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When Is Insurance Not Really Insurance? When You Need Pricey Dental Care.

I’m 61 years old and a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I’ve needed in the past 20 years, I’ve had to rely on handouts — from my mom.

This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.

Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.

In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.

Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.

My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.

My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.

At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, states decide themselves on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.

The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.

“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”

A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.

He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”

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As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.

Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 did not have medical insurance in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.

Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by Mary Otto in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.

Research has demonstrated links between periodontal infections and chronic conditions like diabetes and cardiovascular disease. Studies have found associations between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.

The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.

In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of the world’s first dental school.

Tuller poses for a photograph without his partial dentures. He says during his period of intense dental care, he hated wearing temporaries and often braved the public with missing front teeth. (Heidi de Marco/KHN)

Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.

Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.

With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.

In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.

Meanwhile, the bold line between what is covered or what is not often strikes patients as nonsensical.

Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.

Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.

If only his tumor had placed itself just a few inches away, he thought.

“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Middlemen Who Save $$ On Medicines — But Maybe Not For You

Guess who’s back grabbing headlines? Pharmacy benefit managers — those companies that serve as middlemen in the prescription drug pipeline. President Donald Trump’s plan to reduce the cost of medicines targets so-called PBMs as primary culprits behind the nation’s out-of-control drug prices. At KHN, we were talking about them last week and have written about their role in the marketplace for some time.

But consumers often don’t notice or understand PBMs and how they factor into determining costs at the pharmacy counter. This KHN video, brought out from our vault, details the emergence of these multimillion-dollar corporations and the impact they have on medication costs and patients’ access to treatments.

For more information on drug pricing issues, check out this chart and these videos:

This KHN story also ran on NPR. It can be republished for free (details).

Tracking Who Makes Money On A Brand-Name Drug

Sounds Like A Good Idea? Regulating Drug Prices

The Orphan Drug Machine

KHN also offers other videos examining hot topics such as selling insurance across state lines, high-risk insurance pools, Medicare’s observation care status and how the health law could be disassembled through the congressional budget reconciliation process.

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

Trump Proposes Cutting Planned Parenthood Funds. What Does That Mean?

The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40 percent of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate.

But the imposition of a slightly retooled version of a regulation, which was upheld by the Supreme Court in 1991 after a five-year fight, could potentially accomplish what Congress could not.

The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.
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All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using non-federal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What Is Title X?

The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, three years before the Supreme Court legalized abortion in Roe v Wade.

The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female and low-income. An estimated 11 percent of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What Is Planned Parenthood’s Relationship To Title X And Medicaid?

Planned Parenthood affiliates account for about 13 percent of total Title X sites but serve an estimated 40 percent of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.

Eliminating Medicaid funding for Planned Parenthood has proven more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.

Why Is Planned Parenthood’s Involvement With Title X Controversial?

Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.

In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.

Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.

What Happened The Last Time An Administration Tried To Move Planned Parenthood Out Of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v. Sullivan.

Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.

How Is The Trump Administration’s Proposal Different From Earlier Rules?

According to the summary of the new proposal, released Friday, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”

What Happens Next?

All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.

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

Readers And Tweeters Are Buzzing Over ‘Bill Of The Month’

Send Us Your Medical Bill

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-the-Month Club and tell us about your experience. We’ll feature a new one each month.

Submit Your Bill

It’s a club no one wants to join, but many Americans these days find themselves automatically eligible for the “Bill of the Month” club.

Kaiser Health News and NPR’s Shots blog began collecting readers’ “exorbitant or baffling” health care bills for examination early this year. Editors have waded through roughly 500 submissions, choosing just one each month to decode and dissect.

But the crowdsourced investigation has given voice to countless others on social media — health care consumers and industry players alike. With each installment, hundreds of readers weighed in. The most recent feature, “Sticker Shock Jolts Oklahoma Patient: $15,076 For Four Tiny Screws” (May 14), so far has generated nearly 6,800 shares on Facebook, scores of tweets and lively discussions on both Reddit and LinkedIn.

Readers aren’t merely bellyaching. Discussions quickly veer toward solutions: demanding more transparency and exploring a single-payer health care system.

Among highlights from Twitter:

From @NPRHealth & @KHNews: it's so important to ask healthcare entities for itemized receipts! They ask listeners to share itemized healthcare receipts — which DPC patient wants to step up to share a transparent, fairly priced healthcare invoice? https://t.co/sb911L1byI pic.twitter.com/bILc0X7MbB

— KC DirectPrimaryCare (@KansasCityDPC) May 15, 2018

This is about as good an argument for #MedicareForAll that there is. Sticker Shock Jolts Oklahoma Patient: $15,076 For 4 Tiny Screws https://t.co/S7SuICSTzr

— Michael Yoder (@MichaelYoder1) May 14, 2018

— Michael Yoder, Conway, Ark.

They charge what they can get away with! And most doctors do not know the charge or cost of the tests and drugs they order! A Tale Of Two CT Scanners — One Richer, One Poorer https://t.co/ZhEkXj1AOv via @khnews

— Dr. Susan Love (@DrSusanLove) April 9, 2018

— Dr. Susan Love, Los Angeles; breast cancer advocate, surgeon and author

When your doctor suggests going to an E.R., that's what you do. Patients shouldn't have to question that. The E.R. shouldn't cost 33x more.
Bill Of The Month: A Tale Of 2 CT Scanners — One Richer, One Poorer https://t.co/MGm0aGOEbu

— Kevin Bauman (@smooveb) April 15, 2018

— Kevin Bauman, Denver

How @Novartis can afford to pay Michael Cohen $1.2 million: A toenail fungus medicine that cost $1,500 — A MONTH — and was prescribed for 11 months. Patient never asked, neither PA nor mail-order pharmacy warned her.

Takeaway: Always, always ask.https://t.co/CUhsNP3x0Y

— Gwen Moritz (@gwenmoritz) May 14, 2018

— Gwen Moritz, Little Rock, Ark.

This has little to do with the great care that @OUMedicine provides, and everything to do with a confusing, non-transparent payment system for US healthcare. Hate to say, it happens everywhere
Sticker Shock Jolts Oklahoma Patient: $15,076 For 4 Tiny Screws https://t.co/vezwJX2s5C

— Dr. Kevin Neal (@JaxScoliosisDoc) May 14, 2018

— Dr. Kevin Neal, Jacksonville, Fla.

Between this Vox series and #billofthemonth lots of hard questions being asked about provider billing practices in this country – doesn’t matter if you look at micro billing or macro trends, it’s the prices, it’s the prices, is the prices https://t.co/tnEj4uwQcq

— Niall Brennan (@N_Brennan) April 10, 2018

— Niall Brennan, Washington, D.C.; former chief data officer at the Centers for Medicare & Medicaid Services and current president and CEO of the Health Care Cost Institute

A medical device executive who was mentioned in the story about the $15,076 surgical screws, Steve Lichtenthal, vice president of business development at Orthopaedic Implant Co., based in Reno, Nev., shared the link and received at least 8,300 views. He invited commenters and colleagues on LinkedIn to join in an offline forum. As of Thursday, two had expressed interest.

And Canadians continue to offer insider perspective from the outside. Plucked from one of many Facebook threads:

“When health is considered a for-profit commodity, this is exactly what will happen in an unregulated system.

“It’s sad, but not surprising.

“What many of us who live outside of the US wonder (I’m Canadian), is why you put up with a health-care system that treats you as a financial resource, rather than as a human being?”

— Richard Bott, Port Coquitlam, British Columbia

In Canada we get all medically necessary surgeries and overnight stays without being charged; poor & uninsured people don’t have to worry . We do pay to upgrade to semi or fully private room and of course we pay a fortune in income tax to support the system. That lady got screwed

— Trainer Gloria

Choosing Between Death And Deportation

“Dear the most highly respected judge and court, I’m writing this because I love my mom. My mom is very important to me. I have no idea what to do without her. Even though my mom’s afraid, she’s not giving up.”

This is the beginning of a plea written by a 13-year-old girl to the Department of Homeland Security. The goal: to get her mother the insurance coverage she would need to enter a clinical trial.

Two years ago, the girl’s mother learned she had advanced stomach cancer. Undocumented and uninsured, the mother received free treatment at Bellevue Hospital in Manhattan through New York’s emergency Medicaid program, which undoubtedly prolonged her life.

Then, last fall, her doctor identified her as a good candidate for a medicine that has been remarkably effective for some lung cancers. Would it work for her disease? The researchers were eager for patients like J. to help them answer that question. (Kaiser Health News is identifying the patient by her first initial only, because of the threat of deportation.)

“You look at these clinical trials — there are some patients who just forget to die,” said Dr. Steve Lee, J.’s oncologist. “She could be one of these long-term survivors.”

But it would not be a simple process for J. to enter a clinical trial. She emigrated from China 18 years ago on a visa that had long since expired. Her husband’s visa also expired years ago. The Queens couple have three children who are U.S. citizens, ages 13, 12 and 4.

To be accepted into the trial, J. needed the more complete coverage traditional Medicaid offers. And to get that meant declaring herself to Homeland Security and asking the agency not to act on its standing deportation order against her. That would call attention to herself and her status — and provide the agency with her address and the names of everyone she lived with.

“Before getting sick, legal status was clearly important,” J. said through a translator. “Now, both legal immigration status and my ability to continue to live are intertwined, because I can only get good treatment if I obtain legal status.”

The family faced this dilemma under President Donald Trump’s growing threat of deportations. Federal figures show arrests of undocumented people living in the U.S. were up 40 percent in the first four months of 2017 compared with the same period in 2016. The administration also is considering a change that would penalize legal immigrants if they use public benefits like Medicaid.

Up to the point of the clinical trial, J. got care very similar to what anyone with private insurance might get. And that is a function of residence. Each state covers care for undocumented immigrants through its emergency Medicaid program differently, and New York has one of the most generous programs in the country.

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“In some states, they say giving you dialysis is keeping you from dying. We are going to put you on emergency Medicaid,” said Steven Wallace, a health professor at UCLA, who has studied immigrant health care in the U.S. “In other states — Georgia comes to mind — they will not put you on emergency Medicaid until you are in diabetic shock.”

By the time J. learned of the drug trial, she’d had chemotherapy and separate surgeries to have her ovaries and part of her stomach removed. As comprehensive as New York’s emergency Medicaid program is, it does not cover the costs associated with drug trials, even in dire situations.

For context, some estimates suggest that stomach cancer treatment for one year costs about $100,000. Costs vary by hospital, and Medicaid pays hospitals less.

Bellevue did not provide a tally of J.’s medical bills. The limited research available on care for very sick, undocumented immigrants shows that the treatment can vary even by county within a state. More often than not, Wallace said, when beset by a life-threatening illness such as stomach cancer, undocumented women and men miss out on the tests, procedures and drugs that could extend their lives.

By virtue of living in New York, J. did receive good care. But was the chance at the drug trial worth the risk of her or her husband being deported?

For most of an interview with a reporter, J. spoke Mandarin through a translator because of her limited English skills. But when asked whether she was more afraid to die or be deported, she answered directly, in English.

“Yeah, I [am] afraid to die, more than be deported,” J. said. “Of course. Because my family need[s] me. My children need me.”

Domna Antoniadis, a senior staff attorney at the New York Legal Assistance Group, works just across the hall from Dr. Lee at Bellevue. Her job is to help patients jump through bureaucratic hoops to get health coverage, and she said J. had a compelling case.

“She’s been here for almost 20 years. She has three young U.S. citizen children. She’s never been arrested; no criminal history. She’s worked. And right now, she has a very aggressive form of cancer,” Antoniadis said. “She’s saying, ‘Here I am. This is what’s going on with me, but please don’t remove me.’”

J.’s husband said his wife did everything she could to battle her disease, including changing her diet, walking up hills for exercise and following doctor’s orders. The decision on the drug trial was clear, he said.

“Life is more important than anything else. You have to face the cancer,” he said, speaking through a translator. “You have to face the pressures. You just have to do whatever it takes so that you can keep on living.”

J. submitted the application, and Antoniadis advised the family to be cautious. She told them if federal agents show up at the house, before opening the door the family should make sure the officials have a warrant. Her attorney gave J. a guide outlining her rights in Mandarin.

Over the fall, J.’s husband said the family felt vulnerable.

“We watch the news,” he said. “We see the things Donald Trump says, and we see that he’s been tough on immigration and has tried to make a lot of changes. So, for sure, we’re more worried.”

As they waited to hear from Homeland Security, a kind of balled-up fear settled over the family. J. talked less. Their 13-year-old daughter took over doing the dinner dishes. Their 12-year-old son set the table and played fewer video games, trying to make his mom happy. Their kid sister, age 4, asked why everything was different.

Before Homeland Security could respond, J. got word from New York’s traditional Medicaid program that she was accepted. The application to delay deportation was enough for the state to open the program to J. She had her first drug trial treatment last December. She tried to savor life.

“Now I’m not nearly as strict with my kids. I sort of just let them be kids. Before, I’d give them extra homework on top of what’s assigned at school. Now, I just want them to be happy,” she said. “Between my husband and me, we care a lot less about money. Before, we only go out to dinner once a month. Now we treasure every moment we have.”

Almost as soon as J. was in the drug trial, she was out. Her oncologist, Lee, said J. “had rapid growth of her cancer” and couldn’t remain in the trial. By early January, J. had started hospice. Her husband said it was a very difficult month for her, and on Feb. 6, J. died.

Asked if he thought the trial was worth all the risk and stress it caused the family, Lee said: “I think it’s easier to say that going on the drug trial was a waste of time, in retrospect. But the alternative for cancer like this is that she would invariably die. So I think that the opportunity to give her a shot at long-term survival was one worth putting a lot on the line for.”

Lee said what the trial really gave J., and her family — for a time at least — was hope.

Dan Gorenstein is the health care reporter for Marketplace. This story was produced in partnership with WHYY’s The Pulse and Kaiser Health News.

Vermont Legislators Pass A Drug Importation Law. So What?

This week, Vermont passed a first-in-the-nation law that would facilitate the state’s importation of prescription drugs wholesale from Canada. It represents the state’s effort to tackle head-on the issue of constantly climbing drug prices.

Other states, including Louisiana and Utah, have debated similar legislation and are watching Vermont’s progress closely.

After all, the issue of drug importation polls well across the political spectrum and has been endorsed by politicians ranging from candidate Donald Trump, before he became president, to liberal firebrand Sen. Bernie Sanders (I-Vt.).

So how much impact might a state law like this actually have?

Trump has since stepped back from his campaign position, and the White House did not include drug importation in its proposal last week to bring down drug prices.

And cautions abound that importation may not actually save that much money as questions swirl about whether the policy undermines drug safety standards.

Kaiser Health News breaks down the challenges that lie ahead for importation champions, and what it shows about the future of the drug pricing fight.

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States need federal approval to launch any kind of importation program.

Just having a law like Vermont’s on the books is not enough to legalize importation. The next step is for the state to craft a proposal outlining how its initiative would save money without jeopardizing public health. The proposal, in turn, is then subject to approval by the federal Department of Health and Human Services.

HHS has had yea-or-nay power over state importation programs since at least 2003, because of a provision included in the law creating Medicare Part D. But it’s never actually approved such a plan. And — despite mounting political pressure — there’s little reason to think it will do so now.

In the past weeks, HHS Secretary Alex Azar has come out strongly against importation, calling it a “gimmick” that wouldn’t meaningfully bring down prices.

He also has argued that the U.S. government cannot adequately certify the safety of imported drugs.

HHS declined to comment beyond Azar’s public remarks.

Importation backers — including the National Academy for State Health Policy (NASHP), which helped craft Vermont’s bill and has worked with state lawmakers — hope he’ll reverse these positions. But few are optimistic that this will happen.

“I don’t expect that Vermont alone will be able to bring sufficient pressure to bear on Secretary Azar to convince him to change his mind,” said Rachel Sachs, an associate law professor at Washington University in St. Louis, who tracks drug-pricing laws.

A state’s importation program would also require buy-in from Canadian wholesalers. What’s in it for them?

Perhaps not much. Canadian wholesalers might stand to lose financially.

After all, pharmaceutical companies that market drugs in the United States might limit how much they sell to companies that have supply chains across the border. They could also raise their Canadian list prices.

“Almost inevitably, Canadians would cease getting better prices,” said Michael Law, a pharmaceutical policy expert and associate professor at the University of British Columbia’s Center for Health Services and Policy Research. “If I were a [Canadian] company, I wouldn’t want that to occur — and [drugmakers] could take steps to limit the supply coming north. … It probably results in [Canadians] getting higher prices.”

Trish Riley, NASHP’s executive director, dismissed this concern, saying some Canadian wholesalers have indicated interest in contracting with Vermont.

Vermont would still have to prove to HHS that its proposal would yield “substantial” savings. This  won’t be easy.

In fact, some analysts suggest savings would be limited to a narrow slice of the market.

Importation could bring down the price of some generics and off-patent drugs by increasing competition, suggested Ameet Sarpatwari, a lawyer and epidemiologist at Harvard Medical School who studies drug pricing.

Many generic drugs have also seen substantial price hikes in recent years — but curbing these costs is only part of the equation.

“It’s not a panacea for the drug-pricing reform or high drug prices as a whole,” Sarpatwari said.

Branded drugs, which drive much of the American problem with prescription price tags, are distributed by a single company and, therefore, that company has greater control over supply and pricing pressure.

Drug safety looms over the debate.  

The worry, according to critics, is that American regulators can’t effectively determine whether imported drugs meet the same safety standards as those sold directly in the United States. A year ago, a bipartisan group of former Food and Drug Administration commissioners made that very argument in a letter to Congress.

Azar has argued this same point, as has the influential pharmaceutical industry, represented by the Pharmaceutical Research and Manufacturers of America.

“Lawmakers cannot guarantee the authenticity and safety of prescription medicines when they bypass the FDA approval process,” said Caitlin Carroll, a PhRMA spokeswoman, in a statement released on Vermont’s law.

This position, though, draws skepticism.

In cases of drug shortages or public health emergencies, the United States has imported drugs. And many Canadian and American drugs are made and approved under similar standards, Law noted.

“In terms of general safety, it is kind of nonsense. … We share plants,” he said. “The idea that Canadian drugs are somehow unsafe is a red herring.”

An argument in favor of plans like Vermont’s focuses on the idea that because the state would import drugs wholesale — rather than enabling individuals to shop internationally — it would be able to address concerns about safety or quality, Riley said.

Plus, Sarpatwari suggested, the government has resources to track drugs that come from Canada, especially if a drug were recalled or ultimately found to have problems.

“Our technology is catching up with our ability to do effective monitoring,” he said. “Particularly when it’s coming from a well-regulated country, I think there is less fear over safety.”

States have been leading the charge on addressing the drug price issue, but their efforts reach only so far.

The federal government has taken little action to curb rising drug prices — though HHS now says it plans to change that.

So far, state legislatures have been pushing for laws to penalize price gouging, promote price transparency or limit what the state will pay.

But state initiatives often require federal permission.

Vermont’s law, which is arguably meaningless without HHS’ say-so, is just one example.

Sarpatwari pointed to a request from Massachusetts to develop a drug formulary for its Medicaid insurance program — theoretically giving the state more leverage to negotiate cheaper prices by reducing how many drugs it’s required to cover.

That proposal also is contingent upon approval from HHS. The administration has been publicly silent, though some news reports suggest it leans toward rejecting the request.

Meanwhile, Sachs said Vermont’s law, and others like it, will challenge the White House to show its mettle in taking on drug costs.

“We’re seeing explicit actions by the states to put pressure back on the federal government,” Sachs said. “The administration is publicly committed to lowering drug prices. It is being asked to make decisions which will, in some ways, show how much it really is attempting to accomplish that goal.”

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

Secure API Server Showdown Winner Announced

HHS Gov News - May 17, 2018

The Department of Health and Human Service’s Office of the National Coordinator for Health Information Technology (ONC) today announced the Stage 2 winner of the “Secure API Server Showdown” Challenge. Application programming interfaces (APIs) are technology that allow one software program to access the services provided by another software program. The 21st Century Cures Act calls for the development of APIs that do not require “special effort” for developers to access and exchange health information.

The challenge sought to engage the health IT industry to identify Fast Healthcare Interoperability Resources (FHIR®) servers that reinforce the value of following technical security best practices on an industry-wide scale. These best practices ensure the most widely-accepted and effective measures are taken resulting in a high quality, secure FHIR server, further helping to protect the health information it contains. The winner of the challenge is 1upHealth.

In Stage 1 of the challenge, Asymmetrik built a secure, Health Level 7 (HL7®) FHIR server using current industry technical standards, best practices, and recently issued healthcare-specific technical requirements for security. This included using the Substitutable Medical Apps, Reusable Technology (SMART) App Authorization Guide.

To win stage 2, participants were tasked with finding weaknesses in the FHIR server developed by Asymmetrik. 1upHealth identified ways to strengthen the open source FHIR server, improving the overall security of the server and supporting the sensitive patient data being stored or transmitted.

As a result of this challenge, a unique open source FHIR implementation using JavaScript, Node.js and MongoDB is now available for industry developers to build upon. This implementation meets the security technical requirements as specified in the Argonaut Data Query Implementation Guide Version 1.0.0. The source code is available for public use on GitHub.

Podcast: KHN’s ‘What The Health?’ Much Ado About Drug Prices

Kaiser Health News:States - May 17, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories

President Donald Trump’s blueprint to reduce drug prices frames almost as many questions as answers, but it does shine light on a vexing and complicated problem. Meanwhile, Vermont passed a law to do something that’s not in the president’s plan: import cheaper prescription drugs from Canada. The state will need federal permission to do that, which is unlikely to be granted.

And Timothy Jost, emeritus professor of law at Washington and Lee University in Virginia, discusses the state of the Affordable Care Act and what might be in the health law’s immediate future.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Joanne Kenen of Politico and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • It is not yet clear how many of the myriad proposals in Trump’s 44-page prescription drug price proposal will be implemented, but the plan does jump-start the discussion across a wide range of drug issues.
  • Although Trump walked back his promise to move Medicare toward negotiating drug prices, his drug proposal would move some drugs administered in physicians’ offices — currently paid under a formula — to be handled by the Part D prescription drug plans, for which insurance companies negotiate prices.
  • The drug price initiative is welcomed by Republican candidates who think it will be a potent defense against Democratic charges that GOP efforts on the Affordable Care Act are driving overall health care spending up.
  • With the increasing reports that in the not-too-distant future one or more justices will retire from the Supreme Court, abortion-rights activists are nervous about how a new court would view the issue and are working hard to avoid a big federal lawsuit that could overturn Roe v Wade.

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

Julie Rovner: Kaiser Health News’ “For The Babies Of The Opioid Crisis, The Best Care May Be Mom’s Recovery,” by Sarah Jane Tribble

Joanne Kenen: Science Magazine’s “Hoping to Head Off an Epidemic, Congo Turns to Experimental Ebola Vaccine,” by Jon Cohen

Rebecca Adams: Kaiser Health News’ “Under Trump Proposal, Lawful Immigrants Might Be Inclined To Shun Health Benefits,” by Christina Jewett and Melissa Bailey and Paula Andalo

Anna Edney: Vox.com’s “The Blockbuster Fight Over This Obscure Federal Program Explains America’s Drug Prices,” by Dylan Scott

To hear all our podcasts, click here.

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

California’s Deadly STD Epidemic Sets Record

Kaiser Health News:States - May 17, 2018

Diagnoses of sexually transmitted diseases hit a record high in California last year — with sometimes deadly consequences, according to preliminary state data released this week.

More than 300,000 cases of gonorrhea, chlamydia and syphilis — the most common sexually transmitted bacterial infections — were reported in 2017. That represents a 45 percent increase since 2013 and the highest number since at least 1990, state Department of Public Health numbers show.

Some of those cases had tragic endings: Thirty of the 278 babies affected by congenital syphilis in 2017 were stillbirths, the highest number in 22 years. Congenital syphilis occurs when syphilis passes from a pregnant woman to her fetus.

California has the second-highest rate of congenital syphilis in the country after Louisiana, according to the most recent national data.

“We’re getting a lot of … younger pregnant women infected with syphilis and not getting prenatal care,” said Mario Alfaro, regional program director for education at Planned Parenthood Mar Monte in Fresno.

Fresno County accounted for 60 of the state’s congenital syphilis cases last year, including seven stillbirths, said Joe Prado, a division manager at the county Department of Public Health.

Fresno County participates in a pilot program run by the U.S. Centers for Disease Control and Prevention (CDC) and the state public health department to address congenital syphilis. Officials say the program has already increased outreach and screening but that the number of diagnoses is still rising.

Newborns with congenital syphilis may suffer from deformed bones, severe anemia, blindness, deafness or other symptoms. According to the CDC, up to 40 percent of babies born to women with untreated syphilis may be stillborn or die from the infection as a newborn.

Alfaro cited lack of access to health care, insurance and education as contributing factors to the rise in congenital syphilis. “All of those things are a deadly combination,” he said.

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Prado also pointed to a rise in syphilis among methamphetamine users.

“We’re just seeing this is a more difficult population to get a hold of, to reach and really be able to get them to consent and agree to treatment,” he said.

Chlamydia has increased 9 percent in California since 2016. Chlamydia is more prevalent in women, while gonorrhea, which has increased 16 percent since 2016, is more common in men.

“Half of chlamydia and a third of gonorrhea cases are folks under age 25,” said Dr. Heidi Bauer, the state public health department’s chief of the Sexually Transmitted Diseases Control Branch.

Her division released this preliminary data this week, a few months before the final numbers become available, because the increases are so dramatic, she said.

Rates of both chlamydia and gonorrhea are nearly five times higher among blacks than whites. And men who have sex with men also have much higher rates of infection than the general population. Their rates of syphilis are more than 20 times the overall rate, and their rates of gonorrhea are more than 15 times the overall rate.

The state’s data did not include HIV, a viral STD. New HIV infections fell in both California and nationwide from 2012 to 2016, in part because of improved treatment and increased use of the HIV-prevention pill known as PrEP.

While there’s no one clear reason for the increases of the other STDs, Bauer pointed to “very high rates of folks who are not accessing sexual health services and aren’t getting screened frequently.”

If left untreated, chlamydia and gonorrhea can lead to infertility, ectopic pregnancy and chronic pelvic pain. Syphilis can cause permanent vision and hearing loss, and other neurological problems.

Once diagnosed, doctors can often cure these sexually transmitted diseases with antibiotics, said Dr. Karen Smith, the state’s public health director.

Because these infections often appear without symptoms, San Francisco County wants to make sure the hardest-hit populations have access to regular screenings, said Dr. Susan Philip, a division director at the county Department of Public Health.

“Making sure that there are culturally appropriate and sensitive services … where young people would be willing to seek care becomes really important,” she said.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

HHS Secretary Azar Praises FDA Approval of First Non-Opioid Treatment for Opioid Withdrawal

HHS Gov News - May 16, 2018

HHS Secretary Alex Azar issued the following statement regarding the FDA’s approval of the first non-opioid treatment for the symptoms of opioid withdrawal:

“President Trump and HHS have made fighting the opioid crisis a top priority. That includes working to expand the set of tools we have for solving this crisis, such as new therapies for treating opioid use disorder and helping people stay in recovery. The Food and Drug Administration’s approval today of the first non-opioid treatment for managing opioid withdrawal symptoms is a welcome step forward. I applaud the work of the FDA as well as the National Institute on Drug Abuse, which supported clinical studies of the treatment, in prioritizing efforts to prevent and treat opioid addiction. Evidence-based treatment for addiction saves lives, and HHS will continue to support efforts to develop new treatments and provide approved treatments to those in need.”

Read the FDA statement on the approval here: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm607884.htm

California Hospital Giant Sutter Health Faces Heavy Backlash On Prices

Cooking dinner one night in March, Mark Frizzell sliced his pinkie finger while peeling a butternut squash and couldn’t stop the bleeding.

The 51-year-old businessman headed to the emergency room at Sutter Health’s California Pacific Medical Center in San Francisco. Sutter charged $1,555 for the 10 minutes it treated him, including $55 for a gel bandage and $487 for a tetanus shot.

“It was ridiculous,” he said. “Health insurance costs are through the roof because of things like this.”

California Attorney General Xavier Becerra couldn’t agree more. The state’s top cop is suing Sutter, accusing one of the nation’s biggest health systems of systematically overcharging patients and illegally driving out competition in Northern California.

For years, economists and researchers have warned of the dangers posed by large health systems across the country that are gobbling up hospitals, surgery centers and physicians’ offices — enabling them to limit competition and hike prices.

Becerra’s suit amounts to a giant test case with the potential for national repercussions. If California prevails and is able to tame prices at Northern California’s most powerful, dominant health system, regulators and politicians in other states are likely to follow.

“A major court ruling in California could be a deterrent to other hospital systems,” said Ge Bai, an assistant professor at Johns Hopkins University who has researched hospital prices nationwide. “We’re getting to a tipping point where the nation cannot afford these out-of-control prices.”

Reflecting that sense of public desperation, Sutter faces two other major suits — from employers and consumers — which are wending their way through the courts, both alleging anticompetitive conduct and inflated pricing. Meanwhile, California lawmakers are considering a bill that would ban some contracting practices used by large health systems to corner markets.

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Sutter, a nonprofit chain, is pushing back hard, denying anticompetitive behavior and accusing Becerra in court papers of a “sweeping and unprecedented effort to intrude into private contracting.” Recognizing the broader implications of the suit, both the American Hospital Association and its California counterpart asked to file amicus briefs in support of Sutter.

California Attorney General Xavier Becerra is suing Sutter Health, accusing one of the nation’s biggest health systems of systematically overcharging patients and illegally driving out competition in Northern California. (Stephen Lam/Getty Images)

In his 49-page complaint, Becerra cited a recent study finding that, on average, an inpatient procedure in Northern California costs 70 percent more than one in Southern California. He said there was no justification for that difference and stopped just short of dropping an expletive to make his point.

“This is a big ‘F’ deal,” Becerra declared at his March 30 news conference to unveil the lawsuit. In an interview last week, he said, “We don’t believe it’s fair to allow consolidation to end up artificially driving up prices. … This anticompetitive behavior is not only bad for consumers, it’s bad for the state and for businesses.”

To lessen Sutter’s market power, the state’s lawsuit seeks to force Sutter to negotiate reimbursements separately for each of its hospitals — precluding an “all or nothing” approach — and to bar Sutter employees from sharing the details of those negotiations across its facilities. Becerra said Sutter has required insurers and employers to contract with its facilities systemwide or face “excessively high out-of-network rates.”

Heft In The Marketplace

Overall, Sutter has 24 hospitals, 36 surgery centers and more than 5,500 physicians in its network. The system boasts more than $12 billion in annual revenue and posted net income of $958 million last year.

The company’s heft in the marketplace is one reason why Northern California is the most expensive place in the country to have a baby, according to a 2016 report. A cesarean delivery in Sacramento, where Sutter is based, cost $27,067, nearly double what it costs in Los Angeles and New York City.

For years, doctors and consumers have also accused Sutter of cutting hospital beds and critical services in rural communities to maximize revenue. “Patients are the ones getting hurt,” said Dr. Greg Duncan, an orthopedic surgeon and former board member at Sutter Coast Hospital in Crescent City, Calif.

Sutter says patients across Northern California have plenty of providers to choose from and that it has held its average rate increases to health plans to less than 3 percent annually since 2012. It also says it does not require all facilities to be included in every contract — that insurers have excluded parts of its system from their networks.

As for emergency room patients like Frizzell, Sutter says its charges reflect the cost of maintaining services round-the-clock and that for some patients urgent-care centers are a less costly option.

“The California Attorney General’s lawsuit gets the facts wrong,” Sutter said in a statement. “Our integrated network of high-quality doctors and care centers aims to provide better, more efficient care — and has proven to help lower costs.”

Regulators in other states also have sought to block deals they view as potentially harmful.

In North Carolina, for instance, the state’s attorney general and treasurer both expressed concerns about a proposed merger between the University of North Carolina Health Care system and Charlotte-based Atrium Health. The two dropped their bid in March. The combined system would have had roughly $14 billion in revenue and more than 50 hospitals.

Last year, in Illinois, state and federal officials persuaded a judge to block the merger between Advocate Health Care and NorthShore University HealthSystem. The Federal Trade Commission said the new entity would have had 60 percent market share in Chicago’s northern suburbs. Still, Advocate won approval for a new deal with Wisconsin’s Aurora Health Care last month, creating a system with $11 billion in annual revenue.

Antitrust experts say states can deliver a meaningful counterpunch to health care monopolies, but they warn that these cases aren’t easy to win and it could be too little, too late in some markets.

“How do you unscramble the egg?” said Zack Cooper, an assistant professor of economics and health policy at Yale University. “There aren’t a lot of great solutions.”

A Seven-Year Investigation

California authorities took their time sounding the alarm over Sutter — a fact Sutter is now using against the state in court.

The state attorney general’s office, under the leadership of Democrat Kamala Harris, now a U.S. senator, started investigating Sutter seven years ago with a 2011 subpoena, court documents show. Sutter said the investigation appeared to go dormant in March 2015, just as Harris began ramping up her Senate campaign.

Becerra, a Democrat and former member of Congress, was appointed to replace Harris last year, took over the investigation and sued Sutter on March 29. His aggressive action comes as he prepares for a June 5 primary against three opponents.

Sutter faces a separate class-action suit in San Francisco state court, spearheaded by a health plan covering unionized grocery workers and representing more than 2,000 employer-funded health plans. The plaintiffs are seeking to recoup $700 million for alleged overcharges plus damages of $1.4 billion if Sutter is found liable for antitrust violations. Sutter also has been sued in federal court by five consumers who blame the health system for inflating their insurance premiums and copays. The plaintiffs are seeking class-action status.

San Francisco County Superior Court Judge Curtis E.A. Karnow granted Becerra’s request to consolidate his case with the grocery workers’ suit, which is slated for trial in June 2019.

The judge sanctioned Sutter in November after finding that Sutter was “grossly reckless” in intentionally destroying 192 boxes of evidence that were relevant to antitrust issues. As a result, Karnow said, he will consider issuing jury instructions that are adverse to Sutter.

In a note to employees, Sutter chief executive Sarah Krevans said she deeply regretted the situation but “mistakes do happen.”

In an April 27 court filing, Sutter’s lawyers criticized the state for piggybacking onto the grocery workers’ case. “The government sat on its hands for seven years, exposing the public to the alleged anticompetitive conduct. … Rather than driving the agenda, the Attorney General seeks to ride coattails.”

Outside court, California legislators are taking aim at “all or nothing” contracting terms used by Sutter and other hospital chains. The proposed law stalled last year amid opposition from the hospital industry. But consumer and labor groups are seeking to revive it this year.

In the meantime, Frizzell said he will probably wind up at one of Sutter’s hospitals again despite his disgust over his ER bill. “Most of the hospitals here are Sutter,” he said. “It’s difficult to avoid them.”

KHN senior correspondent Anna Gorman contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

ICYMI: Secretary Azar's Remarks on the Trump Administration's Drug Pricing Blueprint

HHS Gov News - May 15, 2018

Today, Secretary Azar delivered remarks on President Trump's blueprint to bring down the high price of prescription drugs and put American patients first, here are a few excerpts from his speech as prepared for delivery:

"You heard President Trump make it clear on Friday how important tougher negotiation is. That is exactly what our plan brings to Medicare, in an effective and targeted fashion. We are delivering on President Trump's promise to do smart bidding and tough negotiation in Medicare: We are going to bring negotiation to where it doesn't exist, in Part B, and making negotiation more effective than it is today, in Part D."

"You can imagine what happens when you're developing a drug: It's much more appealing for the drug to go into Part B, where the government just pays the bill you send them, than Part D. ... In short order, we will be issuing a request for proposal to make new use of an alternative system for buying Part B drugs, a Competitive Acquisition Program. We believe there are more private sector entities equipped to negotiate these better deals in Part B, and we want to let them do it. More broadly, the President has called for me to merge Medicare Part B into Part D, where negotiation has been so successful."

"For too long, there's been a lot of talk on drug prices, and no action. Drug companies have insisted we can have new cures or affordable prices, but not both. I've been a drug company executive—I know the tired talking points: the idea that if one penny disappears from pharma profit margins, American innovation will grind to a halt. I'm not interested in hearing those talking points anymore, and neither is the President."

To reach the full remarks as prepared for delivery, please visit: https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-drug-pricing-blueprint.html

Lack Of Insurance Exposes Blind Spots In Vision Care

Every day, a school bus drops off as many as 45 children at a community eye clinic on Chicago’s South Side. Many of them are referred to the clinic after failing vision screenings at their public schools.

Clinicians and students from the Illinois College of Optometry give the children comprehensive eye exams, which feature refraction tests to determine a correct prescription for eyeglasses and dilation of their pupils to examine their eyes, including the optic nerve and retina.

No family pays out-of-pocket for the exam. The program bills insurance if the children have coverage, but about a third are uninsured. Operated in partnership with Chicago public schools, the program annually serves up to 7,000 children from birth through high school.

“Many of the kids we’re serving fall through the cracks,” said Dr. Sandra Block, a professor of optometry at the Illinois College of Optometry and medical director of the school-based vision clinics program. Many are low-income Hispanic and African-American children whose parents may not speak English or are immigrants who are not in the country legally.

Falling through the cracks is not an uncommon problem when it comes to vision care. According to a 2016 report from the National Academies of Sciences, Engineering and Medicine, as many as 16 million people in the United States have undiagnosed or uncorrected “refractive” errors that could be fixed with eyeglasses, contact lenses or surgery. And while insurance coverage for eye exams and corrective lenses clearly has improved, significant gaps remain.

The national academies’ report noted that impaired vision affects how people experience their world, including normal communication and social activities, independence and mobility. Not seeing clearly can hamper children’s academic achievement, social development and long-term health.

But when people must choose, vision care may lose out to more pressing medical concerns, said Block, who was on the committee that developed the report.

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“Vision issues are not life-threatening,” she said. “People get through their day knowing they can’t see as well as they’d like.”

Insurance can make regular eye exams, glasses and treatment for medical problems such as cataracts more accessible and affordable. But comprehensive vision coverage is often achieved only through a patchwork of plans.

The Medicare program that provides coverage for millions of Americans age 65 and older doesn’t include routine eye exams, refraction testing or eyeglasses. Some tests are covered if you’re at high risk for a condition such as glaucoma, for example. And if you develop a vision-related medical condition such as cataracts, the program will cover your medical care.

But if you’re just a normal 70-year-old and you want to get your eyes examined, the program won’t cover it, said Dr. David Glasser, an ophthalmologist in Columbia, Md., who is a clinical spokesman for the American Academy of Ophthalmology. If you make an appointment because you’re experiencing troubling symptoms and get measured for eyeglasses while there, you’ll likely be charged anywhere from about $30 to $75, Glasser said.

There are a few exceptions. Medicare will pay for one pair of glasses or contact lenses following cataract surgery, for example. Some Medicare Advantage plans offer vision care.

Many commercial health insurance plans also exclude routine vision care from their coverage. Employers may offer workers a separate vision plan to fill in the gaps.

VSP Vision Care provides vision care plans to 60,000 employers and other clients, said Kate Renwick-Espinosa, the organization’s president. A typical plan provides coverage for a comprehensive eye exam once a year and an allowance toward standard eyeglasses or contact lenses, sometimes with a copayment. Also, individuals seeking plans make up a growing part of their business, she said.

Vision coverage for kids improved under the Affordable Care Act. The law requires most plans sold on the individual and small-group market to offer vision benefits for children younger than 19. That generally means that those plans cover a comprehensive eye exam, including refraction, every year, as well as a pair of glasses or contact lenses.

But since pediatric eye exams aren’t considered preventive care that must be covered without charging people anything out-of-pocket under the ACA, they’re subject to copays and the deductible.

Medicaid programs for low-income people also typically cover vision benefits for children and sometimes for adults as well, said Dr. Christopher Quinn, president of the American Optometric Association, a professional group.

But coverage alone isn’t enough. To bring down the number of people with undiagnosed or uncorrected vision, education is key to helping people understand the importance of eye health in maintaining good vision. Just as important, it can also reduce the impact of chronic conditions such as diabetes, the national academies’ report found.

“All health care providers need to at least ask vision questions when providing primary care,” said Block.

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

Sticker Shock Jolts Oklahoma Patient: $15,076 For Four Tiny Screws

Sherry Young just wanted to be able to walk without pain.

About three years ago, she began to experience sharp pain in her left foot. Her big toe had become crooked and constantly rubbed up against the adjacent toe, making it painful to run, walk or even stand. “I could not walk without intense pain unless I had a pad underneath my toes for cushioning,” Young said.

Sherry Young, a  retired librarian and mother of two in Lawton, Okla., had two back-to-back operations on the same day in June 2017: one on her shoulder and one on her left foot. The bill for her three-day hospital stay was $115,527. (Nick Oxford for KHN)

An orthopedic surgeon told her that he could fix her problem for good. “He thought my foot was hitting the ground too hard and causing pain,” said Young. “That’s what he was trying to correct.”

Though Young had had several orthopedic surgeries, she had always had good insurance and never scrutinized her bills.

At the time of her foot surgery, Young of course knew nothing about hospital charges for surgical screws, medical saws and other hardware used in the operating room.

Then the bill came.

Patient: Sherry Young, 57, a retired librarian on disability and mother of two in Lawton, Okla.

Total Bill: $115,527 for a three-day hospital stay, including $15,076 for four tiny screws — measuring 2.8 millimeters wide and no more than 14 millimeters long — placed in the two middle toes of her left foot.

Service Provider: OU Medical Center, located at the University of Oklahoma Health Science Center in Oklahoma City

Medical Treatment: Young underwent two operations on the same day in June 2017. One surgeon addressed an injury in Young’s shoulder, caused by arthritis and overuse. A second surgeon performed several procedures on her foot, including removing a bone spur. To better align Young’s middle toes, the doctor removed a slice of bone from the center of each toe, and then reconnected the two ends with surgical screws made by Arthrex, a medical device manufacturer based in Naples, Fla.

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What Gives: Two weeks after surgery, Young received a letter from her insurance plan, BlueCross BlueShield of Oklahoma, stating that it had not approved her hospital stay. Staying overnight was not “medically necessary,” according to the letter, because foot and shoulder surgery are typically performed as outpatient procedures.

The letter “put me in a panic,” said Young, who was suddenly worried that she would have to pay the entire $115,000 bill herself. That’s about how much her home is worth, and five times her annual income.

Faced with the astronomical cost, Young asked for an itemized copy of her bill and began checking every charge.

She was floored by the price of the screws, each of which cost more than a high-end computer.

“Unless the metal [was] mined on an asteroid, I do not know why it should cost that amount,” Young said.

An X-ray of Sherry Young’s foot shows the four implanted screws — each of which cost more than a high-end computer. (Courtesy of Sherry Young)

She repeatedly asked officials at OU Medical Center for part numbers for the screws, so she could find out how much they cost the hospital. Hospital officials never provided the information, Young said.

John Schmieding, senior vice president and general counsel for Arthrex, declined to tell Kaiser Health News exactly how much his company charges hospitals for the type of screws implanted in Young’s foot. But he did offer ballpark figures: “Our sale price for screws used in foot and ankle procedures would be below $300 per screw, with the most expensive around $1,000.”

As for what the hospital charges, Schmieding said, “We do not direct or control how a facility bills for their procedure.” Based on the numbers Schmieding provided, the hospital markup on Young’s screws could range from roughly 275 percent to upward of 1,150 percent.

“It’s mind-boggling,” said Dr. James Rickert, an orthopedic surgeon in Bedford, Ind., and president for the Society for Patient Centered Orthopedics, which advocates for affordable health care. “We are talking about little pieces of metal.”

Yet such steep markups are common at hospitals, said Rickert, who was not involved in Young’s care.

Clearly, the screws used in Young’s surgery are more sophisticated than those sold at the local hardware store. Many of the screws in Arthrex’s online catalog are made of titanium, which is popular for surgery because it’s strong and durable. The screws are also hollow, designed to fit over a guidewire so that doctors can place them in precisely the right place.

Sherry Young points to the cost of the four tiny screws that were placed in two of her toes: $15,076. (Nick Oxford for KHN)

Surgical device manufacturers also must comply with strict regulations, said Steve Lichtenthal, vice president of business development at the Orthopaedic Implant Co., based in Reno, Nev., which makes surgical supplies.

But even the fanciest screw is still pretty simple, Lichtenthal said. Tiny screws cost only about $30 to manufacture, and the technology hasn’t changed much in decades, he said. About half the cost of a surgical implant goes toward paying sales and marketing staff, who develop close relationships with doctors and sometimes even attend surgery, Lichtenthal said.

Screws weren’t the only expensive devices figuring into Young’s bill. A drill bit, used for making holes in bone, carried a charge of $4,265; a tool for removing and cauterizing tissue was $5,047; a saw blade, $619.

While screws can be used only once, there’s no reason that other surgical equipment, such as saw blades, should be disposable, Rickert said. Hospitals routinely sterilize tools such as scalpels and scissors, then use them again.

A hospital spokesman declined to comment on the specifics of Young’s bill, as did the surgeon who operated on her foot.

(Story continues below.)

OU Medical Center issued a statement that said: “OU Medical Center provides the highest-quality patient care. We are focused on acquiring the latest tools, treatments and technology, while diligently making sure we have the resources to maintain this commitment our patients deserve. We strive to keep costs down and focus investment on where it really matters — our patients.”

In the statement, OU Medical Center said few patients pay the full price. Instead, insurance companies typically negotiate discounts with hospitals, allowing them to pay less than the amount on the list of charges.
Yet, as Young learned, people who are uninsured — or whose insurance plan refuses to pay — get no discount.

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Resolution: Young is now off the hook. In a statement in response to a reporter’s questions, BlueCross BlueShield of Oklahoma said it never actually denied Young’s insurance claim, but simply needed “additional information from the provider in order to process it correctly.”

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According to Young’s most recent billing statement from OU Medical Center, she does not owe anything for her hospital stay. However, her latest statement from the hospital includes a $413 charge for an “appeal denied.”

Surgery relieved the chronic pain in her shoulder and alleviated some but not all of the pain in her foot, Young said.

The Takeaway: Companies can charge big prices for small surgical supplies and hospitals can mark them up at will.

If you want to know exactly why your bill is so high, ask for an itemized list of charges. Since patients have no ability to shop around for different screws before the surgery, it’s important to complain loudly to the hospital, your insurer and your employer if you see charges that seem outrageous.

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

Jane Greenhalgh produced and edited the interview with Elisabeth Rosenthal for broadcast. Jackie Fortier from StateImpact Oklahoma reported from Lawton, Okla.

L.A. County Unlawfully Terminated Thousands Of Medi-Cal Recipients, Court Rules

Los Angeles County unlawfully dropped an estimated 22,000 people from California’s Medicaid program, including low-income seniors and disabled residents who couldn’t get vital medications and medical care after their coverage was terminated, according to a court ruling late last week.

The May 10 decision, by Superior Court Judge James C. Chalfant, ordered the county’s Department of Public Social Services to fix the problem that resulted in so many people getting cut off — though he did not specify how that should be done.

The department dropped people between December 2016 and December 2017 before processing their renewal applications, even though they had filed on time, according to plaintiffs’ arguments in court papers.

Chalfant also said the county had failed to reinstate beneficiaries who had submitted missing information within a 90-day grace period.

He did not explicitly order the county to reinstate enrollees who were wrongfully dropped from the public health insurance program for people with low incomes, known as Medi-Cal in California.

The renewal applications hit a snag as Medicaid rolls in California swelled following the expansion of the program under the Affordable Care Act. The health law took effect in 2014, and an estimated 3.8 million people newly eligible for Medi-Cal have signed up since then.

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One of the plaintiffs was 50-year-old Thaddeus Moncrief of Lancaster, Calif., who is paraplegic. He said Friday that he couldn’t get his blood pressure medications, catheters or colostomy bags after his Medi-Cal benefits suddenly stopped in 2016. Moncrief said he also was unable to get badly needed repairs made to his wheelchair.

He said he had sent in his renewal documents on time. “When I tried to contact Medi-Cal, they gave me the runaround,” he said. “I was pretty upset. I had been on disability and Medi-Cal for about 20 years. There was never a problem before.”

After seeking legal help, Moncrief’s benefits were reinstated. He said he hoped the ruling “will make a difference for a lot of people.”

Attorneys for the plaintiffs lauded the ruling as a “remarkable protection of patient rights” for L.A. County residents on Medi-Cal.

“Medi-Cal is a lifeline to millions of people in our county,” said David Kane, staff attorney at Neighborhood Legal Services of Los Angeles County, one of the organizations that filed the suit. “When you yank that away from somebody, it jeopardizes their very livelihood.”

Officials at the L.A. County social services department declined to be interviewed but said in a written statement: “It’s important to note that we are strongly committed to serving the public and making improvements in our processes wherever we can.”

Attorneys for the county said in court documents that the thousands of dropped cases represented “a fraction of one percent” of the total renewal packets processed during that time. Though it is “unfortunate” when anyone eligible for benefits is denied, there is no systemic problem, the county’s lawyers argued. The county processes about 120,000 Medi-Cal renewals every month.

The judge did not agree with the plaintiffs’ assertion that the county had systemically failed to send notices and renewal packets to beneficiaries early enough.

The case against L.A. County was originally filed in 2016 on behalf of three beneficiaries and St. John’s Well Child and Family Center, which serves large numbers of Medi-Cal patients. The attorneys who filed the suit asked the judge to order that the county follow the law when processing Medi-Cal applications.

The Medi-Cal program covers more than 13 million Californians, roughly a third of the state’s population. Most Medi-Cal beneficiaries must submit financial and other information annually to have their enrollment renewed.

Carol Northern, a plaintiff who lives in Palmdale, Calif., called the decision a “win in favor of the people out there who can’t fight for themselves.”

Northern, 67, said the county terminated her Medi-Cal benefits in 2016 and she feared she wouldn’t be able to continue getting care for her heart and lung conditions. Northern, who depends on supplemental oxygen and medications, said she was devastated. “I didn’t know how I was going to pay for medical bills if I was not covered,” she said. Her benefits have since been restored.

Jim Mangia, CEO of St. John’s Well Child and Family Center, said many of his patients waited many months for their Medi-Cal benefits to be reinstated. During that time, the health center provided millions of dollars in medical services without reimbursement but was unable to refer many patients for diagnostic tests or to see outside specialists, Mangia said.

“Thousands of patients were getting sicker,” he said. “They did not receive the care that they not only needed but also deserved.”

First, Marijuana. Are Magic Mushrooms Next?

Kaiser Health News:States - May 14, 2018

In Oregon and Denver, where marijuana is legal for recreational use, activists are now pushing toward a psychedelic frontier: “magic mushrooms.”

Groups in both states are sponsoring ballot measures that would eliminate criminal penalties for possession of the mushrooms whose active ingredient, psilocybin, can cause hallucinations, euphoria and changes in perception. They point to research showing that psilocybin might be helpful for people suffering from depression or anxiety.

“We don’t want individuals to lose their freedom over something that’s natural and has health benefits,” said Kevin Matthews, the campaign director of Denver for Psilocybin, the group working to decriminalize magic mushrooms in Colorado’s capital.

The recent failure of a nationally publicized campaign to decriminalize hallucinogenic mushrooms in California may not portend well for the psilocybin advocates in Oregon and Denver — though their initiatives are more limited than California’s.

The proposal in the Golden State would have decriminalized sales and transportation of magic mushrooms, not just possession. The proposed Denver measure would apply only to that city, while in Oregon mushroom use would be allowed only with the approval of a physician and under the supervision of a registered therapist.

None of the proposed initiatives envisions fully legalizing psilocybin mushrooms, which would allow the government to regulate and tax sales in a similar fashion to medical and recreational marijuana.

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In Oregon, advocates face a steep climb to qualify their measure for the ballot, because such statewide initiatives typically require hiring paid signature gatherers, said William Lunch, a political analyst for Oregon Public Broadcasting and a former political science professor at Oregon State University.

Still, familiarity with recreational marijuana may have “softened up” voters and opponents of drug decriminalization, he said. Oregon legalized marijuana for recreational use in 2015, Colorado in 2012.

The Oregon and Denver activists, echoing Lunch, say they hope voters who already accepted pot would now feel comfortable decriminalizing personal use of magic mushrooms as well.

Taking mushrooms can lead to nausea, panic attacks and, rarely, paranoia and psychosis. But they generally are considered safer and less addictive than other illegal street drugs.

Even so, Paul Hutson, professor of pharmacy at the University of Wisconsin who has conducted psilocybin research, says he is wary of the drive for decriminalization. Psilocybin isn’t safe for some people — particularly those with paranoia or psychosis, he said.

“I reject the idea that that this is a natural progression from medical marijuana,” Hutson said, noting that the safety of pot is much better established. Mushrooms, he added, “are very, very potent medicines that are affecting your mind. In the proper setting, they’re safe, but in an uncontrolled fashion, I have grave concerns.”

Kevin Matthews is the campaign director of Denver for Psilocybin, the group working to decriminalize magic mushrooms in Colorado’s capital. (Courtesy of Kevin Matthews)

Even psilocybin advocates share Hutson’s concerns. “It is such a powerful compound. People should take it very seriously when experimenting,” Matthews said.

These efforts to legitimize hallucinogenic mushrooms come at a time of renewed interest in the potential mental health benefits of psychedelics, including mushrooms, LSD and MDMA (known as ecstasy). Two small studies published in 2016 by researchers from Johns Hopkins University and New York University found that a single large dose of psilocybin, combined with psychotherapy, helped relieve depression and anxiety in cancer patients.

A British company backed by Silicon Valley investor Peter Thiel plans clinical studies in eight European countries to test the use of psilocybin for depression. Other research has examined the effectiveness of psilocybin in treating alcohol and tobacco addiction.

In California, the campaign to decriminalize psilocybin was always a long shot — even though the famously liberal state legalized possession of recreational marijuana in November 2016 and sales starting this year.

California ballot measures typically require nearly 366,000 signatures to qualify, and supporters usually have to spend between $1 million and $2 million to pay signature gatherers. A Monterey County couple leading the decriminalization campaign managed to collect more than 90,000 signatures for their proposal with the help of volunteers, but they halted their efforts late last month.

The initiative would have exempted Californians 21 and over from criminal penalties for possessing, selling, transporting or cultivating psilocybin mushrooms.

Possessing them is generally a misdemeanor under California law, but selling them is a felony. State statistics on psilocybin offenses are scarce, but few people are jailed for such crimes, according to an analysis by the California attorney general’s office.

“It’s not a reckless community,” said Kitty Merchant of Marina, Calif., who spearheaded the California psilocybin campaign alongside her husband, Kevin Saunders. “It’s experimentation with your mind and your thoughts. There’s a safeness to it. And there’s an intelligence to it.”

Merchant said she and Saunders, both medical marijuana advocates, spent about $20,000 of their own money on the campaign.

In Denver, Matthews and his pro-psilocybin colleagues want voters to pass a city ordinance eliminating criminal penalties for possessing, using or growing magic mushrooms. City officials have cleared the measure for signature gathering. Supporters need 5,000 signatures to get it on the ballot in November. Matthews said he has already lined up dozens of volunteer signature gatherers.

He said he has used mushrooms to help alleviate depression and other mental health problems. A big part of the decriminalization campaign, he said, is promoting responsible use.

Tom and Sheri Eckert are working to decriminalize hallucinogenic mushrooms in Oregon, but only under the supervision of a therapist. (Courtesy of Tom Eckert)

Denver, a progressive city in a state that was the first to legalize recreational marijuana, “is a good testing place for this initiative nationwide,” Matthews said. Just getting it on the ballot, whether or not it passes, would be “a huge victory,” he added.

In Oregon, activists are proposing a measure for the 2020 ballot that would decriminalize psilocybin statewide for adults 21 and over who get approval from their doctors and agree to participate in a “psilocybin service.” The service would include a preparatory meeting with a therapist, one session of supervised mushroom use and a follow-up visit. Patients would be under the care of state-certified “Psilocybin Service Facilitators.”

Tom Eckert, a Portland, Ore.-based therapist who leads the psilocybin decriminalization campaign with his wife, Sheri, said the proposed limitations on psilocybin use are important.

“Psilocybin is generally safe, but it puts you in a vulnerable state of mind,” he said. “If you do it in the wrong setting, things can go sideways.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Trump Administration Releases Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs

HHS Gov News - May 12, 2018

Today, the Trump Administration released “American Patients First,” the President’s blueprint to lower drug prices and reduce out-of-pocket costs.  Below is the blueprint’s introductory message from HHS Secretary Alex Azar:

The United States is first in the world in biopharmaceutical investment and innovation. Combining our free market system and generous public investment made America home to the first chemotherapy treatments for cancer, the first effective treatments for HIV, the first cure for Hepatitis C, and now, the first therapies that turn our own immune systems against cancer.

But too often, this system has not put American patients first. We have access to the greatest medicines in the world, but access is meaningless without affordability.

When it comes to the cost of prescription drugs, our healthcare system faces four major challenges: high list prices for drugs; seniors and government programs overpaying for drugs due to lack of the latest negotiation tools; out-of-pocket costs for consumers; and foreign governments free-riding off of American investment in innovation.

These problems have often been discussed, but gone unaddressed. Under President Trump, that has now changed. This blueprint is a historic plan for bringing down the high price of drugs and reducing out-of-pocket costs for the American consumer.

The time to act is now: Not only are costs spiraling out of control, but the scientific landscape is changing as well. Securing the next generation of cures for the next generation of American patients will require radical reforms to how our system works. Our blueprint will bring immediate relief to American patients while also delivering long-term reforms.

The men and women of the Department of Health and Human Services (HHS) are looking at every facet of HHS’s programs, authorities, and spending. Working with our partners in the private sector, we will turn this vison into action, and thereby improve the health and well-being of every American.

To view the American Patients First Blueprint visit: https://www.hhs.gov/drugpricing

Trump Vows (Again) To Lower Drug Prices But Skeptics Doubt Much Will Change

President Donald Trump, armed with the expertise of staff seasoned in the ways of the drug industry, unveiled his blueprint to address sky-high drug prices Friday afternoon, promising that increasing industry competition will help Americans save at the pharmacy counter.

“Under this administration, we are putting American patients first,” Trump said  with Secretary of Health and Human Services Alex Azar by his side. Azar, he said, had a mission to “to bring soaring drug prices down to Earth.”

Many of the proposals Trump’s team can accomplish administratively — and some are already in motion — but for others, Trump said, he plans to work with Congress.

The administration’s blueprint proposes 50 actions to reduce what Americans pay for drugs, including giving Medicare more power to negotiate drug prices, Azar said.

Azar said he wants to make drug prices more transparent, as well. For example, he said the Food and Drug Administration should require pharmaceutical companies to disclose drugs’ list prices in their direct-to-consumer television ads.

“It’s material and relevant to know if it’s a $50,000 drug or a $100 drug,” Azar said.

Dr. Jeremy Greene, a professor and health policy expert at Johns Hopkins Medicine, said he was puzzled by how much control the agency would have over requiring drug prices as part of advertising.

“The FDA has had nothing to do with price, especially in advertising,” Greene said. “There have been prominent court cases over whether pharmacies can or cannot advertise based on drug prices.”

Regardless, Trump called the plan “the most sweeping action in history to lower the price of prescription drugs to the American people.”

“We will have tougher negotiations, more competition and much lower prices at the pharmacy counters,” Trump said. “And it will start to take effect very soon.”

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On a separate note, Trump told the audience that “right-to-try is happening,” a nod to congressional efforts to expand access to experimental medications for people with life-threatening conditions.

Trump’s proposals target reducing the out-of-pocket costs for older Americans enrolled in Medicare — but experts say that amounts to more show than substance.

“There’s a difference between reducing the pain people feel associated with out-of-pocket costs at the pharmacy counter and reducing the actual national spend on prescription drugs,” said Allan Coukell, senior director for health programs at the nonpartisan Pew Charitable Trusts.

While 80 percent of Americans say the cost of drugs is unreasonable, 1 in 4 people report having difficulty paying for drugs, according to Kaiser Family Foundation polling. And the government is paying more, too. Medicare’s drug spending grew nearly 90 percent from 2006 to 2015, with an annual average growth rate of 7.6 percent, according to Pew.

During the campaign and his presidency, Trump has used strong language against the pharmaceutical industry, famously saying the manufacturers are “getting away with murder.” Late Thursday, senior administration officials told reporters on a call that the plan will reduce the price pharmaceutical companies set for drugs.

But when asked about whether Medicare will negotiate drugs — as Democrats have called for and the president has talked about — administration officials said that lever would not be pulled.

Instead, Trump’s blueprint calls for measures such as offering free generics to low-income seniors, passing on to consumers more of the negotiated savings that insurers win, and making sure Medicare enrollees don’t spiral into the so-called catastrophic phase of coverage they hit when they pay thousands of dollars a year for drugs.

Leigh Purvis, director of health services research at AARP Public Policy Institute, said the president’s proposals fail to ultimately address that spending. AARP has long called for Medicare to have the ability to negotiate prices.

“Anything that doesn’t address the list price really is just kind of squeezing the balloon in this world,” Purvis said.

For Medicare patients, though, limiting what they pay out-of-pocket could be especially helpful to those taking cancer drugs or other expensive therapies, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine.

Today, patients who pay $5,000 out-of-pocket for prescriptions enter the “catastrophic” category of Medicare coverage, and are charged just 5 percent of their drug costs. But given the astronomical cost of cancer drugs, that can leave patients paying $1,000 a month or more, Dusetzina said.

Medicare patients with the deadly cancer multiple myeloma can spend $14,000 a year out-of-pocket for the drug Revlimid, which costs about $20,000 a month, Dusetzina said.

Trump also accused other developed countries of “freeloading” by enjoying the fruits of American innovation — including drugs developed with taxpayer money or by U.S. companies — without paying a fair price. Because national health systems in other countries have authority to negotiate drug costs — and refuse to cover some drugs entirely — their citizens often pay a fraction of the prices charged in the United States.

“In some cases, medicines that cost a few dollars in foreign countries cost hundreds of dollars for the same pill” in the United States, Trump said. “It’s unfair, it’s ridiculous and it’s not going to happen any longer. It’s time to end the global freeloading once and for all.”

A spokesman for Doctors Without Borders said Trump has it backward. Instead of raising drug prices abroad, costs need to come down everywhere, said Leonardo Palumbo, U.S. advocacy adviser for the group’s access campaign.

“Other countries aren’t ‘free-riding,’ and lifesaving medicines aren’t more expensive here because they cost less elsewhere,” Palumbo said.

Today, Medicare has limited power to negotiate drug prices, partly because many of the most expensive treatments — such as those for cancer patients — are in a protected class that must be covered, Dusetzina said.

To really negotiate better prices, Medicare would need the freedom to reject some drugs completely, Dusetzina added.

But excluding certain expensive drugs from the Medicare program could leave patients in a difficult position, said Chris Hansen, president of the American Cancer Society’s Cancer Action Network. Patients who want an expensive drug would either have to skip it or pay for it themselves, he said.

Azar said Medicare could pressure drug companies to keep prices down in other ways.

“In our drug discount program, if you have a drug in a protected class, it’s almost impossible for drug plans to negotiate and get a discount,” Azar said. “What if we said you only get to be in a protected class if you haven’t raised your price in 18 months?”

Some policy experts, though, said Trump’s proposals are mostly old ideas.

“I don’t think anyone is talking seriously about having Medicare negotiate with drugmakers,” said Tom Bulleit, head of the health care practice at the D.C. office of Ropes & Gray.

Rep. Peter Welch (D-Vt.), who along with Rep. Elijah Cummings (D-Md.) met with Trump at the White House a year ago to propose changes on drug prices, said, “If you listen carefully, you can almost hear the champagne popping in the corporate boardrooms of drug companies across the country.”

David Maris, a pharmaceutical industry analyst for Wells Fargo investors, released a note earlier this month pointing out that the increased social and economic tension on the drug industry is building.

“My guess is this is just the beginning,” Maris said.

Trump’s plan includes tackling the rising costs of drugs in Medicare’s Part B program, which pays for drugs delivered in doctor’s offices or hospital outpatient setting — a challenge previous administrations have failed to tackle.

While the details are still vague, Trump has called for the prices paid for certain drugs under Part B — these could include expensive drugs for cancer chemotherapy and rheumatoid arthritis — to be negotiated using the same tactics insurers and pharmacy benefit managers use under Medicare Part D, which is the program that seniors use for their retail prescription drugs.

Azar said the administration plans to release a request for information to gather input on changes to the program.

The Pharmaceutical Research and Manufacturers of America released a statement Friday saying it was looking forward to working with the administration and warning: “While some of these proposals could help make medicines more affordable for patients, others would disrupt coverage and limit patients’ access to innovative treatments.”

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

Best Reads Of The Week With Brianna Labuskes

The Friday Breeze

Newsletter editor Brianna Labuskes, who reads everything on health care to compile our daily Morning Briefing, offers the best and most provocative stories for the weekend.

So maybe “yesterday was not a good day” for you (as Novartis said after its $1.2 million contract with Michael Cohen made news) but today is Friday! And that means just a couple of hours left until the weekend.

To help you get through that last little bit, here’s a cheat sheet of stories you might have missed this week in health care.

President Donald Trump spoke from the White House about plans to curb drug prices, but pharma wasn’t exactly quaking at the proposed changes. Pharmacy benefit managers (cast by some health care players as the villains-du-jour for high costs), on the other hand, might want to be.

Foreign governments’ “freeloading” is also expected to be a target (though experts say raising costs in Europe isn’t going to affect Americans’ pharmacy bills), while Trump is backing off the idea of letting Medicare negotiate drug prices.

Reuters: Trump Plan for Drug Prices Seen Largely Sparing Industry

The New York Times: Trump to Drop Call for Medicare to Negotiate Lower Drug Prices

Enthusiasm for Medicaid work requirements is running headlong into concerns over Native Americans’ rights over at HHS. Top officials at the agency and Hill Republicans (who are excited — to say the least — about the work mandate for the general public) want to exempt Native Americans from the restrictions. But their hands are tied by the HHS Office of General Counsel, which has ruled that it would be an illegal racial preference. So, no one’s happy, the optics are bad, and a massive legal fight might be about to land at the government’s door.

Politico: Trump Challenge to Native Americans’ Health Splits HHS, Alarms Hill GOP

Officials are drawing a line at lifetime limits, at least for now. And in the states: Budget cuts just got very real for potentially thousands of Louisiana nursing home residents, and California pushes to expand Medicaid benefits to undocumented immigrants.

The Hill: Trump Officials Reject Medicaid Lifetime Limits in Kansas

CNN: Tens of Thousands of Louisiana Residents Could Face Eviction

Sacramento Bee: CA Lawmakers Push Health Care for Undocumented Immigrants

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As the first glimpse of eye-popping premium hikes for next year trickle in, Democrats are being vocal about their plans to point fingers. “We Democrats are going to be relentless in making sure the American people exactly understand who is to blame for the rates,” Senate Minority Leader Chuck Schumer (D-N.Y.) said.

Bloomberg: Obamacare Premiums to Surge Next Year, Early Requests Show

The Hill: Schumer: Dems Will Be ‘Relentless’ in Attacking GOP for Premium Hikes

And Trump might be boasting that he all but got rid of the health law, but the Internal Revenue Service is sending a different message. In fact, the agency is policing the employer mandate more aggressively than it did even under the Obama administration. Businesses are less than pleased, but there’s no political capital lying around right now (see: above) to get lawmakers to attempt any more tweaks to the legislation.

The New York Times: Trump Says He Got Rid of Obamacare. The I.R.S. Doesn’t Agree.

In the miscellaneous file for the week: VA’s leadership vacuum at the top is just the tip of the iceberg for the agency’s dire staffing situation (“I’ve never known the enthusiastic mass exodus of an organization’s most knowledgeable and experienced personnel to be an indication that all is well,” said one official); those outrageous pharma price tags are bad enough for people with insurance, but what happens when those in the Amish community need an $850,000 drug?; to the shock of no one, most of the drug distributors hauled in front of Congress this week skirted any responsibility for the opioid crisis (with the money quote coming from Rep. David McKinley (R-W.Va.): “I just want you to feel shame”); and states desperate for an alternative to lethal injection are eyeing nitrogen, hearkening back to the days of gas chambers.

The New York Times: V.A. Medical System Staggers As Chaos Engulfs Its Leadership

Stat: With No Insurance, Amish Want Discount on Spark’s Pricey Gene Therapy

Stat: Congressman To Drug Distributors: ‘I Just Want You To Feel Shame’

The New York Times: States Turn To An Unproven Method Of Execution: Nitrogen Gas

Have a great weekend! And if your allergies are bad (as I have heard is the case this week), maybe double-check to make sure you aren’t actually leaking brain fluid.

Consumers Brace For Premium Hikes While Lawmakers Grasp At Remedies

As some insurers angle for hefty premium hikes and concerns grow that more Americans will wind up uninsured, the federal health law is likely — once again — to play big in both parties’ strategies for the contentious 2018 election.

Candidates are already honing talking points: Is the current dysfunction the result of the law or of GOP attempts to dismantle it?

The impact of changes to the law made by Republicans over the past year — modifications short of the “repeal and replace” they promised — is becoming clear. Initial announcements show health insurers in several states are seeking big increases in premiums for next year for people who buy their own insurance. That is renewing concerns about the potential for “bare” counties that will have no insurer selling coverage and hints that the number of uninsured Americans could again be on the rise.

“It’s sort of Insurance 101,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. Insurers “are facing a smaller and sicker risk pool as a result of both Trump administration and congressional action, and that means higher premiums,” she said.

“A number of policy changes definitely impacted rates,” said Jeanette Thornton, a senior vice president for the trade group America’s Health Insurance Plans.

Among those changes are the elimination of the tax penalty for those who forgo insurance, included in December’s tax overhaul, and President Donald Trump’s cancellation of federal payments to insurers who provide discounts to some low-income customers.

Democrats say they will make sure voters know that Republicans deserve the blame.

“Senate Democrats will be on the floor of the U.S. Senate every week talking to the American public about these rate increases and make sure they know about this campaign of sabotage,” said Sen. Chris Murphy (D-Conn.).

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Republicans, however, say Democrats are at fault for blocking bipartisan legislation, which might not even have had enough GOP votes to pass. The effort sought to stabilize the Affordable Care Act’s marketplace through measures such as setting up reinsurance funding to help keep an individual insurer from facing devastating losses and guarantees for insurers to help pay their share of the out-of-pocket expenses for low-income customers.

“Democrats could have worked with us to lower premiums by as much as 40 percent but instead choose to cling to an unworkable law,” Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor and Pensions Committee, said on the Senate floor Tuesday. “So if you have an insurance premium that is going up 40 percent next year, on top of an over 105 percent increase since 2013, you can thank a Democrat.”

The heightened political rhetoric comes after the first two states unveiled insurance company premium requests for policies on the individual market for 2019.

These are not final rates, but they give an idea of what premiums for next year might be for people who don’t get insurance through their job or the government and buy their own coverage on the individual market.

That market included about 15.6 million people, both inside and outside the ACA insurance marketplaces, in the final quarter of 2017, according to the consulting firm Mark Farrah Associates.

State deadlines for filing next year’s rates run from May through July. Once insurers have made their initial premium requests, state regulators negotiate final rates before open enrollment begins in the fall.

In Virginia and Maryland, insurers are seeking a wide range of significant increases, from about 15 percent for some plans up to more than 91 percent for one Maryland PPO.

Analysts are not surprised by the requested rate hikes and predict more to come. The first requests in past years have often moderated before being finalized, but this year’s political uncertainties could play a bigger role.

The Congressional Budget Office estimated that the elimination of the tax penalty for people without health insurance, which was included in last December’s tax law, by itself would result in premium increases of around 10 percent per year. That’s because without the prospect of a fine, healthier people would be more likely to forgo coverage, making the pool of people who continue to buy insurance sicker and more expensive for insurers.

Separately, Trump roiled the individual insurance market by canceling federal “cost-sharing reduction” payments for moderate-income insurance buyers.

The administration is also trying to extend the availability of short-term insurance plans, which frequently offer only bare-bones coverage, and “association health plans,” which can provide cheaper alternatives for those who are considered healthy. But such plans don’t include all the benefits of ACA plans. Analysts say both types of options would draw even more healthy people out of ACA plans..

The insurance industry acknowledges the actions have boosted next year’s rates.

Chet Burrell, the CEO of CareFirst Blue Cross Blue Shield, which serves both Maryland and Virginia markets, told The Washington Post that “continuing actions on the part of the administration to systematically undermine the market … make it almost impossible to carry out the mission.”

AHIP’s Thornton cautioned that it is still early in the process and many things could change. Maryland, for example, has passed legislation to create a “reinsurance” pool that could substantially lower premiums for next year. It still requires formal permission from the Trump administration, however.

And while Congress could still help ameliorate next year’s increases, that appears increasingly unlikely.

In a sign that the bipartisanship that characterized the effort last fall has broken down, Alexander said in his Senate speech that he plans to move on to other health issues, including ways to address the opioid crisis.

“Given Democrats’ attitude, I know of nothing the Republicans and Democrats can agree on to stabilize the individual health insurance market,” he said.

Sen. Susan Collins (R-Maine), who was promised a vote on her bipartisan bill by Senate Majority Leader Mitch McConnell (R-Ky.) that never materialized, now blames Democrats.

In a column she wrote for her home-state Portland Press-Herald late last month, Collins said Democrats refused to accept additional restrictions on abortion funding.

“Although federal funding has not been used to pay for elective abortions for decades, some Democrats reopened the long-settled debate on the Hyde Amendment in order to block these much-needed insurance reforms,” she wrote.

Democrats, however, say it was Republicans who reopened the abortion debate by demanding language to create new, permanent restrictions that could eliminate abortion even in private insurance plans.

Even so, some say they still hope consensus may be reached.

“Patients and families deserve better than the higher costs and dysfunction they are getting under Trumpcare by sabotage,” Sen. Patty Murray (D-Wash.) told reporters Tuesday. “And as soon as Republicans are ready to work again in a bipartisan way and act actually to lower families’ costs, Democrats will be at the table.”

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