medicare Beneficiaries Finds Significant Burden

HHS Gov News - February 14, 2020

U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

Sepsis is a life-threatening condition caused by the body’s extreme response to an infection. The research team analyzed data from all Medicare beneficiaries from 2012 through 2018. The study included more than 9.5 million inpatient hospital admissions, making this the largest sepsis study based on contemporary Medicare data to be published in the United States. Research team members included the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), the Centers for Medicare & Medicaid Services (CMS), and collaborators from Acumen LLC of Burlingame, California. The study appears in the journal Critical Care Medicine

Researchers determined that the increase in sepsis was not due to the growing number of American seniors enrolling in Medicare. From 2012 through 2018, the U.S. saw a 22 percent increase in the Medicare enrollment rates but a 40 percent increase in the rate of sepsis-related hospital admissions among beneficiaries.

“Sepsis is a lethal and costly health threat affecting Americans’ lives and our economy, yet many Americans may have never heard of it,” said HHS Assistant Secretary for Preparedness and Response Dr. Robert Kadlec. “Any infection can lead to sepsis, including infections caused by influenza or emerging diseases like coronaviruses, which makes sepsis a significant concern in public health emergencies.”

“This groundbreaking study sheds new light on the sepsis-related challenges faced by patients, providers, and taxpayers alike,” said CMS Administrator Seema Verma. “It demonstrates the urgent need for an approach to address a problem that is threatening the health and lives of Medicare beneficiaries. To that end, CMS continues to clear away regulatory obstacles and financial disincentives that have long inhibited the development of life-saving antibiotics capable of treating sepsis patients. Patients suffering from sepsis deserve to see America’s full innovative potential mobilized to address this devastating condition.”

Most patients with sepsis arrived at the hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis. However, two-thirds of these sepsis patients had a medical encounter in the week prior to hospitalization. This finding represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.

The analysis explored the impact of sepsis severity on health outcomes for Medicare beneficiaries. Despite declining mortality overall, 10 percent of patients with non-severe forms of sepsis died while in the hospital or within a week of discharge, and 60 percent with non-severe forms of sepsis died within three years.

Outcomes were worse among patients with the most severe form of sepsis known as septic shock. Forty percent of these patients died while in the hospital or within a week of being discharged, and 75 percent died within three years. The risk of sepsis was even greater for patients who had other chronic health conditions and the risk of death in the hospital and within three years was greater among these patients if they developed sepsis.

The study also identified the high costs of treating sepsis. Although the inpatient costs of care per stay among Medicare beneficiaries decreased between 2012 and 2018, the increase in the number of patients with sepsis led to an estimated overall increase in Medicare spending from $27.7 billion in 2012 to more than $41.5 billion in 2018 for inpatient hospital admissions and subsequent skilled nursing facility care.

The research team also projected future costs by modeling the increasing number of cases and estimates for all payer costs outside the Medicare population, and concluded that overall costs rose 12-14 percent every two years. Based on that estimate, inpatient hospital and skilled nursing care for sepsis care in 2019 may exceed $62 billion.

“We were astonished by the study’s results,” said Rick Bright, Ph.D., a study author, HHS deputy assistant secretary for preparedness and response (ASPR) and director of the Biomedical Advanced Research and Development Authority (BARDA) at ASPR. “To save lives in public health emergencies, we must solve sepsis. The findings of this study have implications not only for patient care, particularly after patients are discharged, but also for investments by industry, non-government organizations and government agencies. Solving sepsis requires working together. Because of the health security implications, we are taking a holistic approach to this national threat.”

BARDA currently is partnering with industry and academia to develop and encourage adoption of new technologies to detect sepsis earlier as well as to predict and identify the severity of the infections. BARDA also is collaborating with other government agencies and non-government organizations on improved awareness, education, and training for healthcare providers.

CMS has implemented an inpatient bundled sepsis measure in its Inpatient Hospital Quality Reporting Program. This measure is a series of steps to detect and treat sepsis earlier in its course. CMS data have shown that since implementation, organizations that follow all the steps have significantly lower mortality rates for patients diagnosed with severe sepsis and septic shock. The agency is also tackling sepsis in post-acute care settings and is developing a measure for early detection and treatment of healthcare-associated infections, including sepsis in post-acute care settings.

To foster innovation in treating infections that lead to sepsis, CMS is removing barriers to developing new antimicrobial therapies to treat drug-resistant infections. In 2019, CMS finalized an expanded pathway for certain new antibiotics to more quickly receive additional Medicare payments and to increase payments for them. The agency also updated its payments to hospitals to provide them with appropriate resources to treat sick patients with drug-resistant infections. This step helps people who need these medications get access to them.

In addition, to broaden the understanding of the epidemiology of sepsis, CDC continues to assess the adult sepsis burden and identify factors that put people at higher risk for sepsis and has begun a similar effort to assess sepsis burden in children.

CDC has also developed tools for tracking sepsis in individual hospitals to help healthcare facilities assess adult sepsis incidence within their facilities and measure their prevention progress. By working with partners, including the CDC Prevention Epicenters, CDC has invested in innovative ways to improve sepsis early detection and treatment. CDC’s national educational campaign, Get Ahead of Sepsis for patients, healthcare professionals, and the general public emphasizes the importance of early recognition, timely treatment, reassessment of antibiotic needs, and prevention of infections.

The study analyzed claims made on behalf of traditional Medicare beneficiaries as well as from Medicare Advantage plans to explore the burden of sepsis in highly impacted populations including older Americans, those with end-stage renal disease, and those who depend on both Medicare and Medicaid.

The publication includes detailed methods that could enable similar analyses of data from patients covered by private insurance, Veterans Affairs, Department of Defense healthcare facilities, and state Medicaid programs that could lead to an even more accurate understanding of how sepsis affects Americans.

The study will be discussed in two free webstreamed sessions at 2 p.m. EST, Feb. 16, and 3:15 p.m. EST, Feb. 17, during the Critical Care Medicine Congress 2020. The study was published in the journal as three articles:

Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012–2018

Sepsis Among Medicare Beneficiaries: 2. The Trajectories of Sepsis, 2012–2018

Sepsis Among Medicare Beneficiaries: 3. The Methods, Models, and Forecasts of Sepsis, 2012–2018

Learn more about sepsis and find clinical resources from the Centers for Disease Control and Prevention, and explore what BARDA is doing to solve sepsis at drive.hhs.gov/solvingsepsis.html.

Changing Clocks Is Bad For Your Health, But Which Time To Choose?

Kaiser Health News:States - February 14, 2020

Changing over to daylight saving time — a major annoyance for many people — may be on its way out as lawmakers cite public health as a prime reason to ditch the twice-yearly clock-resetting ritual.

The time change, especially in the spring, has been blamed for increases in heart attacks and traffic accidents as people adjust to a temporary sleep deficit. But as legislatures across the country consider bills to end the clock shift, a big question looms ahead of this year’s March 8 change: Which is better, summer hours or standard time?

There are some strong opinions, it turns out. And they are split, with scientists and politicians at odds.

Retailers, chambers of commerce and recreational industries have historically wanted the sunny evenings that allow more time to shop and play.

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Researchers on human biological rhythms come down squarely on the side of the standard, wintertime hours referred to as “God’s time” by angry farmers who objected to daylight saving time when it was first widely adopted during World War I.

What’s not in question is that the clock switching is unpopular. Some 71% of people want to stop springing forward and falling back, according to a 2019 Associated Press-NORC Center for Public Affairs Research poll.

Politicians have reacted accordingly. More than 200 state bills have been filed since 2015 to either keep summer hours or go to permanent standard time, according to the National Conference of State Legislatures.

The measures getting the most traction right now are for permanent daylight saving time, which makes more sun available for after-work activities. In 2018, Florida passed a bill and California voters backed a ballot measure to do so. Maine, Delaware, Tennessee, Oregon and Washington joined in 2019, passing permanent daylight saving bills. President Donald Trump even joined the conversation last March, tweeting: “Making Daylight Saving Time permanent is O.K. with me!”

But none of those efforts can become reality without the blessing of Congress. States have always been able to opt out of summer hours and adopt standard time permanently, as Arizona and Hawaii have done. But making daylight saving time year-round is another story.

Still, Scott Yates, whose #Lock the Clock website has become a resource for lawmakers pushing for change, believes this year will be another big year. Yates is particularly encouraged by the attitude he saw from state legislators in August when he presented on the issue at the legislators’ annual national summit in Nashville, Tennessee.

“I wasn’t the court jester and it wasn’t entertainment,” he said. “It was like, ‘What are the practical ways we can get this thing passed?’”

Seeking To End ‘Spring Ahead, Fall Back’ Cycle

Yates, 54, a tech startup CEO based in Denver, has been promoting an end to clock switching for six years. He doesn’t pick a side. It’s the switching itself that he wants to end. At first, it was just about the grogginess and annoyance of being off schedule, he said. But then he began to see scientific studies that showed the changes were doing actual harm.

A German study of autopsies from 2006 to 2015, for instance, showed a significant uptick just after the spring switch in deaths caused by cardiac disease, traffic accidents and suicides. Researchers have also noted a significant increased risk for heart attacks and strokes.

Three measures pending in Congress would allow states to make daylight saving time permanent. But, in the meantime, state lawmakers who want the extra evening sunlight are preparing resolutions and bills, some of which would be triggered by congressional approval and the adoption of daylight time in surrounding states.

The Illinois Senate passed such a bill, and Kansas is considering one after a bill to end daylight saving time died there last year. Utah passed a resolution in support of the congressional bill last year, and state Rep. Ray Ward, a Republican family physician from Bountiful, is steering a recently passed state Senate permanent daylight bill through the House.

“The human clock was not built to jump back and forth. That’s why we get jet lag,” said Ward, who was a co-presenter with Yates at the NCSL summit. “It is very easy to show that if you knock people off an hour of sleep there’s a bump temporarily in bad things that will happen.”

Efforts have been particularly strong in California, where 60% of voters passed a ballot issue for permanent daylight time in 2018. A bill is pending in the state Assembly.

Science Backs Sticking With Standard Time

All of this alarms scientists who study human biological rhythms.

Researchers in the U.S. and the European Union have taken strong positions about permanent summer hours. The Society for Research on Biological Rhythms posts its opposition prominently at the top of its website.

Messing with the body’s relationship to the sun can negatively affect not only sleep but also cardiac function, weight and cancer risk, the society’s members wrote. According to one often-quoted study on different health outcomes within the same time zones, each 20 minutes of later sunrise corresponded to an increase in certain cancers by 4% to 12%.

“Believe it or not, having light in the morning actually not only makes you feel more alert but helps you go to bed at the right time at night,” said Dr. Beth Malow, director of the sleep division of Vanderbilt University School of Medicine. Malow has seen a lot of anecdotal evidence to back that up at the sleep clinic. Parents report their children with autism have a particularly hard time adjusting to the time change, she said.

Jay Pea, a freelance software engineer in San Francisco, was unhappy enough about California’s proposed permanent daylight time that he started the Save Standard Time website to promote the health arguments for keeping it permanent. He said he doesn’t think the scientific community is being heard.

“Essentially it’s like science denial,” he said. “It’s bizarre to me that politicians are not hearing the experts on this.”

Pea, 41 and an amateur astronomer, understands the human need to have the sun directly overhead at noon. “It’s a wonderful connection to natural reality that unfortunately is lost on many people,” he said. Daylight saving time “distances us from the natural world.”

At the very least, lawmakers ought to consider history, he said. Daylight saving time was originally a plan to save energy during the two world wars but wasn’t popular enough to be uniformly embraced after the conflicts were over. In 1974, the federal government decided to make it temporarily year-round as a way to deal with the energy crisis (although energy savings were later found to be underwhelming).

Its popularity fell off a cliff after the first winter, when people discovered the sun didn’t rise until 8 a.m. or later and parents worried for the safety of kids waiting in the dark for school buses.

Pea finds it frustrating that the momentum now is for permanent summer hours — a fact he attributes to the emotional attachment with summer. “It’s a shame that every generation we have to revisit this issue,” he said.

The AP-NORC poll found 40% of its respondents support permanent standard time, with 31% opting for permanent daylight saving time.

Ward said people have gotten comfortable with daylight saving time since its duration has been lengthened to eight months by extensions in 1986 and 2007. (Before 1986, daylight saving time lasted six months.)

“So now really most of the year we are on the summer schedule, and people are used to that and they like it,” he said. “That makes them more aggrieved when we change back to the winter schedule.”

In any case, changing the clocks is a rare issue in that it isn’t partisan, Ward said. “If the government can’t respond to people when they want something and it’s not even a partisan issue, that’s just a sad commentary,” he said. “Can’t we please fix something that doesn’t make sense anymore?”

Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No.

Kaiser Health News:Insurance - February 14, 2020

“Sanders’ ‘Medicare for All’ plan “would cost more than the entire federal budget that we spend now.”

Former Vice President Joe Biden in comments during the New Hampshire presidential primary debate, Feb.7

This story was produced in partnership with PolitiFact.

This story can be republished for free (details). During the Feb. 7 Democratic presidential debate, former Vice President Joe Biden once again questioned the price tag of “Medicare for All,” the single-payer health care proposal championed by one of his key rivals, Sen. Bernie Sanders of Vermont.

Biden argued that the plan was fiscally irresponsible and would require raising middle-class taxes. Specifically, he claimed, the plan “would cost more than the entire federal budget that we spend now.”

Medicare for All’s price — and whether it’s worth it — is a subject of fierce discussion among Democratic presidential candidates. But we had never heard this figure before. It caught our attention, so we decided to dig in.

Biden’s campaign directed us to the 2018 federal budget, which totaled $4.1 trillion. It compared that amount with the estimated cost of Sanders’ single-payer proposal: between $30 trillion and $40 trillion over a decade. The math, they said, shows Medicare for All would cost more than the national budget.

But it turns out, based on the numbers and interviews with independent experts, Biden’s comparison of Medicare for All’s price to total federal spending misses the mark because the calculation is flawed.

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The Numbers

Sanders has said publicly that economists estimate Medicare for All would cost somewhere between $30 trillion and $40 trillion over 10 years. Research by the nonpartisan Urban Institute, a Washington, D.C., think tank, puts the figure in the $32 trillion to $34 trillion range.

We pointed out to Biden’s campaign that comparing 10-year spending estimates to one-year budgets is like comparing apples to oranges. The campaign suggested that if you take 10 times the current federal budget, you get a figure smaller than the estimated cost of Medicare for All over that 10-year window.

That calculation would lead you to multiply $4.1 trillion by 10 to get $41.1 trillion. That result is close to the high mark Sanders set for his program’s cost but well above the $34 trillion that Urban researchers projected.

Still, that’s not the correct way to formulate a comparison, experts say. “That’s not good math,” said Marc Goldwein, the senior vice president and senior policy director at the Committee for a Responsible Federal Budget. “That’s taking a 2018 number and multiplying it by 10, whereas the $34 trillion is a 10-year number that assumes a lot of growth.”

What you would need to do is add up the Congressional Budget Office’s projected budget outlays from 2020 to 2029, and compare the sum to the Medicare for All spending figure.

So we spoke to Linda Blumberg, an institute fellow at Urban’s Health Policy Center, who arrived at the $34 trillion estimate. She ran the CBO’s numbers: The next 10 years of on-budget outlay, the government office projects, add up to $44.8 trillion.

Sources:

ABC News / WMUR Democratic debate, Feb. 7, 2019

Centers for Medicare & Medicaid Services, “National Health Expenditure Data,” Dec. 17, 2019

Congressional Budget Office, “The Budget and Economic Outlook,” January 2020

Telephone interview with Linda Blumberg, Urban Institute, Feb. 7, 2020

Telephone interview with Marc Goldwein, Center for Responsible Federal Budget, Feb. 11, 2020

Urban Institute, “Don’t Confuse Changes in Federal Health Spending with National Health Spending,” Oct. 16, 2019

Urban Institute, “From Incremental to Comprehensive Health Reform: How Various Reform Options Compare on Coverage and Costs,” Oct. 16, 2019

To be clear, $34 trillion (34 followed by 12 zeros) is no small sum. It accounts for about 75% of that nearly $45 trillion budget estimate and would represent a bigger single increase to the federal budget than we’ve ever experienced, Blumberg said.

That raises one point on which Biden may have some ground. Goldwein argued that you would indeed need significant tax increases to finance the Sanders proposal.

But its price tag still would be less than the projected budget.

“If he said [Medicare for All] was as big as the current federal budget, that would be incorrect,” Blumberg said.

Goldwein looked at the numbers another way: Including interest, he found, the federal budget would consume about $55 trillion between now and 2030. Again, that’s more than what Medicare for All would cost during the same period.

Big picture: No matter how you slice Biden’s math, his numbers are off.

“If what he said was Medicare for All will cost as much as the entire rest of the budget, that would be fair,” Goldwein said. But that’s not the same thing.

Our Ruling

Biden argued that Medicare for All “would cost more than the entire federal budget that we spend now.”

This relies on faulty math. Medicare for All would certainly represent a substantial increase to the federal budget. But it would neither match nor dwarf current federal spending overall. We rate this claim False.

KHN’s ‘What The Health?’: Live from D.C. With Rep. Donna Shalala

Kaiser Health News:Insurance - February 13, 2020
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Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Paige Winfield Cunningham

The Washington Post

@pw_cunningham

Read Paige's Stories

President Donald Trump’s proposed budget for the fiscal year that begins in October proposes big cuts to popular programs, including Medicaid and the National Institutes of Health. Although those cuts are unlikely to be enacted by Congress, both Republicans and Democrats are likely to use the budget blueprint as a campaign issue.

Meanwhile, several House committees this week relaunched work on legislation to address “surprise” medical bills — unexpected charges from out-of-network providers. And Congress is still trying to come to a bipartisan agreement on how to address drug prices.

Rep. Donna Shalala (D-Fla.), a former Health and Human Services secretary and a former member of the Kaiser Family Foundation board, was the special guest for this week’s podcast, taped before a live audience at the KFF headquarters in Washington, D.C. Also joining host Julie Rovner of Kaiser Health News were Paige Winfield Cunningham of The Washington Post, Rebecca Adams of CQ Roll Call and Joanne Kenen of Politico. Also joining host Julie Rovner of Kaiser Health News were Paige Winfield Cunningham of The Washington Post, Rebecca Adams of CQ Roll Call and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • One surprise in the president’s budget is a proposal to move tobacco regulation out from under the Food and Drug Administration’s purview. That comes despite a law Congress passed several years ago that specifically named the FDA as the regulator for tobacco.
  • Last year, it seemed clear that Congress and the White House were determined to find a way to protect consumers from surprise medical bills. But heavy lobbying on the issue and deep fissures in pinpointing the best remedy have slowed that effort. Shalala said she thinks Congress will produce a bill this year that will be balanced so that insurers and medical providers have to compromise.
  • Shalala said that in the 21 town meetings she has held in South Florida, no one has asked about efforts to end surprise bills. Most of the health questions focus on high drug prices and out-of-pocket costs. High out-of-pocket costs have been driven by the large number of people shifted into high-deductible insurance plans.
  • Shalala also said she doesn’t expect a plan to import drugs from Canada, endorsed by the Trump administration and some states, to go forward. Drugmakers sell Canada enough medicine to cover the population there, and not consumers in Florida, she added.

To hear all our podcasts, click here.

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Coronavirus Tests Public Health Infrastructure In The Heartland

Kaiser Health News:States - February 13, 2020

JEFFERSON CITY, Mo. — Every weekday at noon since Jan. 27, the Missouri Department of Health and Senior Services Director Randall Williams gathers his outbreak response team for a meeting on coronavirus.

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Missouri has yet to have a confirmed case of what officials are now calling COVID-19, but about 20 people statewide are being monitored for the novel viral infection originating from Wuhan, China. While 15 cases have been confirmed in the U.S. so far, tens of thousands of people have been infected worldwide and more than 1,300 have died. Global — and local — fears of the spread of the respiratory virus are fueling concerns about a lack of preparation in the U.S.

Missouri health department staff have been working overtime preparing for if, and when, the cases come by ensuring they have adequate supplies of non-expired protective gear like masks and planning how to trace the movements of those who have come in contact with potentially infected people.

They’re also helping set up coronavirus testing capabilities at a regional lab based here in the state capital to evaluate potential cases from Missouri, Kansas, Nebraska and Iowa. The U.S. Centers for Disease Control and Prevention has started shipping testing kits around the country.

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Coronavirus may not require a front-line battle yet in places like Missouri as it does in states with confirmed cases, such as Washington, California, Illinois and Texas. But it’s still taxing public health officials in Missouri, which has one of the lowest levels in the nation for public health spending per person. And they, like health officials in other states, are stuck in the tricky position of trying not to be over- or underprepared for a potential public health crisis that may never come.

Missouri’s legislature is considering an additional $300,000 in emergency funding for events like coronavirus. This money is vital for responding to outbreaks in the state, Williams said, including more common concerns like mumps and measles or ongoing fights against hepatitis A and tuberculosis.

However, according to Williams, the legislature denied such an appeal for $300,000 last year.

“We are essentially like a fire department, right? People want us to be available when there’s a fire,” the director said. “But when there’s not a fire, they don’t really give a lot of thought to it.”

Limited Budget

As state officials gear up for possible problems from coronavirus, local health departments in Missouri are at a disadvantage because they have lost staff amid state budget cuts, according to Lindsey Baker, research director for the Missouri Budget Project, a nonprofit focused on public policy decisions.

Similar patterns hold true across the nation. Almost a quarter of local health department jobs have been lost since 2008, according to the National Association of County and City Health Officials, and a quarter of local health departments experienced budget cuts last year.

While federal funding has supplemented public health funding in Missouri, Baker said, the federal cash comes with strict rules on how it can be used.

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Williams stressed that, despite Missouri’s limited budget, his state ranked in the top tier for emergency preparedness by Trust for America’s Health, a nonprofit advocacy group promoting public health.

Money notwithstanding, viruses like COVID-19 force the staff to work longer hours, according to state epidemiologist Dr. George Turabelidze, as the health department juggles its existing workload with pressing concerns.

“Everything else is happening — it’s not like we can switch, we have to do all this at once,” Turabelidze said.

Plus, he added, since this outbreak involves world travelers arriving at all times of the day, his staff has had to work weekends to track down where travelers have come from and whether they’ve had contact with infected people. For now, salaried staffers — who do not receive overtime — are expected to shoulder the extra load.

Even as they work extra hours, some routine health department matters such as onsite sewage inspections “get put in the back seat,” said Adam Crumbliss, chief director of Missouri’s Division of Community and Public Health.

If coronavirus reaches a pandemic level — in which it spreads worldwide — Crumbliss said the National Guard could be activated.

Relying On Existing Relationships And Stockpiles

Vital to any public health emergency response are the underlying relationships, stressed Paula Nickelson, the state’s program coordinator for health care system readiness. Knowing whom to call and having an established rapport with key health care providers such as the Missouri Hospital Association is critical during a crisis.

As is experience. Nickelson said the state’s response capabilities were tested and strengthened during a successful practice transport of a hypothetical Ebola patient from St. Louis to the University of Iowa in May.

Through that exercise, they learned that the material of their ISOPODs — portable, see-through isolation units that quarantine infected patients while allowing them to still see and speak to other people — was so thick it made it hard to hear those inside. Now, they are equipping them with walkie-talkies.

Another major question in recent days is a potential onslaught of shortages of protective medical equipment — everything from masks to latex gloves ― often manufactured in China. Nickelson said the state has assessed what materials are on hand.

“They’re fairly small amounts,” she said. “What we found over the course of a decade is that a lot of that stuff sits on the shelf, doesn’t necessarily get used, and so we’re better off to have just-in-time, vendor-managed processes in place.”

Still, Nickelson noted, that could become a problem for everyone if a pandemic occurs and those vendors become swamped with orders.

“This is by no means a sprint,” Crumbliss said. “This is a long wind race.”

No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

Kaiser Health News:States - February 13, 2020
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ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

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The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

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While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”

To Fight Chinese Outbreak, Doctors Deploy Drugs Targeting HIV, Malaria And Ebola

As the scientific community scrambles to find a drug that can effectively treat tens of thousands of patients sickened by a new respiratory virus, they are trying some surprising remedies: medicines targeting known killers like HIV, Ebola and malaria.

American drugmakers have shipped two antiviral medications to China as doctors and public health officials there seek an effective treatment for patients sickened by the novel coronavirus, which has recently been named COVID19. The virus has afflicted tens of thousands of people worldwide and killed more than 1,300. Most of the cases and deaths occurred in Hubei province, China, where the outbreak began.

Among potential remedies is an HIV medication that may work to block an enzyme needed by the virus to mature. An unapproved medicine used to fight the Ebola virus is being tested in Chinese patients to see whether it can disrupt the new virus’s genetic material.

A third drug, widely used around the globe to fight the parasite that causes malaria, is also being tried in China to see if it can slow infection by preventing the virus from infiltrating cells.

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The evidence behind some of these medicines is flimsy, researchers acknowledged. But even with strong data, they said, human trials are the only way to know whether these drugs are effective.

“Just because it works well in a test tube and in animals doesn’t mean that it will work in people,” said Dr. Stanley Perlman, a professor of microbiology and immunology at the University of Iowa.

The effort is not unprecedented. When a novel virus surfaces and endangers large populations, scientists sometimes turn to existing drugs that can be repurposed. Medications available in the United States have already gone through rigorous testing to prove they are safe, eliminating the need to run costly human trials to assess safety in an emergency.

That said, officials generally look at the evidence surrounding the drugs and the virus to try to find a viable option.

“They usually cast a pretty wide net because they don’t know for any given virus what’s gonna work,” said Dr. Rajesh Gandhi, a professor of medicine at Harvard University and chair-elect of the HIV Medicine Association.

In 2003, a related coronavirus with no known treatment caused a global outbreak of severe acute respiratory syndrome (SARS). The response involved testing a litany of drugs, including a combination of ritonavir and lopinavir, antiretroviral medications used to fight HIV.

Early studies hinted that the medicines were effective in fighting the virus in patients. The combination of drugs, known by the brand name Kaletra, appears to work to stop enzymes called proteases from allowing the virus to mature and replicate. But the outbreak — and the ability to robustly test treatments — all but disappeared in a little over a year.

Nine years later, another coronavirus caused Middle East respiratory syndrome (MERS). That outbreak gave scientists another chance to test the HIV medication against this family of viruses, and a clinical trial is underway in Saudi Arabia.

Chinese doctors are using Kaletra now against the novel coronavirus.

Despite these opportunities to test the HIV drug against pathogens related to the one causing the current outbreak, “everyone agrees we don’t have a standard therapy for the novel coronavirus,” Gandhi said.

One of the more unorthodox remedies being tested against the coronavirus in China is chloroquine.

The drug is intended to treat malaria, a condition caused by a parasite transmitted through a mosquito bite. A limited number of studies have found the drug to work against SARS. A study published this year in the journal Cell Research found the drug was effective in laboratory tests at keeping the virus from spreading by stopping its method of infecting cells.

The lack of certainty surrounding treatment for coronaviruses is partly due to the boom-and-bust nature of outbreaks — they can spread like wildfire and then disappear, as SARS did, said Gandhi. Although that is good for the public’s health, it also means scientists sometimes don’t have the means to thoroughly test a treatment that combats the specific virus in humans.

Dr. Anne Schuchat, principal deputy director of the Centers for Disease Control and Prevention, said in a press conference Tuesday that research on the virus causing the outbreak must not be “an afterthought. Because we don’t know how long some of these new emerging infections will persist.”

An outbreak of a new, potentially deadly disease can make physicians want to try everything possible to save their patients, said Perlman, the Iowa professor. But human trials are essential to understanding how a drug will work against a virus.

Experimental medicines that have not been vetted for safety through human trials may harm patients, he said. However, he added, using approved medications still leaves the door open to important questions, like how big the dosage should be.

“It’s just so hard when you’re on the front line and your patient is sick and you want to do something,” Perlman said.

Scientists treating coronavirus patients are pairing treatment with research to test the effectiveness of one unapproved drug: remdesivir. Made by Gilead Sciences, the broad-spectrum medication has been used in experiments to combat the Ebola virus, and tests in animals suggest it helps keep the SARS and MERS coronaviruses from replicating. But it is not yet clear if it will work against this virus.

The drug was outperformed by two other medicines during the 2018 Ebola outbreak in the Democratic Republic of the Congo. Researchers in China are now testing remdesivir in a randomized, controlled trial against the outbreak there.

The ramp-up in research and investments into outbreaks can wreak havoc on private drug companies, especially if the virus disappears at some point, as SARS did, said Dr. Jesse Goodman, a professor of medicine at Georgetown University in Washington, D.C. The federal government helps offset these costs through initiatives such as the Department of Health and Human Services’ Biomedical Advanced Research and Development Authority, which helps public-private partnerships develop drugs against public health threats.

Because of the volatility in outbreaks, “it becomes very daunting for companies to actually justify those investments” in targeted therapeutics, said Dr. Amesh Adalja, an infectious-disease physician and senior scholar at the Johns Hopkins Center for Health Security in Baltimore.

Goodman said one of the lessons learned from previous outbreaks is the need to invest more in the infrastructure needed to conduct clinical trials, like physicians, laboratories and systems that allow them to share samples. Looking ahead, the World Health Organization is trying to equip countries with the means to quickly begin researching a disease in the event of an outbreak.

“The time to prepare for clinical studies is not in the middle of an outbreak,” said Goodman, a former chief scientist for the Food and Drug Administration. “It’s beforehand.”

Conservative Indiana Adopted Needle Exchanges But Still Faces Local Resistance

Kaiser Health News:States - February 12, 2020

Back when Cody Gabbard was shooting heroin, his only significant human contact was with others in the throes of addiction, who only cared to see him when he had drugs.

Then he walked into the basement of Fayette County’s courthouse in the eastern Indiana city of Connersville, where two women — a public health nurse and a recovery coach — ran a syringe exchange program.

“There were days I went in there, to be honest with you, I just felt like killing myself. That would usually change by their spirits,” said the now-27-year-old Gabbard, who contracted hepatitis C during his drug use. “As people say, a smile can do a lot for a person, and it certainly does, especially when you’re in a dark spot in life.”

Cody Gabbard poses for a portrait at Fayette County Community Corrections in Connersville, Indiana, on Jan. 23, 2020, when he was participating in a work-release program. Now in recovery, Gabbard previously used a syringe exchange in Connersville. He recalls that the women who operated the exchange were not only the first people in a long time who treated him like a human being, but they also put a new idea in his head: You don’t have to live like this.(Meg Vogel for KHN)

Besides hope and connection, the program he visited in 2017 offered free, clean needles and a place to dispose of dirty ones. People could also get HIV and hepatitis C testing, the overdose-reversal drug naloxone, fentanyl test strips, immunizations and wound care, plus referrals to drug treatment and other community resources.

Such programs were illegal in Indiana until 2015. That’s when an HIV outbreak among injection drug users in southern Indiana’s Scott County caused lawmakers to reconsider their objections to syringe exchanges, making the state ground zero for conservatives’ growing acceptance of giving clean needles to people struggling with addiction.

But five years later, syringe exchanges are operating in only nine of Indiana’s 92 counties, including Fayette, even though federal health officials warn that eight more are vulnerable to an HIV outbreak similar to Scott County’s. Some public health experts say this reflects a continuing reluctance to treat addiction as a health issue and the political and logistical difficulties of starting exchanges and keeping them open.

“We’ve definitely made a lot of progress since the Scott County outbreak,” said Don Des Jarlais, a professor in the School of Global Public Health at New York University, noting that the number of syringe exchanges nationwide has roughly doubled since 2015. “But we still have a very, very long way to go.”

Darci Moore and Charmin Gabbard collect safe injection equipment and syringes for a participant at the Fayette County Harm Reduction Alliance syringe exchange in Connersville, Indiana, on Jan. 23, 2020.(Meg Vogel for KHN)

Charmin Gabbard, who runs the Fayette County Harm Reduction Alliance syringe exchange, talks with a participant on Jan. 23, 2020. The syringe exchange is open twice a week at the offices of Meridian Health in Connersville, Indiana. Gabbard says she hopes to increase its hours of operation and extend services to perform street outreach.(Meg Vogel for KHN)

In Indiana and West Virginia, he said, syringe exchanges have shut down or had restrictions placed on them because of backlash in the communities. This has happened despite decades of research showing that syringe programs prevent the spread of disease and reduce health care costs without increasing illegal drug use or crime.

Other conservative states that lifted restrictions on syringe exchanges in the wake of Indiana’s HIV outbreak have fared better. For instance, Kentucky and North Carolina, which eased regulations in 2015 and 2016, respectively, both have exchanges available in about half their counties.

Darci Moore, an intern at the Fayette County Harm Reduction Alliance, collects safe injection equipment for a participant at the syringe exchange in Connersville, Indiana, on Jan. 23, 2020.(Meg Vogel for KHN)

Indiana state Rep. Ed Clere, a Republican who authored the original needle exchange legislation in 2015, would like to see greater acceptance of the programs in his state.

“Syringe service programs have saved countless lives and prevented countless cases of HIV and hepatitis C,” he said. “I see how well it’s working in the counties that have a program, and I hate it that syringe programs aren’t available for all Hoosiers.”

Indiana’s law requires syringe exchanges to be authorized by either a county’s executive body or a municipality’s legislative body, and then be renewed at least every two years. Alternatively, Indiana’s health commissioner can declare a local state of emergency. The statewide law, once set to expire in 2019, was amended to end on July 1, 2021. A bill in the Indiana Senate to repeal the expiration date was defeated in early February.

Since April 2015, when the first legal syringe exchange opened in Scott County, nine more have launched across the state. Three have closed, with two of them eventually reopening.

The bigger issue is “we have a lot of communities that want to get one started, but they can’t,” said Indiana University researcher Carrie Lawrence.

Enabling Drug Use Or Saving Lives?

Instead, some local health departments in Indiana have resorted to distributing so-called harm reduction kits that include everything but syringes, such as sterile supplies to cook, snort and smoke narcotics. Still, these, too, have drawn the ire of some politicians and law enforcement.

“We’re handing people equipment we know [is] going to be used for injection or ingestion of narcotics. We’re not getting anywhere,” said Lt. John Watson, a police officer in Seymour, Indiana, who has spoken out against his county health department’s harm reduction program.

Charmin Gabbard, who runs the Fayette County Harm Reduction Alliance in Connersville, Indiana, shows a syringe exchange participant the intramuscular Narcan on Jan. 23, 2020.(Meg Vogel for KHN)

The syringe exchange run by the Fayette County Harm Reduction Alliance provides access to and disposal of syringes and injection equipment. (Meg Vogel for KHN)

But public health officials argue that the supplies are critical to stopping the spread of infection, and that people will get high regardless of whether they have clean equipment.

“They’re going to use a spoon. But they’re going to use their mother’s kitchen spoon instead,” noted Khala Hochstedler, administrator of the Tippecanoe County Health Department, which has operated an exchange since 2017. “That could have hepatitis C on it, and another family member could pick it up.”

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One of the most vocal opponents of the syringe service programs has been Indiana Attorney General Curtis Hill, who argues for strict one-on-one exchanges of used needles for clean ones.

“Distributing needles without any reasonable degree of accountability … simply leads to wider abuse of illegal drugs and increased likelihood of death by overdose,” he said in a statement, citing anecdotal testimony from public safety officials he had visited throughout the state. He also pointed to a media report from Richmond, Indiana, saying the county prosecutor had documented a fatal overdose involving a needle from the local syringe exchange.

The Centers for Disease Control and Prevention cites research showing that syringe exchanges reduce the amount of needle waste in a community, by providing avenues for safe disposal; in the past, Hill has publicly quarreled with the agency over its research. According to the Indiana State Department of Health, 82% of syringes distributed by the programs have been returned.

Indiana has seen a drop in new HIV diagnoses linked to injection drug use — from 175 in 2015, the year of the outbreak, to 17 three years later. During that period, new hepatitis C cases rose from 7,144 to 7,837, though some syringe exchange officials said they expected those numbers to initially increase as more people got tested.

A participant gives Charmin Gabbard used syringes that she had been collecting in a disposal box for used needles for months at the syringe exchange run by the Fayette County Harm Reduction Alliance in Connersville, Indiana, on Jan. 23, 2020. The participant said she would reuse the needles until they “felt like a fishing hook and hurt.”(Meg Vogel for KHN)

Politics Has Closed Exchanges

Stephenie Grimes, administrator for the Madison County Health Department, said she finds one-for-one exchanges problematic because staffers are forced to ask confrontational questions that might turn people away. Users bring their soiled needles back in disposal containers that are not transparent, so you can’t tell how many syringes are inside.

“There is no good way to ensure you’re getting one for one,” she said.

In 2016, a year after an exchange started in her central Indiana community, her agency went to the one-for-one model to address public concerns. Opponents weren’t assuaged.

The Fayette County Courthouse is a historic courthouse located in Connersville, Indiana, on Central Avenue. Back when Cody Gabbard was shooting heroin, he would go to a syringe exchange program in the basement of the courthouse.(Meg Vogel for KHN)

The following year, even though the Madison County commissioners — the county’s executive body — had renewed the exchange, the county council — the fiscal body — voted to pull funding for the health department if it continued the program.

The initiative shut down for 12 months until a local nonprofit health system, Aspire Indiana, agreed to operate it.

About 120 miles away, in southern Indiana, Lawrence County abandoned its syringe exchange in 2017, after only a year, when county commissioners expressed concerns about abetting illegal drug use. Commissioner Rodney Fish elicited national attention when he cited a verse from the Old Testament that commands people to pray and “turn from their wicked ways.”

Reached in December, Fish said his opinion on the matter hasn’t changed and added: “Our community is dealing with the issue in other, compassionate ways.” He declined to comment further.

The syringe exchange in Connersville, where Gabbard used to go, shut down last May after the local hospital where it had moved, Fayette Regional, went bankrupt and closed.

But the exchange reopened Jan. 22 at Meridian Health’s Connersville clinic. The program aims to serve the same number of people it did before, about 100 a month.

Gabbard recalled that the women who operated the exchange not only were the first people in a long time who treated him like a human being, they also put a new idea in his head: You don’t have to live like this.

So after his last narcotics-related arrest, in June 2018, he opted for drug court, which allows defendants to get treatment in lieu of jail time.

Research has found that IV drug users who go to a syringe exchange are significantly more likely to enter treatment and stop or cut back on shooting narcotics than those who don’t.

“Really, the needle exchange was the reason why I even started to think about getting clean,” Gabbard said.

Now in recovery, he hopes to be a better role model for his 7-year-old son. He has dreams of starting a landscaping business. And he no longer needs a syringe exchange.

Charmin Gabbard, who runs a syringe exchange through the Fayette County Harm Reduction Alliance in Connersville, Indiana, embraces a participant on Jan. 23, 2020. Gabbard used drugs for almost 30 years and served about 10 years in prison, but she has been in recovery for six years.(Meg Vogel for KHN)

When Your Doctor Is Also A Lobbyist: Inside The War Over Surprise Medical Bills

When Carol Pak-Teng, an emergency room doctor in New Jersey, hosted a fundraiser in December for Democratic freshman Rep. Tom Malinowski, her guests, mostly doctors, were pleased when she steered the conversation to surprise medical bills.

This was a chance to send a message to Washington that any surprise billing legislation should protect doctors’ incomes in their battle over payments with insurers. Lawmakers are grappling over several approaches to curtail the practice, which can leave patients on the hook for huge medical bills, even if they have insurance.

As Congress begins its 2020 legislative session, there is evidence the doctors’ message has been received: The bills with the most momentum are making more and more concessions to physicians.

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As surprise medical billing has emerged as a hot-button issue for voters, doctors, hospitals and insurers have been lobbying to protect their own money flows. All that lobbying meant nothing got passed last year.

Television and internet ads are the most visible manifestation of the battle. But in taking their cause to politicians, doctors like Pak-Teng have waged an extraordinary on-the-ground stealth campaign to win over members of Congress. Their professional credentials give them a kind of gravitas compared with other lobbyists, who are merely hired guns.

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Ending the practice of billing patients for the amount of their treatment not covered by insurance — sometimes triggered by unwittingly seeing a doctor out of network — is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills — or suffer the enormous financial strain — lawmakers are under pressure to protect patients. In turn, powerful lobbying forces have activated to protect doctors and insurers who don’t want to pay the price for a fix.

The main message physicians are using to bring lawmakers into their corner? “We just want to be paid a fair amount for the services rendered,” Pak-Teng said.

Her congressman, Malinowski, has not endorsed any surprise billing legislation. In congressional testimony in July, he cited the “extra $420 million” in medical debt patients in New Jersey reckon with each year.

“There are many things that Republicans and Democrats sincerely disagree about in this body,” he said. “I don’t think that this is one of them. I don’t see any philosophical difference amongst us about whether people should be stuck with massive surprise medical bills.”

Doctors say they are taking the brunt of the criticism.

But little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level.

They are throwing in a lot of money, too, funneling millions to lawmakers ahead of the 2020 elections. Four physician organizations that have heavily lobbied on surprise medical bills and have private equity ties — the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and U.S. Anesthesia Partners — gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

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The biggest recipients, from all four PACs combined, were Reps. Donna Shalala and Stephanie Murphy, Florida Democrats who got $26,000 each. Sen. Thom Tillis (R-N.C.) took in $25,500, Senate Majority Leader Mitch McConnell got $25,000, and Rep. Brett Guthrie (R-Ky.) received $22,500.

That was in tandem with a ground game led by local doctors. ER doctors, anesthesiologists, radiologists and other specialists who most often charge out-of-network prices — and also are among the highest-compensated practitioners — fanned out to shape legislation in a way that maintains their pay, and to voice their concern to lawmakers that insurance companies would have too much leverage to control their compensation.

“We by necessity place a tremendous amount of trust in our physicians,” said Zack Cooper, an assistant professor at Yale University who has extensively researched surprise medical bills. “Frankly, they have an easier time lobbying members [of Congress] than the folks who are affected by surprise billing.”

Arguing Over The Fix

Lawmakers in both parties appear unified on the need to resolve the problem of surprise billing. But as was clear when all the air blew out of legislative proposals on the table at year’s end, that is largely where the agreement ends.

Fixing the problem comes down to settling on a system for deciding how much to pay for a disputed bill. One approach is to set up an outside arbitration process, in which doctors and insurance companies would negotiate payment — this is the model preferred by doctors, who contend it puts them on better footing against insurance companies. Another option would be to resolve surprise billing disputes by having insurance companies pay doctors based on the median in-network rate for the service, an approach known as benchmarking. Large employers, labor unions and insurance companies prefer this.

The failure to get legislation through Congress set up a potentially explosive battle in an election year. Republicans and Democrats who have vowed to do something about health care costs must reckon with powerful industry groups whose influence transcends party lines.

Meanwhile, physicians and hospitals have made their case in Washington and back home through in-person meetings and phone calls with lawmakers and congressional staff. They’ve hosted dinners and fundraisers and organized fly-ins to swarm Capitol Hill with in-person meetings. They’ve even led tours of their emergency rooms.

Pak-Teng is among them, coming to Washington this month with other physicians to petition lawmakers. She is employed by Envision, a physician staffing company backed by private equity firm KKR. She’s also on the board of the American Academy of Emergency Medicine, a trade organization representing ER doctors.

“There is a lot of anti-physician rhetoric out there,” said Pak-Teng, who is pushing her physician colleagues to be more active in shaping public policy by sharing stories about the reality of caring for patients.

The lobbying by hospitals and physicians trying to protect their reimbursements has divided key lawmakers, compounding disagreements among senior House Democrats over the policy details of a bill and turf wars in Congress. Three House committees have now unveiled legislation to ban surprise medical bills, each with different details.

“We are not trying to stop legislation. We are trying to stop bad legislation,” said Anthony Cirillo, an emergency medicine physician who describes a “bad” bill as one that favors insurance companies over doctors.

Cirillo is also a lobbyist for US Acute Care Solutions, a physician staffing company backed by private equity firm Welsh, Carson, Anderson & Stowe. WCAS, which manages $27 billion in assets and is focused on health care and technology investments, is based in New York City and co-founded US Acute Care Solutions in 2015.

In an interview, Cirillo said he met with lawmakers and their aides about “10 to 12 times” in Washington last year. Financial disclosures show he spent $340,000 between July and September lobbying on surprise billing on behalf of US Acute Care Solutions. USACS’ political committee also contributed $134,500 to lawmakers in 2019, according to FEC records.

Tilt Toward Doctors

Before the private equity-fueled dark-money group Doctor Patient Unity started running ads warning of the dangers of government price controls as an argument against legislation, surprise billing legislation being drafted in one of Congress’ most powerful health care committees was already tilting to be more favorable to doctors.

“People on the Hill are very sympathetic to hospitals and physicians because they’re actually providing the care itself,” said one Democratic aide, speaking on the condition of anonymity to candidly describe sensitive political dynamics. “Nobody wants to defend the insurers.”

In May, a House Energy and Commerce Committee draft proposal included no mention of outside arbitration. The same was true for a bill the Senate Health, Education, Labor and Pensions Committee approved in June. Instead, under those proposals, surprise billing disputes would be resolved by insurance companies paying doctors based on similar rates in that area.

By mid-July, though — roughly a week before Doctor Patient Unity registered as a business in Virginia — the Energy and Commerce legislation was amended to allow doctors to appeal to an independent arbiter if their payments exceed $1,250. The revision was pushed by two physicians on the committee — Democrat Raul Ruiz of California and Republican Larry Bucshon of Indiana — and was a moment Sherif Zaafran, a Texas anesthesiologist, describes as a “turning point” in negotiations over the bill.

“It’s all about fairness,” said Zaafran, who works for private equity-backed U.S. Anesthesia Partners. He has been involved for a decade in surprise billing fights in Texas, which enacted a new law with an arbitration process last year. U.S. Anesthesia Partners gave $197,900 in campaign contributions to members of Congress last year.

Zaafran chaired another coalition of medical specialists, Physicians for Fair Coverage, in 2019, and pressured Congress to pursue a surprise billing approach modeled on a New York law under which insurers and providers rely on arbitration. Under that process, if there is a payment dispute between doctors and insurers, the two sides submit a proposed dollar amount to an independent mediator, who then selects one.

In New York, the mediators were told to base their decisions on the 80th percentile of the prices set by the hospital or physician. Research has suggested that the model is broadly making health care more expensive for state residents because of higher payments to doctors, according to findings from the USC-Brookings Schaeffer Initiative for Health Policy.

Still, on Capitol Hill, doctors complained that many procedures would fail to cost enough to qualify for arbitration as proposed in the Energy and Commerce bill, bolstered by data ER doctors presented to lawmakers showing that prices mainly fall below $1,250.

“It’s largely out of reach,” said Laura Wooster, a lobbyist with the American College of Emergency Physicians, whose political action committee contributed $708,000 to lawmakers in 2019. “The problem with a threshold is, you just have one threshold. It’s going to impact different specialties so differently.”

By December, House Energy and Commerce Committee leaders and Sen. Lamar Alexander, a Republican who chairs the Senate HELP Committee, agreed to lower the arbitration threshold to $750 as part of a bipartisan agreement on a bill. Notably, several hospital lobbying organizations, such as the American Hospital Association and the Greater New York Hospital Association — the latter a strong financial backer of Senate Minority Leader Chuck Schumer — refused to back the deal.

Pak-Teng and other physicians also say that arbitration threshold is still too high. The House Education and Labor Committee has unveiled surprise billing legislation with a similar framework.

“I’m open to listening to all sides on this,” Rep. Greg Walden of Oregon, the top Republican on the House Energy and Commerce Committee, said in an interview. “We want to make sure doctors are adequately compensated.”

Walden had harsh words for private equity firms that have attacked the Energy and Commerce legislation in a series of TV and internet ads, saying they were “misleading and scaring people” and just made lawmakers dig in deeper. The ads prompted a bipartisan probe from Walden and committee Chairman Frank Pallone (D-N.J.) into how the companies have influenced surprise billing practices.

“I’m not trying to hurtle a rock at them, but they’ve been throwing a few my way,” he said.

What’s Coming

Arvind Venkat, a Pittsburgh emergency physician employed by US Acute Care Solutions, traveled to Washington multiple times last year to meet with congressional offices representing Pennsylvania. But he also made sure to bring up surprise bills on his home turf, giving his congressman, freshman Democrat Conor Lamb, a tour of the emergency room at Allegheny General Hospital last summer.

“There are two issues here,” said Venkat, who leads the Pennsylvania chapter of the American College of Emergency Physicians and has practiced at Allegheny General for 12 years. “Patients need to be protected, [and] we need to avoid anything that disrupts in-network relationships between insurers and clinicians.”

The call seems to have been heard: Legislation is likely to change further this year as the House Ways and Means Committee pushes an approach that is friendlier to hospitals and doctors. It builds off a one-page document committee leaders issued Dec. 11 that blunted momentum for a bipartisan deal that was to be included in a December spending bill.

The latest proposal from the committee includes an arbitration process to resolve payment disputes, with no minimum dollar amount needed to trigger it, and doesn’t ban surprise billing from air ambulance companies — a win for yet another special-interest lobbying group. The patient protections would not take effect until 2022.

U.S. Rep. Richard Neal, a Massachusetts Democrat who chairs the House Ways and Means Committee, remains an ally of Massachusetts hospitals.(Hannah Norman/KHN Illustration; Getty Images)

Richard Neal, a Massachusetts Democrat who chairs the committee, remains an ally of Massachusetts hospitals. He released the brief December surprise billing document two days after the Massachusetts Medical Society and Massachusetts Hospital Association wrote a joint op-ed in The Boston Globe arguing that benchmarking physician payments — as the Senate HELP and Energy and Commerce deal would do — would wreck the state’s health care system.

“The heavy hand of government would create an unfair imbalance in the health care marketplace and insurers would have no incentive to engage physicians in building robust health care networks. The connected system of care we have all been working toward in Massachusetts would immediately become fragmented and disjointed,” the two groups wrote in The Boston Globe.

“They weren’t asking for favorable treatment. They were asking for fair treatment, and there’s a big difference,” Neal said in an interview. “I don’t want to rule anything out, but I think that the momentum right now is arbitration.”

“We need to get a little bit more balance,” added Shalala, who endorsed the Ways and Means legislation unveiled earlier this month.

Shalala has at least two hospitals in her Miami-area district that rely on private equity-supported physician staffing companies.

“I’m worried about the hospitals,” she said. “And the providers obviously include the docs.”

Victoria Knight contributed to this story.

HHS, Janssen Join Forces On Coronavirus Vaccine

HHS Gov News - February 11, 2020

To expedite development of vaccines that protect against the 2019 novel coronavirus, the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Preparedness and Response (ASPR) will expand an existing partnership with New Jersey-based Janssen Research & Development, part of Johnson & Johnson.

Janssen and the Biomedical Advanced Research and Development Authority (BARDA), a component of ASPR, will share research and development costs and expertise to help accelerate Janssen's investigational novel coronavirus vaccine into clinical evaluation.

"When it comes to infectious diseases, vaccines are the backbone of the public health response," said BARDA Director Rick A. Bright, Ph.D. "With emerging infectious diseases such as COVID-19, speed is crucial to saving lives and reducing further spread of the virus. Janssen is a proven partner with a flexible, rapid, vaccine platform which gives us an edge in the race to protect people in the U.S. and worldwide from the health security threat posed by this novel coronavirus."

Janssen also will work on the scale-up of production and manufacturing capacities required to manufacture the candidate vaccine. This same approach was used to develop and manufacture Janssen's investigational Ebola vaccine with BARDA support; that vaccine is being used in the Democratic Republic of the Congo as part of the current Ebola outbreak response.

In addition to an investigational Ebola vaccine, the BARDA and Janssen partnership has supported development of other products and technologies to help save lives in public health emergencies, including a treatment for blood injuries caused by acute levels of radiation and a treatment for injuries caused by inhaled sulfur mustard. The partnership also has supported two JLABS respiratory protection technology innovation challenges and established a health security innovation zone at the new JLABS@Washington DC facility to spur breakthrough technologies needed for health security.

There is currently no approved vaccine, treatment, or diagnostic for novel coronavirus infections; however, the U.S. Food and Drug Administration issued an emergency use authorization (EUA) to enable emergency use of a diagnostic test developed by the Centers for Disease Control and Prevention.

In addition to expanded collaboration with Janssen, BARDA is working with counterparts across the government, including within HHS and with the Department of Defense. The team is reviewing potential vaccines, treatments and diagnostics from across the public and private sectors, particularly products in development for Middle East Respiratory Syndrome (MERS) or Severe Acute Respiratory Syndrome (SARS), to identify promising candidates for development to detect, protect against or treat people with novel coronavirus infections.

To obtain information about any potential products in development in the private sector that could be used in responding to the novel coronavirus outbreak, this task force launched a single point-of-entry website for innovators and product developers to submit brief descriptions of their relevant diagnostics, therapeutics, vaccines, and other products or technologies. The task force is particularly interested in identifying products and technologies that have progressed into or beyond non-clinical studies, have established large-scale commercial Good Manufacturing Practices (cGMP) manufacturing capability, or utilize an FDA-cleared diagnostic platform.

To further support the novel coronavirus response, BARDA also opened an easy broad agency announcement, an EZ-BAA, specific to diagnostics that utilize FDA-cleared platforms, with a viable plan to meet requirements for the FDA to consider issuing an EUA within 12 weeks of an award.

About HHS, ASPR, and BARDA

HHS works to enhance and protect the health and well-being of all Americans, providing for effective health and human services and fostering advances in medicine, public health, and social services. The mission of ASPR is to save lives and protect Americans from 21st century health security threats. Within ASPR, BARDA invests in innovation, advanced research and development, acquisition, and manufacturing of medical countermeasures – vaccines, drugs, therapeutics, diagnostic tools, and non-pharmaceutical products needed to combat health security threats. To date, 54 BARDA-supported products have achieved regulatory approval, licensure or clearance. BARDA DRIVe brings together the best ideas from the medical and scientific communities, together with government and venture capital investment, to drive innovation that will strengthen our nation's health security. To learn more about preparing for and responding to public health emergencies, from new infectious diseases to natural disasters and bioterrorism, by visiting the HHS public health emergency website, www.phe.gov. For more information on partnering with BARDA on developing medical countermeasures, visit www.medicalcountermeasures.gov, and for more on DRIVe, visit drive.hhs.gov.

HHS Assistant Secretary for Administration Scott W. Rowell Statement on the launch of Enterprise Infrastructure Solutions Program Management Office at HHS

HHS Gov News - February 11, 2020

Today, the U.S. Department of Health and Human Services (HHS) announced the standup of the Enterprise Infrastructure Solutions (EIS) Program Management Office (PMO) to support the budget, finance, contracting, technical services, and governance activities for the department’s EIS contract.

HHS Assistant Secretary for Administration Scott W. Rowell issued the following statement:

“Today’s event represents months of hard work by staff to deliver on the President’s Management Agenda and enhance operational excellence at HHS. The Enterprise Infrastructure Solutions (EIS) is the largest and most complex implementation that HHS has ever undertaken. It will enable us to leverage bulk buying opportunities and eliminate redundancies and duplicate costs that will assist our operating and staff divisions to promote greater collaboration and unified communications. I am thankful to Jose Arrieta, HHS Chief Information Officer and James Simpson, Deputy Assistant Secretary for Acquisitions for their leadership on this important issue and look forward to seeing the EIS implementation in the months to come.”

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

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Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

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He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify's website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

Newsom Touts California’s ‘Public Option.’ Wait — What Public Option?

Kaiser Health News:States - February 11, 2020

Several Democratic presidential hopefuls are pitching a federal “public option” as a way to expand health coverage and make it more affordable.

The details of their proposals vary, but the general idea is to create a government-sponsored plan that could compete with private insurance.

“We have a public option, just so folks know,” California Gov. Gavin Newsom claimed last month as he unveiled his proposed 2020-21 state budget. “It’s called Covered California.”

Hmm, really?

California does not have a public option in the way most people understand the term. According to Newsom’s definition, offering a public option simply means ensuring that consumers have choices and affordable coverage, and that health plans are held accountable, things Covered California already does, his office said.

That’s a stretch, say some health care and political experts.

Covered California “is manifestly not a public option,” said Thad Kousser, chair of the political science department at the University of California-San Diego.

Kousser theorized that Newsom may be co-opting the term to make it seem like the state is making progress toward his goal of creating a single-payer system.

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But if Newsom wants to flout the term, the state should “create a public option that doesn’t involve insurance companies, and Covered California is a market to buy insurance from insurance companies,” Kousser said.

Covered California is the state-run exchange, created under the Affordable Care Act, where some individuals, families and small businesses can purchase insurance.

A public option is considered less sweeping than single-payer, a system in which health care is paid for by a single public authority. As a candidate, Newsom, a Democrat, campaigned for the creation of a single-payer program.

But that isn’t likely to happen anytime soon, for a variety of reasons. For one, the Trump administration has said it would reject any state plans to use federal dollars to implement single-payer.

At the national level, Democratic presidential candidates including former Vice President Joe Biden and former South Bend, Indiana, Mayor Pete Buttigieg have pitched public-option plans that would allow, but not require, people to buy into government-run plans similar to Medicare.

The idea is to boost competition by allowing people to choose between private plans and a government-run plan — and reduce costs.

Only one state, Washington, is implementing its own version of a public option, but other states are considering it.

Cascade Care, a hybrid system in which the state will contract with an insurer to administer a public-option plan, will debut in 2021. The state will attempt to control costs by setting payment rates at 160% of what Medicare would pay for the same service. Colorado is proposing a similar idea.

This version is different from the presidential candidates’ proposals because an insurance company will be responsible for running the public-option plan — not the government. But, ultimately, Washington will give its residents a new health insurance option, and that’s not the case in California, said Billy Wynne, chairman of the Wynne Health Group, which recently launched the Public Option Institute, a group analyzing the implementation of public-option programs.

But in California’s defense, he said, what constitutes a public option “is in the eye of the beholder.”

Peter Lee, executive director of Covered California, is also calling the exchange a public option. He argues that public-option plans assume different forms, just like single-payer or Medicare for All proposals.

On the exchange, “plans don’t compete on their own terms; they compete on our terms,” Lee said.  So, “is a public option only a government plan, or is it a public program that sets the rules of how private plans compete?”

Linda Blumberg, a health policy fellow at the Urban Institute, hazards an answer: While Covered California actively negotiates with health plans to keep premiums down, it “doesn’t quite have the spirit of a public option” because it doesn’t bear the financial risk that insurance companies do.

Newsom’s Healthy California for All Commission, which is debating how to get every Californian covered — with an emphasis on single-payer — gathered in Sacramento last month for its inaugural meeting. The commissioners briefly discussed the possibility of implementing a public option as a steppingstone to achieving universal coverage.

But the concept didn’t get much love, and some commissioners suggested that instead of creating a public option, the state should strengthen existing public programs. One commissioner said the idea of a public option had already fizzled.

“Whatever happened to Vanilla Ice, and whatever happened to Tiny Tim and Miss Vicki? Whatever happened to public option?” asked Dr. Robert Ross, president of the California Endowment, a foundation that focuses on expanding health care access among Californians. “It just kind of went away.”

The closest thing to a functioning public option in California, under the traditional definition, may be the L.A. Care Health Plan, a public, nonprofit insurer equally available to Los Angeles County residents with Medi-Cal, the state’s Medicaid program for low-income residents, and to those who earn too much to qualify for Medi-Cal.

John Baackes, the plan’s CEO, said L.A. Care functions like the public-option plan described in the U.S. House version of the Affordable Care Act, before it was axed in the Senate. “Their definition of the public option was a public entity that did not have shareholders that would compete with commercial insurers in the individual market,” Baackes said.

L.A. Care, created to serve Medi-Cal patients, later opened to individuals and families who purchase their own insurance through Covered California or the open market.

For some time, Baackes said, the plan was the lowest-priced option in the Los Angeles area.

“Our enrollment skyrocketed because this is a very price-sensitive market, but in 2020, we were underbid by competition,” Baackes said. “To me, that’s exactly what the public option was supposed to do: put pressure in the marketplace. So I’m saying if you want to see how it works, look here.”

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

Better Than Other Plans Or Better Than Nothing? Trump’s Claim About ‘Affordable’ Options

Kaiser Health News:The Health Law - February 11, 2020
“Our new plans are up to 60% less expensive and better.”

President Donald Trump in his State of the Union address to Congress, Feb. 4, 2020

In his wide-ranging State of the Union address, President Donald Trump returned to a favorite theme: the cost of health insurance.

This story was produced in partnership with PolitiFact.

This story can be republished for free (details). He cited the high cost of premiums for people who buy their coverage through the Affordable Care Act marketplaces and said his administration has provided new, less costly coverage.

“I moved quickly to provide affordable alternatives. Our new plans are up to 60% less expensive and better,” Trump told the lawmakers gathered at the Capitol.

So we wondered, to which new alternatives was he referring? We reached out to the White House to ask.

Spokesperson Adam Kennedy responded that the president was talking about short-term, limited-duration plans. But that got us thinking: Are they really less expensive and better? Or simply better than nothing?

First, Are They New?

They are not. As background, short-term insurance plans have been around for decades in various iterations and are generally considered a stopgap solution for people between jobs or attending school. They provide some protections, usually paying a percentage of hospital and doctor bills after the policyholder meets a deductible.

But they’ve always been a bit controversial.

Unlike the ACA plans now available, short-term plans can bar people with health conditions from enrolling or exclude coverage for specific conditions or treatments. They also offer fewer benefits — meaning they are not required to comply with the health law’s mandated essential benefits requirement.

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So, for example, they don’t have to cover prescription drugs, or mental health services or substance abuse treatment — and many don’t. In addition, they can set annual or lifetime caps on benefits. Almost all exclude maternity care.

If a person develops a health condition during the coverage term, insurers can look through their medical records and, in some cases, retroactively cancel the plans — or refuse to renew the coverage at the end of the policy’s term.

The Obama administration restricted these policies, which still cannot be sold on the ACA marketplaces and do not qualify for subsidies, to a maximum coverage period of 90 days, down from the 364 days that applied previously.

The Trump administration reversed that time-limit restriction in 2018 and built on it by allowing insurers to offer policies renewable for up to three years.

Officials, including Health and Human Services Secretary Alex Azar, said at the time that these short-term plans provide an alternative but aren’t a good fit for everyone.

For instance, the Trump rules require the policies to carry a warning that they aren’t “required to comply with federal requirements for health insurance.” They also state that consumers should “check the policy carefully to make sure you understand what the policy does and doesn’t cover.”

Are These Plans Less Expensive?

The White House pointed us toward a January 2019 report produced by the Congressional Budget Office and the Joint Committee on Taxation as the source for the president’s assertion that these plans are 60% less expensive.

It quickly becomes clear that the analysis is very wonky and complex.

After all, it’s not easy to project what benefits insurers will include in short-term plans or what they will charge individuals, which can vary based on their health. Even the analysts called the estimating process “challenging.”

When it came right down to it, they hedged: Short-term plans are likely cheaper than the lowest-cost ACA plan for some consumers, but more expensive for others. For example, people who get a federal tax credit to buy ACA-compliant insurance or those who are older or less healthy would likely pay more in premiums for a traditional short-term plan, the analysts said.

Conversely, those without subsidies, especially younger or healthier consumers, might pay as much as 60% less than they would for the lowest-cost plan through the ACA, the analysis concluded. Another study, not cited by the White House but done by the conservative Manhattan Institute, also listed caveats, but more robustly defended the plans as less expensive. Premiums for short-term plans are lower — in some cases, almost half the cost — of ACA plans, it concluded.

But critics put these price tags in context. “I don’t have a reason to suspect the 60% is wrong if they’re lining them up against ACA plans, but if you’re a health plan that doesn’t cover much, it’s easy enough to offer a cheap premium,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

So That Gets To The Question, Are They Better?

The consensus is that the coverage short-term plans provide is not better than that of ACA plans. But it could be better than going without insurance entirely.

“Why not throw another option out there?” said Doug Badger, senior fellow at the conservative Galen Institute. “You might say this plan isn’t as good as that plan, but we may both agree that having this one is better than nothing.”

He said that should be a decision made by consumers, who can weigh the pros and cons: “They know their circumstances and risk tolerance.”.

Still, it’s a gamble, as no one knows what health conditions might befall them. A plan that doesn’t cover prescription drugs may be fine the first month, but if a serious illness crops up, it suddenly has unexpected costs.

Others also note that short-term plans may have wider networks of doctors and hospitals than some ACA plans, giving consumers more options.

“In Texas, for example, you cannot buy an ACA plan that covers MD Anderson,” the cancer center of the University of Texas, said Brian Blase, CEO of Blase Policy Strategies. Blase has advised Trump on his health policy efforts. “The only way you can have such a plan that includes MD Anderson — unless you have employer coverage — is in a short-term plan.”

Sources:

Email response from Adam Kennedy, spokesperson, Executive Office of the President, Feb. 5, 2020

Telephone interview with Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, Feb. 5, 2020

Telephone interview with Tom Miller, resident fellow at the American Enterprise Institute, Feb. 5, 2020

Telephone interview with Brian Blase, CEO of Blase Policy Strategies, Feb. 5, 2020

Telephone interview with Doug Badger, senior fellow at the Galen Institute, Feb. 5, 2020

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

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

Federal Register, “Short-Term, Limited-Duration Insurance,” Aug. 3, 2018

Commonwealth Fund, “States Step Up to Protect Insurance Markets and Consumers from Short-Term Health Plans,” May 2, 2019

FierceHealthcare, “Azar touts agency progress on growing insurance options,” Feb. 28, 2019

Manhattan Institute, “Renewable Term Health Insurance: Better Coverage Than Obamacare,” May 16, 2019

Commonwealth Fund, “Short Term Health Plan Gaps and Limits Leave People at Risk,” Oct. 20, 2018

Again, nice to have a wide network. But there’s a conundrum. Someone with cancer — attracted to a network because it includes MD Anderson — would be rejected by most short-term plans.

That ability to reject applicants — or seriously limit coverage of their preexisting conditions — helps keep premiums down.

But those are also the main reasons experts say the plans are not better than those offered under the ACA, which bars such limits.

A preexisting condition is often defined as anything treated — or for which a “prudent person” should have sought treatment — during the previous 12 months to five years, depending on the insurer.

“If you have high blood pressure and, while on one of these plans, you have a heart attack, the plan could say that was a preexisting condition,” said Corlette.

State regulation of such plans varies widely, as do the coverage benefits and limits offered by various insurers. Some have limits listed in the fine print.

While short-term plans have been embraced by regulators in some states, nearly half of all states have moved to limit them to less than 12 months. Four — California, Massachusetts, New Jersey and New York — have barred them altogether.

Those states cite concerns about the effect on ACA premiums and the risk that consumers could be left hanging by the more limited nature of the short-term plans.

Our Ruling

Trump said these are new plans that are 60% cheaper and better.

But short-terms plans are not a new idea. Just how much cheaper they are depends on a lot of factors, experts told us. And it’s very hard to examine them in an apples-to-apples comparison with ACA plans, which cover far more and are required to accept all applicants.

Given the limitations of short-term plans, they’re not better than ACA plans for most people, because policyholders could face potentially significant financial risk — or find their treatment needs are not covered. They’re definitely not better for people who qualify for federal subsidies to buy ACA insurance, especially those at the lower end of that income range, where the subsidies are larger.

That said, a short-term plan may be better than going without coverage at all, particularly for a young or otherwise healthy person, whose income is above subsidy limits.

We rate this claim as Mostly False.

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