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Wisconsin Reinstates Coverage Of Transgender Treatment For State Workers

Kaiser Health News:Insurance - August 29, 2018

In a surprising reversal, a Wisconsin board has voted to again offer insurance coverage to transgender state employees seeking hormone therapy and gender confirmation surgery.

Members of the Group Insurance Board, which manages the insurance program for Wisconsin’s public workers and retirees, last week voted 5-4 to overturn its current policy barring treatments and procedures “related to gender reassignment or sexual transformation.”

The change will take effect Jan. 1, allowing insurance to defray the cost of care deemed medically necessary.

“This was an empowering moment, offering up hope things can get better,” Wren Logan, a trans woman and psychiatry resident at UW Health who fought the policy, wrote in an email to Kaiser Health News.

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The board’s decision comes less than a month after Kaiser Health News, in partnership with NPR, published a project as part of its Bill of the Month series about a 24-year-old trans woman, Wren Vetens, who fought to get her gender confirmation surgery covered after the Group Insurance Board’s initial decision left her without insurance coverage.

It has been two years since the board first opted to pay for such expenses. That decision came shortly after the Obama administration unveiled a rule in May 2016 prohibiting discrimination based on gender identity, and the board was advised that refusing to cover certain treatments for trans patients could run afoul of that rule. Members voted unanimously in July 2016 for the change.

State officials soon began pressuring the board to not cover these services, despite the Obama administration’s directive.  About the same time, Wisconsin’s justice department joined a lawsuit challenging the anti-discrimination rule.

The board voted to reinstate the restrictive policy should a handful of conditions be met — one of which was a court decision to halt the rule. By coincidence, that ruling came the following day. A month later, in February 2017, the restrictions took effect once more, again barring trans patients from obtaining coverage.

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In a recent memo to the board, a state health policy adviser noted the “legal landscape” had changed, broadening protections for the transgender community. Last month, a federal judge ordered Wisconsin to pay for gender confirmation surgery for two individuals on Medicaid, who sought coverage to treat their gender dysphoria.

Gender dysphoria is the diagnosis for those with “significant distress” due to the difference between their gender and sex, according to the American Psychiatric Association.

In another case, two transgender women employed by the University of Wisconsin and covered by the state insurance program have sued the Group Insurance Board and the university’s board of regents, among others, accusing them of discrimination based on their inability to get coverage for gender confirmation surgery. The case is scheduled to go to trial in October, before the same judge who ruled in favor of the patients on Medicaid.

Officials from the University of Wisconsin — as well as UnitedHealthcare, which is opening a Medicare Advantage program for Wisconsin’s public employees and retirees — have also raised concerns about the policy.

The decision comes amid speculation that the Trump administration will soon unveil a new rule formally overturning the Obama-era anti-discrimination rule.

Earwax, Of All Things, Poses Unrecognized Risk In Long-Term Care

Kaiser Health News:Marketplace - August 29, 2018

Of all the indignities that come with aging, excessive earwax may be the most insidious.

Don’t laugh.

That greasy, often gross, buildup occurs more often in older ears than those of the young, experts say. And when it goes unrecognized, it can pose serious problems, especially for the 2.2 million people who live in U.S. nursing homes and assisted living centers.

“The excessive amount [of earwax] can cause hearing loss or ringing in your ears. Some people experience vertigo, which increases the risk of falling,” said Jackie Clark, a board-certified audiologist who is president of the American Academy of Audiology. “Right now, we see some correlation between hearing loss and cognitive decline.”

Earwax — which is not really wax at all, but a substance called cerumen that binds with dirt, dust and debris — is normally produced by the body as a way to clean and protect the ears. In most people, the self-cleaning process works fine.

But in others — including about 10 percent of young children, 20 percent of adults and more than 30 percent of elderly and developmentally disabled people — the wax collects to the point where it can completely block the ear canal.

Up to two-thirds of people in nursing homes may suffer from that condition, known as impaction, according to 2017 guidelines for removal of impacted earwax issued by the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

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In 2016, federal Medicare recipients logged nearly 1.7 million earwax removal services at a cost of more than $51 million, according to payment records analyzed by Kaiser Health News.

“In elderly patients, it’s fairly common,” said Dr. Seth Schwartz, a Seattle otolaryngologist who led the most recent update of the guidelines. “It seems like such a basic thing, but it’s one of the most common reasons people present for hearing-related problems.”

It’s so bad that Janie York, of Omaha, Neb., started Hear Now mobile hearing solutions, one of a growing number of businesses devoted to cleaning hearing aids and checking the ears of elderly people living in residential care settings.

“It’s epidemic,” said York, whose clients now include 10 local centers. “About 3 in 5 people I see have some degree of impaction and most are completely impacted.”

York runs Hear Now mobile hearing solutions, a business aimed at cleaning hearing aids and checking the ears of older people living in residential care settings.(Chris Machian for KHN)

York cleans Martin's hearing aid. (Chris Machian for KHN)

Julie Brown, assistant director of nursing in the memory support unit at SilverRidge Assisted Living in Gretna, Neb., said impacted earwax can be a particular problem for patients with dementia. It exacerbates hearing loss, which can impede communication and worsen aggression and other difficult behaviors.

“As soon as the earwax is cleared up, even their behavior has calmed down,” Brown said.

Excessive earwax sends about 12 million people to see health workers every year, including about eight million who require wax removal, according to the otolaryngology association.

That’s not counting the people who try DIY treatments to get rid of earwax, nearly all of which are frowned on by the professionals.

“People put everything in their ears: Q-tips, bobby pins, pencils, fingernails,” Schwartz said.

Usually, the best way to control earwax is to leave it alone, Schwartz said. But that advice can backfire when families or caregivers neglect to check the ears of elderly people in residential care.

In about 10 percent of young children, 20 percent of adults and more than 30 percent of elderly and developmentally disabled people, earwax collects to the point where it can completely block the ear canal.(Chris Machian for KHN)

Hearing-aid users should have regular ear checks every three to six months, the guidelines suggest. People with dementia should also have earwax removed regularly.

It can take a professional with an otoscope — a device that can look deep inside the ear — to tell if cerumen is blocking the ear canal. Usually, earwax can be safely removed by softening it with water, saline or commercial ear drops and then through gentle syringing or manual extraction with a device called a curette.

The effects in the elderly can be immediate. A small 2014 study by Japanese researchers found significant improvements in hearing and cognitive performance in elderly patients with memory disorders when impacted cerumen was removed.

Too often, though, earwax in the elderly goes unnoticed.

“I’m seeing 15 people here, but what about the other hundred?” York said. “Nobody’s looking. I don’t know why it’s been neglected for so long.”

KHN’s coverage of these topics is supported by Gordon and Betty Moore Foundation and John A. Hartford Foundation

Shifting Gears: Insuring Your Health Column — Born With The ACA — Draws To A Close

Until I started writing the Insuring Your Health column eight years ago, I had no idea what a medical loss ratio was, and I’d surely never used the words “benchmark silver plan” in a story. If asked, I would have guessed that “ACA” stood for the American Canoe Association (which is actually a thing, by the way).

Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Now it’s time to shift gears. This is the last Insuring Your Health column. But it isn’t the last time you’ll hear from me at Kaiser Health News. I’ll continue writing regularly about consumer health care for KHN, just not every Tuesday. With the added flexibility I want to be able to now and then take a broader look at some of the consumer health areas I’ve been writing about over the years. I hope you will keep reading and giving me feedback.

I couldn’t do this work without a lot of help. Thanks to the many, many smart and thoughtful pros who’ve carved out time to talk with me again and again to help me understand the devil-in-the-details of medicine, health law and policy. I expect I’ll be calling on some of you this week to chat.

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Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

Most of all, I’d like to thank the many people who’ve shared their stories with me over the years and allowed me to write about them. People like Kristen Catton, who faced thousands of dollars in bills when her health plan changed how it covered her multiple sclerosis drug. Or Phyllis Petruzzelli, who avoided a hospital stay for pneumonia by being “admitted” to her living room through a hospital-at-home program. Those experiences explain health policy in personal terms for readers, and I’m so grateful to the many people who’ve trusted me to tell their stories.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at I look forward to hearing your thoughts and ideas.

A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack

Kaiser Health News:Insurance - August 27, 2018

Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.

Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.

“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.

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The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.

The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.

Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

And then the bills came.

Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.

Total Bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver’s insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.

Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.

Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.

What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.

The hospital’s billing company sent a notice June 26, urging him to take advantage of this “FINAL opportunity to settle your balance.

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“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”

In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

The total bill for Drew Calver’s four-day hospital stay at St. David’s Medical Center in April 2017 was $164,941.(Callie Richmond for KHN)

His insurer paid $55,840, leaving Calver responsible for the unpaid balance of $108,951.31.(Callie Richmond for KHN)

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s a huge loophole: Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds.  Federal law governs those health plans — and it does not include such protections.

About 60 percent of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.

Drew Calver sits with his wife, Erin, and daughters Eleanor (left) and Emory (middle) in their Austin, Texas, home where he had a heart attack on April 2, 2017.(Callie Richmond for KHN)

This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”

In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.

Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.

This case also raises questions about the validity of the hospital’s charges.

Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.

WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.

Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.

Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.

St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.

The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.

“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.

St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.

Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.

In fact, the hospital’s debt collector sent the Calvers a letter Aug. 3 demanding payment in full.

After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”

Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.

A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.

Calver said the whole ordeal has been incredibly stressful for him and his wife.

“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”

Drew Calver’s daughters visit him at the hospital in April 2017 after his heart attack and resulting emergency surgery.(Courtesy of the Calver family)

The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.

Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.

If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

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

The Doctors Want In: Democratic Docs Talk Health Care On The Campaign Trail

Dr. Rob Davidson, an emergency physician from western Michigan, had never considered running for Congress. Then came February 2017. The 46-year-old Democrat found himself at a local town-hall meeting going toe-to-toe with Rep. Bill Huizenga, his Republican congressman of the previous six years.

“I told him about my patients,” Davidson recalled. “I see, every shift, some impact of not having adequate health care, not having dental insurance or a doctor at all.”

His comments triggered cheers from the audience but didn’t seem to register with Huizenga, a vocal Obamacare critic. And that got Davidson thinking.

Dr. Rob Davidson (Courtesy of Rob Davidson’s campaign)

“I’ve always been very upset … about patients who can’t get health care,” he said. But it never inspired him to act. Until this June, that is, when the political novice joined what is now at least eight other Democratic physicians running in races across the country as first-time candidates for Congress.

Democrats hope to gain control of Congress by harnessing what polls show to be voters’ dissatisfaction with both Capitol Hill and President Donald Trump. The president maintains Republican support but registers low approval ratings among Americans overall, according to news organization FiveThirtyEight. Democrats also see promise in candidates such as Davidson, a left-leaning physician who may have a special advantage: firsthand health system experience.

Polls by Quinnipiac University, The Wall Street Journal and the Kaiser Family Foundation suggest health care is among voters’ top concerns as midterm elections approach. (Kaiser Health News is an editorially independent project of the foundation.)

Of the Democratic doctors running for office, all but one are seeking House seats. In addition to the nine newcomers, there are two incumbents up for re-election. Each candidate is campaigning hard on the need to reform the health care system.

And they present a stark contrast to Congress’ current physician makeup.

Twelve of the 14 doctors now in Congress are Republicans. Three are senators. Half of the 14 practice in high-paying specialties such as orthopedic surgery, urology and anesthesiology.

By contrast, these stumping Democratic physicians hail predominantly from specialties such as emergency medicine, pediatrics and internal medicine, though one is a radiologist. They’re fighting to represent a mix of rural, urban and suburban districts.

(Story continues below.)


“Electing Democratic doctors would certainly change the face of medicine in Congress, and perhaps lend more credence in that body to more liberal health care policies,” said Dr. Matthew Goldenberg, a psychiatrist at Yale School of Medicine who has researched political behavior and advocacy among doctors.

Physicians once trended Republican. The infusion of female and minority doctors, experts said, has changed this. Now, more than 50 percent of party-affiliated doctors are Democrats, and the medical establishment has — following Republican efforts to undo Obamacare — emerged as a staunch defender of the law.

Indeed, many doctor-candidates point to the GOP’s repeal-and-replace efforts as their motivation.

“It’s at a boiling point for many of these physicians,” said Jim Duffett, executive director of the left-leaning Doctors for America, which supports universal health care.

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While health care consistently emerges as a top issue, Democrats are more likely to rank it No. 1. For independents and Republicans, though, it’s neck and neck with the economy — and some political analysts question how effective it will be in flipping conservative districts.

“Democrat voters blame Republicans for the problems with health care right now. Republicans blame Democrats. Independents say, ‘A pox on both your houses,’” argued Jim McLaughlin, a Republican pollster working on several 2018 races who has previously worked with Trump. “They’re making a big mistake thinking they can run on [health care].”

That said, doctors can be effective messengers, especially in their communities.

Research suggests Americans hold their own physicians in high regard.

“Voters listen carefully to what physicians have to say about health policy,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina. “In a district that’s not so one-sided red or blue, there’s no question that the white coat confers prestige. It’s something physician candidates can speak to with authority.”

Dr. Kyle Horton (Courtesy of Kyle Horton’s campaign)

Davidson, for instance, supports a “Medicare-for-all”-style overhaul, an approach that involves expanding the federal insurance program for seniors and disabled people to all Americans. If elected, he said, he intends to join Democrats’ burgeoning support for a single-payer system, in which the government runs the sole health insurance program, guaranteeing universal coverage. He did not have a primary challenge and is running against Huizenga, the Republican incumbent, in the general election for Michigan’s 2nd Congressional District.

Or there’s Dr. Kyle Horton, an internist running in the North Carolina 7th District. She supports expanding Medicare, by lowering the eligibility age from 65 to 50. She also supports a “public option” health insurance plan sold by the government.

Dr. Hiral Tipirneni (Courtesy of Hiral Tipirneni’s campaign)

Dr. Hiral Tipirneni, an emergency physician in Arizona’s 8th Congressional District, asserts all Americans should be able to buy in to Medicare.

Physicians can have an advantage on other controversial topics, by casting them as public health issues, said Howard Rosenthal, a political scientist at New York University.

Davidson’s campaign, for instance, posts videos on Facebook in which he talks about topics such as health care access and gun violence. One — filmed after an overnight ER shift — has gotten 41,000 views so far.

Also spurring physicians: concerns about abortion access.

Dr. Cathleen London (Courtesy of Kathleen London’s campaign)

Dr. Cathleen London, a Maine doctor, launched her campaign against four-term incumbent GOP Sen. Susan Collins for the 2020 election. She said she had been considering a run, but the upcoming vote for a justice to replace Anthony Kennedy on the Supreme Court — which could have sweeping implications for reproductive health law — pushed her to declare.

“Doctors are really frustrated with Washington, frustrated with the lack of listening to us,” London said.

Many of these Democrats face steep climbs.

Dr. Kim Schrier (Courtesy of Kim Schrier’s campaign)

Of races featuring newcomer physicians, the Cook Political Report, which analyzes elections, rates only Arizona’s 2nd Congressional District as leaning Democratic, and the doctor in that race is just one of seven candidates in the primary. The outcome for Washington’s 8th District, where Dr. Kim Schrier, a pediatrician, is a candidate, is considered a toss-up and a Democratic pickup target.

Tipirneni is the only non-incumbent doctor to have a fundraising advantage so far, according to data from Open Secrets, a nonpartisan, nonprofit project tracking campaign-finance records.

Regardless of electoral results, many observers say the potential implications are sizable — even if few doctors go to Washington.

“They are planting a flag, and they’re going to be raising some important issues — not just health care, but health care is going to be front and center,” said Duffett, from Doctors for America. “That will help change the political debate and political landscape.”

Pediatricians Put It Bluntly: Motherhood And Marijuana Don’t Mix

Kaiser Health News:States - August 27, 2018

More and more people consider smoking marijuana harmless or even beneficial, but mounting research suggests women who are pregnant or breastfeeding should avoid it altogether.

That’s according to new recommendations from the American Academy of Pediatrics, which cites growing evidence of marijuana’s potential harm to children’s long-term development.

The strong direction to women and pediatricians comes as more than half of states, including California, have legalized marijuana for medical or recreational use, and studies show that a growing number of babies are being exposed to the drug.

The march toward marijuana legalization has outpaced scientific research about its effects. Because marijuana is a Schedule 1 drug — by definition, one with potential for abuse and no approved medical use — federal law has limited research on it. But in a detailed review of the existing safety data published Monday in the journal Pediatrics, researchers concluded that enough concerns exist about both short-term growth and long-term neurological consequences for children to recommend against it.

“Women should definitely be counseled that it’s not a good idea to use marijuana while pregnant. If you’re breastfeeding, we would encourage you to cut back or quit,” said Seth Ammerman, a co-author of the report and professor of pediatrics at Stanford.

If a breastfeeding mother does not stop using, however, “the benefits of breastfeeding would outweigh the potential exposure to the infant,” he added.

A second study, also published in Pediatrics, found that THC, the molecule that gives marijuana most of its psychoactive effects, accumulates in breast milk, even up to six days after the mother’s last use.

The findings come as marijuana use among pregnant women is rising. From 2002 to 2014, self-reported use of marijuana in the past month increased by 62 percent to 3.85 percent. Since then, a growing number of states have legalized marijuana for recreational use, so this is likely an underestimate of current rates. In studies of urban, young and socioeconomically disadvantaged pregnant women, 15 to 28 percent of women reported using the drug.

California legalized use of recreational marijuana among adults 21 and older beginning in January.

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Unlike for alcohol and cigarettes, even legally sold marijuana may not carry a safety warning for pregnant women, depending on the state. California and Colorado do require safety warnings.

“There’s a myth out there that it’s benign. And for many adults who are sporadic users, that’s probably true. But in these circumstances it may be harmful,” said Ammerman.

Of particular concern, he added, is that the potency of THC in marijuana has more than quadrupled since 1983. Several of the largest studies were conducted when potency was much lower, according to the report.

Research has found that THC can easily cross the placenta and accumulate in the brain and fat of the growing fetus. Studies, while limited, suggest that prenatal exposure to marijuana could cause harm to children’s executive functioning, including concentration, attention, impulse control and problem-solving.

Nonetheless, mothers groups online are filled with women touting the benefits of marijuana during pregnancy, citing the drug as a remedy for the nausea of morning sickness.

“A lot of women may be getting the info from online media and from marijuana dispensaries. As health professionals, we need to educate women that there are a lot of concerns both for the fetus and for later development,” said Kelly Young-Wolff, a research scientist at the Kaiser Permanente Northern California Division of Research, who was not involved in the Pediatrics studies. (Kaiser Health News is not affiliated with Kaiser Permanente.)

A recent study in the journal Obstetrics and Gynecology, for example, found that 70 percent of cannabis dispensaries in Colorado recommended marijuana to treat morning sickness during the first trimester. No evidence suggests that marijuana use is safe or indicated for morning sickness, said Young-Wolff, though there are plenty of other options that a health professional can recommend. And the worst nausea happens in the first trimester, when the developing fetus might be the most vulnerable to substances like marijuana.

But convincing women of the dangers of cannabis use during pregnancy can be challenging. “A lot of the public equates legalization with some kind of endorsement of safety. Of course, that’s not true,” said Dana Gossett, a professor of obstetrics and gynecology at the University of California-San Francisco.

When she counsels patients to avoid marijuana, Gossett said, she runs into a “fair amount of indifference.”

Pregnancy is often a time when women are receptive to changing their habits to protect their growing baby. But while they generally accept that smoking cigarettes is bad — that’s been clear since the 1960s — they often view marijuana as safe and natural, and therefore harmless.

“Just because something is plant-based or natural doesn’t make it safe.” Arsenic, added Gossett, is also a natural substance.

So far, the news of the dangers of marijuana during pregnancy and breastfeeding does not appear to be reaching its target audience.

On Facebook, the group “Stoner Moms” has more than 22,000 followers. And the Glow Nurture pregnancy app has several community groups devoted to users, including “420 Friendly,” “Ganja Mommies,” “CannaMoms” and “Stoners.”

The chats are filled with women asking not whether marijuana could be harmful, but rather whether smoking marijuana could put them at risk of involvement from Child Protective Services.

“I live in Georgia. … I’m only 5 weeks but I plan to keep smoking since there’s no evidence of it being harmful. Has anyone given birth here without being tested?” asked one user on the “Moms for Marijuana” group on the popular BabyCenter app.

A user in Wisconsin wrote: “Did you have any issues with being tested at delivery or having CPS getting involved while on Medicaid? Thanks in advance!!”

“I wonder if moms that smoke cigarettes have to go through the same worries that moms that smoke weed do?” asked a third poster in North Carolina. “I stopped smoking at 24 weeks and it just sucks that we have to live in fear of our babies being taken away! Even though there’s no evidence of weed being harmful!”

Screening rules vary by hospital, but 24 states and the District of Columbia require health care professionals to report suspected prenatal drug use, according to the Guttmacher Institute. In many states, drug use can be used as evidence of child neglect or abuse in a civil case.

According to Young-Wolff, although pregnant and breastfeeding women should certainly be educated about the risks of marijuana, “none of this research should be used to penalize or stigmatize women.”

Correction: An earlier version of this story incorrectly reported that no states require safety warnings for pregnant women on legally sold marijuana. At least six states do require labeling.

KHN’s coverage of these topics is supported by Heising-Simons Foundation, The David and Lucile Packard Foundation and Blue Shield of California Foundation

McCain’s Complicated Health Care Legacy: He Hated the ACA. He Also Saved It.

There are many lawmakers who made their names in health care, seeking to usher through historic changes to a broken system.

John McCain was not one of them.

And yet, the six-term senator from Arizona and decorated military veteran leaves behind his own health care legacy, seemingly driven less by his interest in health care policy than his disdain for bullies trampling the “little guy.”

He was not always successful. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990, most of the health initiatives he undertook failed after running afoul of traditional Republican priorities. His prescriptions often involved more government regulation and increased taxes.

In 2008, as the Republican nominee for president, he ran on a health care platform that dumbfounded many in his party who worried it would raise taxes on top of overhauling the U.S. tradition of workplace insurance.

Many will remember McCain as the incidental savior of the Affordable Care Act, whose late-night thumbs-down vote halted his party’s most promising effort to overturn a major Democratic achievement — the signature achievement, in fact, of the Democrat who beat him to become president. It was a vote that earned him regular — and biting — admonishments from President Donald Trump.

McCain died Saturday, following a battle with brain cancer. He was 81. Coincidentally, his Senate colleague and good friend Ted Kennedy died on the same date, Aug. 25, nine years ago, succumbing to the same type of rare brain tumor.

Whether indulging in conspiracy theories or wishful thinking, some have attributed McCain’s vote on the ACA in July 2017 to a change of heart shortly after his terminal cancer diagnosis.

But McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs.

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His prey were the sort of boogeymen that made for compelling campaign ads in a career stacked with campaigns. But McCain was “always for the little guy,” said Douglas Holtz-Eakin, the chief domestic policy adviser on McCain’s 2008 presidential campaign.

“John’s idea of empathy is saying to you, ‘I’ll punch the bully for you,’” he said in an interview before McCain’s death.

McCain’s distaste for President Barack Obama’s health care law was no secret. While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace the law with something better.

After Republicans spent months bickering amongst themselves about what was better, McCain was disappointed in the option presented to senators hours before their vote: hobble the ACA and trust that a handful of lawmakers would be able to craft an alternative behind closed doors, despite failing to accomplish that very thing after years of trying.

What bothered McCain more, though, was his party’s strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory.

In his 2018 memoirs, “The Restless Wave,” McCain said even Obama called to express gratitude for McCain’s vote against the Republican repeal bill.

“I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” McCain wrote. “That had not been my goal.”

Better known for his work on campaign finance reform and the military, McCain did have a hand in one landmark health bill — the Americans with Disabilities Act of 1990, the country’s first comprehensive civil rights law that addressed the needs of those with disabilities. An early co-sponsor of the legislation, he championed the rights of the disabled, speaking of the service members and civilians he met in his travels who had become disabled during military conflict.

McCain himself had limited use of his arms due to injuries inflicted while he was a prisoner of war in Vietnam, though he was quicker to talk about the troubles of others than his own when advocating policy.

Yet two of his biggest bills on health care ended in defeat.

In 1998, McCain introduced a sweeping bill that would regulate the tobacco industry and increase taxes on cigarettes, hoping to discourage teenagers from smoking and raise money for research and related health care costs. It faltered under opposition from his fellow Republicans.

McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients’ bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies, said Sonya Elling, who served as a health care aide in McCain’s office for about a decade. But he came around.

“It was the human, the personal aspect of it, basically,” said Elling, now senior director of federal affairs at Eli Lilly. “It was providing him some of the real stories about how people were being hurt and some of the barriers that existed for people in the current system.”

The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed.

McCain’s health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate’s Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans’ care measures he undertook.

It was McCain’s relationship with Kennedy that stood out, inspiring eerie comparisons when McCain was diagnosed last year with glioblastoma — a form of brain cancer — shortly before his vote saved the Affordable Care Act.

That same aggressive brain cancer killed Kennedy in 2009, months before the passage of the law that helped realize his work to secure better access for Americans to health care.

“I had strenuously opposed it, but I was very sorry that Ted had not lived to see his long crusade come to a successful end,” McCain wrote in his 2018 book.

While some of his biggest health care measures failed, the experiences helped burnish McCain’s résumé for his 2000 and 2008 presidential campaigns.

In 2007, trailing other favored Republicans, such as former New York City mayor Rudy Giuliani in early polling and fundraising, McCain asked his advisers to craft a health care proposal, said Holtz-Eakin. It was an unusual move for a Republican presidential primary.

The result was a remarkable plan that would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued employer-provided plans were driving up costs, as well as keeping salaries lower.

The plan was controversial, triggering “a total freakout” when McCain gained more prominence and scrutiny, Holtz-Eakin said. But McCain stood by it.

“He might not have been a health guy, but he knew how important that was,” he said. “And he was relentless about getting it done.”

Readers And Tweeters Revisit Surgery Centers, Think Twice About Single-Payer

Kaiser Health News:Insurance - August 24, 2018

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

A Duty To Report On Surgery Centers

Your article regarding unreported bad outcomes from outpatient surgery centers (“Lax Oversight Leaves Surgery Center Regulators And Patients In The Dark,” Aug. 9) had been a concern of mine for some time. I am a retired radiologist and have personally seen bad outcomes and wondered if they are a public safety issue and go unreported. Accredited hospitals must keep track of outcomes, but the outpatient surgery centers are variable. Good investigative journalism as yours provides a valuable service to the public and will save lives.

— James LaManna, Gillette, Wyo.

On Twitter, a spine surgeon pointed out what he sees as holes in the story. Dr. Paul Kraemer, a specialist at North Meridian Surgery Center in Carmel, Ind., argued that the story was based on the false assumption that hospitals have better trained staff than do surgery centers. Rather than set up the dichotomy of surgery center vs. hospital, he told KHN, the article should have differentiated between generalist and specialty centers — that is, those performing spine procedures occasionally vs. every day. At specialty centers, the nurses in the recovery room can spot a problem — especially an airway problem — and alert a surgeon or anesthetist to intervene, he said. They see what is normal and recognize early warning signs of trouble, whether the procedure is simple or complex.

1. No mention of millions who have had surgery safely to provide perspective.

2. No mention that same complication can happen in hospital (seen it)

3. No mention of conflicts inherent in hospital news promoting and funding story

4. No mention of steps taken to prevent tragedy

— Paul Kraemer MD (@PK_Spine) August 1, 2018

— Dr. Paul Kraemer, Carmel, Ind.

Dr. Ronald Hirsch of Illinois told KHN he has been trying for a year to get insight from the Centers for Medicare & Medicaid Services on its fast-track approval of increasingly complex procedures — while oversight lags.

And yet, @CMSGov allows @Humana to authorize "Inpatient Only" surgeries to be done at surgery centers on Medicare Advantage beneficiaries. Hip fracture repair? Open cholecystectomy? Carotid artery stenting?

— Ronald Hirsch, MD (@signaturedoc) August 10, 2018

— Dr. Ronald Hirsch, Elgin, Ill.

Glenn Krauss of Vermont explained why he avoids surgery centers at all costs.

— Glenn Krauss, Burlington, Vt.

Filling A Gnawing Need On Campus

“Insuring Your Health” columnist Michelle Andrews did her homework on solutions for a rampant problem: food insecurity among college students (“For Many College Students, Hunger Can ‘Make It Hard To Focus In Class,” July 31). Readers such as J.K. Devine of Gainesville, Ga., joined a chorus of those commending universities for coming to the aid of hungry scholars.

Enjoyed reading your story about college students going hungry. The University of North Georgia is one of those universities that has started food pantries on 3 of its 5 campuses to help students, faculty and staff who need it.

— J.K. Devine (@JKDevine1) July 31, 2018

— J.K. Devine, Gainesville, Ga.

A Californian shared her firsthand experience with hunger as a college freshman.

I remember freshmen year going to bed hungry every night, wishing I was home so I could at least have cereal. I did have a dinning hall pass, but social anxiety and peak dinner times don’t mix.

— Korahline (@Krhddg) August 1, 2018

— Paola Viveros, Oxnard, Calif.

Doctors for America, a coalition of 18,000 physicians and medical students whose goal is to improve access to health care, also rallies to fight hunger, especially among medical students who are at risk of being saddled with tuition debt.

While the US is the wealthiest country, up to a half of all college students suffer from food insecurity. We must not allow future medical students to suffer from such a gap. All while the US is declining their contribution to student financial aid

— Doctors for America (@Drsforamerica) August 3, 2018

Zachary LeClaire of California has adopted the philosophy that he would rather go hungry than let his college bills add up. On Twitter, he mused: Are parents doing enough to tend to the financial needs of their “dependents”?

One of the main problems with this is many college students are under the age of 24 and are considered "dependent students" regardless of whether or not they're parents actually give them any money. Also I'd rather eat 1 meal a day than be in debt for the rest of my life

— The Useless Philosopher (@GenYDiogenes) July 31, 2018

— Zachary LeClaire, Huntington Beach, Calif.

Although nutrition needs are being addressed where she lives in Washington state, Erin Davis looked at the big picture.

Proud and thankful that my institution has a food bank for students. Food insecurity among community college students is a pervasive problem that also needs larger, systemic solutions.

— Erin Davis (@FreckleErin) August 1, 2018

— Erin Davis, Spokane, Wash.

Second Thoughts On Single-Payer

In almost 100 percent of the discussions on health coverage plans, it is assumed that providers will both exist and will work for whatever the plan will pay them (“Once Its Greatest Foes, Some Doctors Are Now Embracing Single-Payer,” Aug. 7). Most people, when they hear “single-payer,” expect that everything will be covered with minimal copay and deductible. They are wrong, but no one will admit it upfront.

The alleged coverage crisis — wherein medical insurance was conflated with service availability, resulting in Obamacare — was caused by the government. Both Medicaid and Medicare health benefits were originally designed to provide basic health services while paying providers little more than direct costs, allowing private pay and commercial insurance payments to cover overhead and profit. Medicaid and Medicare were not expected to be a significant percentage of any provider’s practice. Over time, the good-hearted liberals kept expanding the scope of benefits with marginal improvements in reimbursement calculations and certainly without consideration of “unintended consequences,” especially the predictable ones pertaining to demand and cost.

Experience shows that A) any national single-payer system will be run at least as well as the VA and the Indian Health Services and B) our Fearless Leaders will exempt themselves from the system.

— Ed Connelly, Shaftsbury, Vt.

On Twitter, Ryan Quattro of Michigan wondered how an overhaul in health care policy might play against the backdrop of precarious foreign, defense and other domestic policies.

We need to have a conversation on what single-payer means for US role in the world.

End of role in NATO and seriously reduced military means reduced influence in world. Then there is the issue of infrastructure. $2.5 trillion. America is a hot mess.

— Ryan Quattro (@forzaquattro77) August 2, 2018

— Ryan Quattro, Ann Arbor, Mich.

A reader in Iowa warned that the flip side of single-payer means doctors would earn far less than they traditionally do, and that American innovation would be sacrificed.

Wait until these new physicians have to pay back their student loans on single payer compensation…good luck…oh, say goodbye to innovation, too. #Shame
Once Its Greatest Foes, Doctors Are Embracing Single-Payer via @khnews

— Sean Yolish (@SeanYolish) August 8, 2018

— Sean Yolish, West Des Moines, Iowa

Power to the younger generation, was the message from an Idaho tweeter.

The youngin's are gonna change our country for the better. I believe that. Enough is enough.

— IndiraShanti (@IndiraShanti) August 2, 2018

— Tina Neidig, Boise, Idaho

Tuition-Free Med School Touches Off Multimillion-Dollar Debate

Kaiser Health News:Marketplace - August 24, 2018

New York University’s School of Medicine is learning that no good deed goes unpunished.

The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018.

NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place.

“A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt,” Dr. Robert Grossman, the dean of the medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans.

The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.

“As I start rank ordering the various charities I want to give to, the people who can pay for medical school in cash aren’t at the top of my list,” said Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management.

“If you had to find some cause to put tons of money behind, this strikes me as an odd one,” said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University.

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Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000.

But it is less clear how much of an impact that debt has on students’ choice of medical specialty. The AAMC’s data suggests debt does not play as big a role in specialty selection as some analysts claim.

If debt were a huge factor, one would expect that doctors who owed the most would choose the highest-paying specialties. But that’s not the case.

“Debt doesn’t vary much across the specialties,” said Julie Fresne, AAMC’s director of student financial services and debt management.

Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. “No one [who chooses a higher-paying job] says they did it because they want two Teslas,” he said. “They say they have all this debt.”

Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. “Doctors in general do just fine,” he said. “The idea we should pity physicians or worry about them strikes me as odd.”

Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted for pediatrics, calling it a “garbageman” specialty.

There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers.

Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master’s degree.

This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings.

In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia’s program is based on students’ financial need.

The programs are funded, in whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU.

Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all “is not the most target-efficient way to reach that goal.”

Medicaid Covers Foster Kids, But Daunting Health Needs Still Slip Through The Cracks

Kaiser Health News:Madicaid - August 24, 2018

“We would not be able to foster without Medicaid,” says Sherri Croom of Tallahassee, Fla. Croom and her husband, Thomas, have fostered 27 children in the past decade. They’re pictured here with four adopted children, two 18-year-old former foster daughters and those daughters’ sons. (Courtesy of the Croom family)

Sherri and Thomas Croom have been foster parents to 27 children — from newborns to teenagers — during the past decade.

That has meant visits to dozens of doctors and dentists for issues ranging from a tonsillectomy to depression.

While foster parenting has innumerable challenges, health care coverage for the children isn’t one of them. Medicaid, the federal-state health insurance program for the poor, picks up the tab for nearly all children in foster care and often continues to cover them if they are adopted, regardless of their parents’ income. And as a result of the 2010 Affordable Care Act, foster children who have Medicaid at 18 can retain the coverage until they turn 26.

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

More Stories

“We would not be able to foster without Medicaid,” said Sherri Croom, 41, of Tallahassee, Fla. “It pays for everything.”

Yet, Croom and other foster parents say that even with the coverage they struggle to meet the extraordinary health needs of their children. Part of the trouble is too few doctors accept Medicaid, most notably mental health specialists.

Families also face the challenge of coordinating treatment decisions between government welfare agencies and foster kids’ biological parents.

Treating The Effects Of Abuse And Neglect

Although foster care children make up only a tiny portion of the 74 million Americans who receive Medicaid, this population faces significantly more health needs than most enrollees. These children often have experienced abuse, neglect, violence and parental substance abuse. About half of them have been diagnosed with mental health disorders, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s largest health program, yet its broad reach beyond traditional populations of low-income children and parents and people with disabilities is less known. Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly.

A 2016 study in the journal Pediatrics found that children in foster care were twice as likely as others to have learning disabilities and developmental delays, five times as likely to have anxiety, six times as likely to have behavioral problems and seven times as likely to have depression.

And the number of these enrollees has increased in recent years, largely as the opioid epidemic has devastated many families. Between 2012 and 2016, children in foster care nationally rose from roughly 397,000 to 437,500, according to federal data.

Foster children’s health problems frequently demand specialized and consistent care, yet these children’s often unstable lives make it difficult for doctors or other health specialists to care for them, said Dr. Moira Szilagyi, a pediatrician based in Los Angeles. The kids often move between foster homes or from foster homes back and forth to their families.

“Every time they change providers, some information is lost and leads to some duplication of services or children fall out of treatment,” she said.

Melanie Stimmell, a foster parent currently to a dozen children in Winter Garden, Fla., said nearly all the children she and her husband have taken in have had some mental health issues. She recalled it took months to find a nearby, Medicaid-friendly therapist for an 11-year-old who was bipolar and had been hospitalized before coming to her home.

Delays in getting these kids care has lasting consequences, she said.

“The issues snowball into other issues,” she said. “It affects their performance in school, which hurts their ability to make friends, which hurts their self-esteem and then they fall behind in classes and get held back and it affects everything in their life.”

In addition, some experts warn that children who have aged out of foster care at age 18 may delay care because they don’t know that they still have access to Medicaid until they turn 26.

“We are concerned that there are thousands of kids who should be getting Medicaid but aren’t because they are not plugged in to the system,” said Irene Clements, executive director of the National Foster Parent Association.

State performance varies widely on signing up former foster kids through age 25. For example, according to state officials, Florida has signed up about 7,900 of them; Iowa, about 700; Colorado, more than 21,000; and Indiana, 1,685.

Ali Caliendo says Medicaid coverage has been invaluable since she and her husband, Terry, became Anthony’s foster parents over four years ago. The child had bronchitis and pneumonia in his first year and struggled with some social and emotional problems early on. The Caliendos have adopted Anthony, who is now 5 and on a “good trajectory” as he prepares for kindergarten this fall, his mom says.(Courtesy of Ali Caliendo)

An Experiment In Care Coordination

A few states, including Florida, Georgia and Texas, have started to test an idea that might improve foster children’s access to care.

They are placing foster children in their own Medicaid health plan — separate from the coverage offered to most Medicaid families.

These plans are typically run by private, mostly for-profit Medicaid managed care companies, including Centene, Amerigroup and United Healthcare.

Supporters say these plans can be designed to meet the higher health needs — particularly for mental health services — of foster children.

For instance, Florida’s child welfare plan is required to have more primary care doctors and mental health specialists available than traditional Medicaid health plans. It also offers extra benefits such as nutrition counseling, art therapy and a $25 monthly allowance for over-the-counter items such as cough syrup and vitamins. About 34,000 foster kids are in the plan managed by Centene Corp.

“This is a promising model,” said Roxann McNeish, a research assistant professor of child and family studies at the University of South Florida.

She said having health plans with administrators and physicians trained to address the unique needs of foster kids has helped better coordinate care to them. But more study is needed to see if children’s health has improved care compared to traditional health plans, she cautioned.

These plans can also allow children to remain under the same coverage if they move to different parts of the same state.

Szilagyi says getting care to foster children is often difficult because responsibilities vary between state agencies, birth parents and guardians. “Obtaining consent from parents to provide health to the child can be challenging,” she said.

The foster-care only plans try to improve this because they are trained to work with state foster care caseworkers to speed care to children.

But a 2016 study conducted by researchers at the University of South Florida for the state Agency for Health Care gave the plan mixed results. It found that parents often complained about lack of access to doctors. On the other hand, child welfare agencies reported having more input in health decisions for children. This is important because those agencies are responsible for recruiting and supporting foster parents and coordinating health services for the children.

The report did not examine whether the children in the plan had better outcomes.

Glen Casel, chief executive of Community Based Care of Central Florida, a foster care agency that contracts with the state to provide child welfare services, said these specialized plans have limited benefit. “I don’t think a foster-care-only plan is a silver bullet,” he said.

His nonprofit has worked with Centene to get more mental health providers in the network, particularly in communities that typically don’t have large numbers of Medicaid enrollees but have foster parents.

“It’s a daily fight for us,” he said.

Despite the challenges, foster parents do recount success stories.

Ali and Terry Caliendo, of Las Vegas, said Medicaid has been invaluable since they became foster parents to 7-month-old Anthony in 2013. He had bronchitis and pneumonia his first year and later was repeatedly sent home from day care for being too aggressive toward other children.

“He was so sick as a baby, and then socially and emotionally he really struggled with violent rages and attachment issues,” Ali Caliendo said.

Medicaid paid for him to see psychiatrists, psychologists and physical and occupational therapists.

“Having the support through Medicaid made it an easier decision to be foster parents,” Caliendo said.

The Caliendos adopted Anthony at 18 months and were able to keep his Medicaid coverage. This fall, he begins kindergarten.

“Because we were able to intervene early, he is on a good trajectory, and we are really pleased,” she said.

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

Podcast: KHN’s ‘What The Health?’ Opioids, EpiPens And Health Funding

Kaiser Health News:Insurance - August 23, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Joanne Kenen



Read Joanne's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

The Senate is still working, well into August – something it hasn’t done in years — and it’s debating the funding bill for the Department of Health and Human Services.

There is a back-to-school shortage of EpiPens, needed by people with severe allergies to treat potentially life-threatening reactions, and the Food and Drug Administration is weighing in. And “reinsurance” is back in the picture. The Trump administration has granted permission for New Jersey and Maryland to create such programs aimed at helping bring down premiums in the individual insurance market by helping pay for the most expensive enrollees.

And in weird science: An asthmatic otter sends a signal about the serious public health impact of this summer’s wildfires in the western U.S.

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

This is your last chance to send questions for next week’s “ask us anything” episode. You can email us at

Among the takeaways from this week’s podcast:

• One provision of the HHS funding bill that is getting attention is the effort to require drugmakers to add their prices to any advertisements. President Donald Trump is pushing for this, and it could be popular politically. But since consumers pay different prices depending on a variety of factors, including their insurance and the source of drugs, it isn’t clear how impactful such a law would be.

• The announcement this week by federal authorities that an estimated 72,000 people had died of drug overdoses — 49,000 of them as a result of opioids — has spurred interest on Capitol Hill for legislation to help fight the opioid epidemic. Bills that had been expected to move after the election could now see a faster track to voting.

• Consumers are reporting a shortage in EpiPens, the prescription drug and self-injector that can prevent death from a lethal allergy. The FDA has agreed with the EpiPen maker to extend the expiration date to ease the shortage. The FDA also approved a generic version of the EpiPen, but that is unlikely to lower costs anytime soon. Generics often don’t have much impact on pricing until there are several generic options available.

• The announcement by New York University’s medical school that it will provide free tuition to all students sent a shock wave through the academic community. Although it appears to be a great strategy to attract students, it’s unclear whether it will encourage more new doctors to choose primary care rather than higher-paying specialties. Doctors do come out of school with high debt levels, but most studies show that they also have high salaries and pay off those debts within 10 years.

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

Julie Rovner: NPR’s “NYU’s Move To Make Medical School Free For All Gets Mixed Reviews,” by Julie Rovner

Joanne Kenen: Politico’s “Lax State Ethics Rules Leave Health Agencies Vulnerable to Conflicts,” by Brianna Ehley, Sarah Karlin-Smith, Rachana Pradhan and Jennifer Haberkorn

Alice Ollstein: The New York Times’ “Vitamin D, the Sunshine Supplement, Has Shadowy Money Behind It,” by Liz Szabo

Margot Sanger-Katz: The Wall Street Journal’s “What Does Knee Surgery Cost? Few Know, and That’s a Problem,” by Melanie Evans

To hear all our podcasts, click here.

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

A Black Eye For Blue Shield: Consumers Lash Out Over Coverage Lapses

Ashley Summers said she got an unpleasant surprise in February when she tried to pick up a prescription for her rheumatoid arthritis: Her pharmacy said her insurance had been canceled, even though her premiums were paid.

Summers called Blue Shield of California and got her policy reinstated — then she said it happened again in March and this time, the lapse in coverage dragged on for three months.

Without insurance to cover her medications and doctor visits, her arthritis and fibromyalgia worsened to the point that she could barely walk, she said. In June, she said, the state granted her permission to switch to another insurer.

“This entire mess has been so incredibly stressful,” said Summers, 49, a personal assistant in Los Angeles who had paid $593 a month in premiums. “For Blue Shield just to pull the plug like this is infuriating.”

Around the state, consumers with individual Blue Shield policies, like Summers, say they have been subject to sudden, erroneous cancellations, especially in recent months, forcing them to go without heart medicine, skip vaccinations for their children and pay hundreds of dollars out-of-pocket for other medical care. On social media, customers have described frantic attempts to get their coverage reinstated.

We apologize for the inconvenience. DM you member ID and a Specialist can look into this for you. – AV

— Team Shield (@TeamShieldBSC) July 2, 2018

We apologize for the trouble and would like to look into this. DM us your member ID and contact info and a member of our team will reach out to address this with you. – JN

— Team Shield (@TeamShieldBSC) July 31, 2018

We apologize for the frustration. A Specialist will reach out shortly to assist you. – JN

— Team Shield (@TeamShieldBSC) July 30, 2018

Blue Shield has acknowledged failures in enrollment and billing for some customers who purchased individual policies since 2014, both inside and outside the Covered California exchange. The company declined to specify how many customers were affected. The problems don’t appear to involve people with employer coverage or enrolled in government health programs.

In a June 22 lawsuit, the San Francisco insurer blamed many of these problems on an outside contractor it had hired in preparation for the launch of the Affordable Care Act in 2014. In a countersuit, the contractor, HealthPlan Services, denied the allegations and accused Blue Shield of sharing inaccurate customer data.

Consumers with individual Blue Shield policies, like Ashley Summers, say they have been subject to sudden, erroneous cancellations. (Courtesy of Ashley Summers)

In a statement, Blue Shield said: “The roll out of the Affordable Care Act was hard on the entire health care system. Our vendor failed to provide the support it promised and we spent millions of dollars to mitigate the impacts to our members.”

On Friday, Summers sued Blue Shield in Los Angeles County Superior Court, alleging breach of contract and seeking class-action status on behalf of other customers. The insurer couldn’t be reached for comment about the complaint.

Scott Glovsky, a Pasadena, Calif., attorney representing Summers, said Blue Shield has known about these problems for years. “Blue Shield is taking people’s hard-earned dollars and then abandoning them when they’re sick,” he said.

Tina Hoover, 47, a horse trainer in Sherman Oaks, Calif., said Blue Shield canceled her policy twice in two months, even though she’d been paying her premiums faithfully for years.

Blue Shield denied more than $1,000 in doctor visits, saying she’d been terminated. After four calls, inconsistent responses, non-responses and a pointed comment by her husband on Twitter, she finally got her insurance back, she said.

“It was frightening that Blue Shield could be so disorganized on something so important like my health care,” said Hoover, who pays $858 a month in premiums and has been a policyholder with the insurer for 15 years.

All health insurers face complaints, from improper denials of care to annoying customer service. But some experts say these persistent breakdowns in customer service at Blue Shield represent a black eye for California’s third-largest health insurer, which has 460,000 customers on the Covered California exchange and 3.8 million enrollees overall.

“I’ve never seen anything on this scale for such basic insurance operations,” said Paula Wade, an industry analyst at Decision Resources Group in Nashville, Tenn. “Honest to goodness, if you can’t take people’s money and credit their account — that’s incredibly simple.”

We apologize for the frustration. DM us your member ID and a member of our team will look into this. – SS

— Team Shield (@TeamShieldBSC) July 25, 2018

We're sorry for the inconvenience. DM us your member ID and a Specialist will look in to this for you. – AV

— Team Shield (@TeamShieldBSC) July 2, 2018

I rarely tweet, but @BlueShieldCA has the absolute worst customer service. They accidentally terminated my insurance, and apologized for the error. After losing approx. 13 hours of work time on the phone, still no solution. What the heck??

— Paris Hotel Boutique (@parishotel) January 3, 2018

Across its plans last year, Blue Shield had the highest complaint rate per 10,000 enrollees among the eight largest health insurers statewide, according to the California Department of Managed Health Care. Blue Shield had 7.43 complaints per 10,000 enrollees, followed by Anthem Blue Cross (5.83), UnitedHealthcare (4.72) and Kaiser Permanente (4.6). (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

For its individual market plans, Blue Shield chose to outsource sign-ups, billing and payment processing to HealthPlan Services, a major contractor for insurers industrywide. In its breach-of-contract lawsuit against the contractor, Blue Shield said it needed outside help to handle the dramatic overhaul of the individual market in 2014 under the ACA.

By June 2014, Blue Shield said it had formed a team of people “whose sole job was to address the failures in HPS’ services to ensure that Blue Shield’s customers’ interests were not impacted,” according to the lawsuit.

But the glitches persisted, and Blue Shield said in its lawsuit that it has lost tens of millions of dollars due to the contractor’s “egregious” failures on billing, refunds and related matters.

HealthPlan Services’ “data was ever-changing, inconsistent and flat-out incorrect,” Blue Shield said in the 15-page complaint in San Francisco federal court.

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In a statement to California Healthline, HealthPlan Services called Blue Shield’s claims “baseless” and said it has a “successful track record of providing quality services to its clients and their members.”

But in court papers, Blue Shield said the problems went beyond the sudden cancellations.

For instance, about 14,000 Blue Shield customers experienced “multiple attempted charges on their bank accounts” over one weekend, according to the insurance company’s lawsuit. About half the time, Blue Shield alleged, its contractor proposed refunds or credits that were excessive or had no basis at all. One time, a $27,000 refund went to the wrong customer, according to the lawsuit.

In April 2017, Blue Shield said, it initiated termination of the vendor’s contract.

In an Aug. 13 counterclaim, HealthPlan Services said “Blue Shield’s highly unusual data maintenance and transmission methods and business processes resulted in customer-facing errors that were directly attributable to Blue Shield’s conduct.”

In a statement, Blue Shield countered that “HPS’ allegations are unfounded and we look forward to responding to them in the legal proceedings.”

Meantime, San Francisco resident Burcu Sivrikaya, 32, said she found out late last month that Blue Shield had canceled her coverage — effective May 1. She spent hours on the phone talking to seven different company representatives trying to get her policy reinstated, only to be told it would take 30 days, she said. “Are they using pen and paper? Why does it take 30 days? It’s insane.”

Now Sivrikaya, a social media manager, is trying to get Blue Shield to refund the $1,179 she said she paid in premiums for the three months the company withdrew coverage.

The Department of Managed Health Care fined Blue Shield and a subsidiary $557,500 last year for improper cancellations and a variety of customer grievance violations. Blue Shield is contesting some of those allegations and penalties, according to the state.

Blue Shield noted that it performed well on certain categories in the state data, such as an extremely low complaint rate among medical providers.

The company also said its customer satisfaction score improved in a recent consumer survey by Forrester Research, increasing by nearly 2 percentage points to 63.6 out of 100. Forrester still labeled Blue Shield’s performance as “poor,” putting it in ninth place out of 17 health insurers that were rated this year.

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

100 Days of Action on the President’s American Patients First Blueprint

HHS Gov News - August 21, 2018

“The President’s blueprint for lower drug prices is working, drug prices are coming down, and American patients are going to see the savings in their pocketbook.” — Secretary Alex Azar  

Tomorrow, August 21, marks 100 days since the release of President Trump’s American Patients First Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs. In this short period of time, an unprecedented number of actions have been taken toward structurally rebuilding this entire segment of the economy to lead to enduring lower prices that are sustainable, support innovation, and put American patients first.

Below is the introduction to a new report on the 100 days of action from Dan Best, Senior Advisor to the Secretary for Drug Pricing Reform: 

“For years, American patients have suffered under a drug-pricing system that provides generous incentives for innovation, while too often failing to deliver important medications at an affordable cost. The flaws in America’s drug markets have been a topic of discussion in healthcare policy circles for years, but no comprehensive approach to reform has ever been undertaken.

“On May 11, President Trump and Health and Human Services (HHS) Secretary Alex Azar released the American Patients First blueprint, a comprehensive plan to bring down prescription drug prices and out-of-pocket costs.

“The extensive number of proposals in the blueprint reflect the scale of the task: restructuring and reforming a fundamentally flawed drug-pricing system that governs a more than $400 billion sector of our economy. Reforms of significant parts of the healthcare market on a similar scale, such as Medicare Part D, have generally taken several years to implement, and several years after that to effect changes across the entire drug market.

“In the 100 days since May 11, HHS has taken dozens of actions on the four strategies contemplated in the blueprint: increased competition, better negotiation, incentives for lower list prices, and reducing out-of-pocket costs. Together, these actions have helped bring into focus a vision for a more competitive pharmaceutical marketplace. Pharmaceutical manufacturers, pharmacy benefit managers, and other actors in the market have indicated that they recognize the scale of disruption this would involve.

“At the time of the release of the blueprint, few observers believed that, within months, drug manufacturers would begin to change their annual ritual of significant price hikes. Yet that is what happened in the months following.

“Within these first 100 days, 15 drug companies have reduced list prices, rolled back planned price increases, or committed to price freezes for the rest of 2018. Cutting list prices and rolling back proposed increases in particular are an unprecedented recognition of the fundamental changes going on in drug markets.”

To read the full report, please visit:

And to read a fact sheet on 100 days of results from the blueprint, please visit:

Biorhythms And Birth Control: FDA Stirs Debate By Approving ‘Natural’ App

Kaiser Health News:Insurance - August 21, 2018

The Food and Drug Administration took a “big tent” approach earlier this month when it approved two new forms of birth control that prevent pregnancy in very different ways.

Women’s health advocates applauded the availability of a new vaginal ring that could be used for up to a year. But some questioned the approval of a mobile phone app that helps women avoid pregnancy by tracking their body temperature and menstrual cycle, a type of contraception called “fertility awareness.”

Critics pointed to reports that three dozen women in Sweden got pregnant despite monitoring their cycle with the app. They also fear that the FDA approval of the app may encourage patients to think that fertility awareness methods, which include a range of practices to track ovulation, and avoid unprotected sex during that time, are just as good at preventing pregnancy as some highly effective types of birth control, like the intrauterine device, or IUD. While “natural” methods can be successful, they generally require close daily attention.

There’s still room for improvement in contraceptive use by women and men. Nearly half of the 6.1 million pregnancies in the United States — 45 percent — in 2011 were unplanned, according to a study published in the New England Journal of Medicine. That figure is lower than the 51 percent rate in 2008, but is higher than the rate in many other industrialized countries.

The FDA has approved nearly two dozen contraceptive methods, including the pill, the patch, IUDs and hormonal implants and shots, among others. Insurance is required to cover all FDA-approved methods without charging women anything out-of-pocket.

The new vaginal ring, Annovera, releases hormones that prevent ovulation and must be removed after three weeks for seven days, then reinserted. It can be used for a year. The device will not be on the market until at least late 2019, and the price hasn’t been released by the manufacturer.

The Natural Cycles app instructs women to take their temperature at the same time every morning when they awake and record it in the app. They also track information about their menstrual cycle. When a slight temperature increase indicates they are ovulating, the app signals that women should avoid unprotected sex. It costs about $80 per year.

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Both of the new methods require more attention on the part of the user than say, an IUD, which once inserted can be ignored and is designed to prevent pregnancy for five to 10 years, depending on the brand.

Still, some women’s health experts worry that the FDA stamp of approval may be misinterpreted by some women.

“People will interpret this to mean that the FDA approves this and thinks it’s a good method,” said Dr. Christopher Zahn, vice president of practice activities for the American College of Obstetricians and Gynecologists.

“That’s why counseling is so important,” he said, noting that doctors should discuss all forms of birth control with women, and the conversation should include the efficacy of different methods.

But Dr. Gillian Dean, senior director of medical services at Planned Parenthood Federation of America, welcomes the approval of both new methods.

“More options are always better,” she said. “It isn’t one size fits all, and more options increases the likelihood that women will find a method that works for their needs.”

The right contraceptive depends on a woman’s goals, Dean said, including her reproductive plans, what her menstrual cycle is like, the number of partners she has and how important it is for her not to get pregnant. She said most women who visit Planned Parenthood clinics ask for and receive birth control pills, but an increasing number are asking for long-acting reversible methods of contraception, such as IUDs and hormonal implants.

The IUD and hormonal implants have a “failure rate” of less than 1 percent, making them among the most effective ways of preventing pregnancy (on par with permanent sterilization). Birth control pills, the patch and the vaginal ring have effectiveness rates of about 91 percent, according to the federal Centers for Disease Control and Prevention.

Fertility awareness methods, on the other hand, have a failure rate of about 24 percent, according to the CDC. But that figure is widely misunderstood, said Chelsea Polis, a senior research scientist at the Guttmacher Institute, a sexual and reproductive health research and advocacy organization.

Polis co-authored an analysis of studies of fertility awareness-based contraceptive methods that was published in August in the journal Obstetrics and Gynecology.

The 24 percent figure, she said, primarily reflects the expected failure rate for women who used the rhythm method, a calendar-based approach to calculating when ovulation occurs, rather than newer biometric methods that track body temperature, cervical mucous or urinary hormones. Some of those methods may be more effective, she said.

Based on a review of published studies, Polis and colleagues reported that the Natural Cycles app had a 9.8 percent unintended pregnancy rate. The FDA announcement, which includes the results of an additional study, noted a 6.5 percent rate.

Polis said her research indicates that about 3 percent of women who use contraception practice fertility awareness-based methods, either alone or with other types of birth control, and their numbers are growing.

“I think [the app approval] is largely a positive step forward,” Polis said. “I’m relieved that the FDA has a regulatory pathway to evaluate these uses and claims.”

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

The Man Who Sold America On Vitamin D — And Profited In The Process

Kaiser Health News:Marketplace - August 20, 2018

Dr. Michael Holick’s enthusiasm for vitamin D can be fairly described as extreme.

The Boston University endocrinologist, who perhaps more than anyone else is responsible for creating a billion-dollar vitamin D sales and testing juggernaut, elevates his own levels of the stuff with supplements and fortified milk. When he bikes outdoors, he won’t put sunscreen on his limbs. He has written book-length odes to vitamin D, and has warned in multiple scholarly articles about a “vitamin D deficiency pandemic” that explains disease and suboptimal health across the world.

His fixation is so intense that it extends to the dinosaurs. What if the real problem with that asteroid 65 million years ago wasn’t a lack of food, but the weak bones that follow a lack of sunlight? “I sometimes wonder,” Holick has written, “did the dinosaurs die of rickets and osteomalacia?”

Holick’s role in drafting national vitamin D guidelines, and the embrace of his message by mainstream doctors and wellness gurus alike, have helped push supplement sales to $936 million in 2017. That’s a ninefold increase over the previous decade. Lab tests for vitamin D deficiency have spiked, too: Doctors ordered more than 10 million for Medicare patients in 2016, up 547 percent since 2007, at a cost of $365 million.

But few of the Americans swept up in the vitamin D craze are likely aware that the industry has sent a lot of money Holick’s way. A Kaiser Health News investigation found that he has used his prominent position in the medical community to promote practices that financially benefit corporations that have given him hundreds of thousands of dollars — including drugmakers, the indoor-tanning industry and one of the country’s largest commercial labs.

In an interview, Holick acknowledged he has worked as a consultant to Quest Diagnostics, which performs vitamin D tests, since 1979. Holick, 72, said that industry funding “doesn’t influence me in terms of talking about the health benefits of vitamin D.”

There is no question that the hormone is important. Without enough of it, bones can become thin, brittle and misshapen, causing a condition called rickets in children and osteomalacia in adults. The issue is how much vitamin D is healthy, and what level constitutes deficiency.

Holick’s crucial role in shaping that debate occurred in 2011. Late the previous year, the prestigious National Academy of Medicine (then known as the Institute of Medicine), a group of independent scientific experts, issued a comprehensive, 1,132-page report on vitamin D deficiency. It concluded that the vast majority of Americans get plenty of the hormone through diet and sunlight, and advised doctors to test only patients at high risk of vitamin D-related disorders, such as osteoporosis.

A few months later, in June 2011, Holick oversaw the publication of a report that took a starkly different view. The paper, in the peer-reviewed Journal of Clinical Endocrinology & Metabolism, was on behalf of the Endocrine Society, the field’s foremost professional group, whose guidelines are widely used by hospitals, physicians and commercial labs nationwide, including Quest. The society adopted Holick’s position that “vitamin D deficiency is very common in all age groups” and advocated a huge expansion of vitamin D testing, targeting more than half the United States population, including those who are black, Hispanic or obese — groups that tend to have lower vitamin D levels than others.

The recommendations were a financial windfall for the vitamin D industry. By advocating such widespread testing, the Endocrine Society directed more business to Quest and other commercial labs. Vitamin D tests are now the fifth-most-common lab test covered by Medicare.

The guidelines benefited the vitamin D industry in another important way. Unlike the National Academy, which concluded that patients have sufficient vitamin D when their blood levels are at or above 20 nanograms per milliliter, the Endocrine Society said vitamin D levels need to be much higher — at least 30 nanograms per milliliter. Many commercial labs, including Quest and LabCorp, adopted the higher standard.

Yet there’s no evidence that people with the higher level are any healthier than those with the lower level, said Dr. Clifford Rosen, a senior scientist at the Maine Medical Center Research Institute and co-author of the National Academy report. Using the Endocrine Society’s higher standard creates the appearance of an epidemic, he said, because it labels 80 percent of Americans as having inadequate vitamin D.

“We see people being tested all the time and being treated based on a lot of wishful thinking, that you can take a supplement to be healthier,” Rosen said.

Patients with low vitamin D levels are often prescribed supplements and instructed to get checked again in a few months, said Dr. Alex Krist, a family physician and vice chairman of the U.S. Preventive Services Task Force, an expert panel that issues health advice. Many physicians then repeat the test once a year. For labs, “it’s in their financial interest” to label patients with low vitamin D levels, Krist said.

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In a 2010 book, “The Vitamin D Solution,” Holick gave readers tips to encourage them to get their blood tested. For readers worried about potential out-of-pocket costs for vitamin D tests — they range from $40 to $225 — Holick listed the precise reimbursement codes that doctors should use when requesting insurance coverage. “If they use the wrong coding when submitting the claim to the insurance company, they won’t get reimbursed and you will wind up having to pay for the test,” Holick wrote.

Holick acknowledged financial ties with Quest and other companies in the financial disclosure statement published with the Endocrine Society guidelines. In an interview, he said that working for Quest for four decades — he is currently paid $1,000 a month — hasn’t affected his medical advice. “I don’t get any additional money if they sell one test or 1 billion,” Holick said.

A Quest spokeswoman, Wendy Bost, said the company seeks the advice of a number of expert consultants. “We feel strongly that being able to work with the top experts in the field, whether it’s vitamin D or another area, translates to better quality and better information, both for our patients and physicians,” Bost said.

Since 2011, Holick’s advocacy has been embraced by the wellness-industrial complex. Gwyneth Paltrow’s website, Goop, cites his writing. Dr. Mehmet Oz has described vitamin D as “the No. 1 thing you need more of,” telling his audience that it can help them avoid heart disease, depression, weight gain, memory loss and cancer. And Oprah Winfrey’s website tells readers that “knowing your vitamin D levels might save your life.” Mainstream doctors have pushed the hormone, including Dr. Walter Willett, a widely respected professor at Harvard Medical School.

Today, seven years after the dueling academic findings, the leaders of the National Academy report are struggling to be heard above the clamor for more sunshine pills.

“There isn’t a ‘pandemic,’” A. Catharine Ross, a professor at Penn State and chair of the committee that wrote the report, said in an interview. “There isn’t a widespread problem.”

Ties To Drugmakers And Tanning Salons

In “The Vitamin D Solution,” Holick describes his promotion of vitamin D as a lonely crusade. “Drug companies can sell fear,” he writes, “but they can’t sell sunlight, so there’s no promotion of the sun’s health benefits.”

Yet Holick also has extensive financial ties to the pharmaceutical industry. He received nearly $163,000 from 2013 to 2017 from pharmaceutical companies, according to Medicare’s Open Payments database, which tracks payments from drug and device manufacturers. The companies paying him included Sanofi-Aventis, which markets vitamin D supplements; Shire, which makes drugs for hormonal disorders that are given with vitamin D; Amgen, which makes an osteoporosis treatment; and Roche Diagnostics and Quidel Corp., which both make vitamin D tests.

The database includes only payments made since 2013, but Holick’s record of being compensated by drug companies started before that. In his 2010 book, he describes visiting South Africa to give “talks for a pharmaceutical company,” whose president and chief executive were in the audience.

Holick’s ties to the tanning industry also have drawn scrutiny. Although Holick said he doesn’t advocate tanning, he has described tanning beds as a “recommended source” of vitamin D “when used in moderation.”

Holick has acknowledged accepting research money from the UV Foundation — a nonprofit arm of the now-defunct Indoor Tanning Association — which gave $150,000 to Boston University from 2004 to 2006, earmarked for Holick’s research. The International Agency for Research on Cancer classified tanning beds as carcinogenic in 2009.

In 2004, the tanning-industry associations led Dr. Barbara Gilchrest, who then was head of Boston University’s dermatology department, to ask Holick to resign from the department. He did so, but remains a professor at the medical school’s department of endocrinology, diabetes and nutrition and weight management.

In “The Vitamin D Solution,” Holick wrote that he was “forced” to give up his position due to his “stalwart support of sensible sun exposure.” He added, “Shame on me for challenging one of the dogmas of dermatology.”

Although Holick’s website lists him as a member of the American Academy of Dermatology, an academy spokeswoman, Amanda Jacobs, said he was not a current member.

Dr. Christopher McCartney, chairman of the Endocrine Society’s clinical guidelines subcommittee, said the society has put in place stricter policies on conflict of interest since its vitamin D guidelines were released. The society’s current policies would not allow the chairman of the guideline-writing committee to have financial conflicts.

A Miracle Pill Loses Its Luster

Enthusiasm for vitamin D among medical experts has dimmed in recent years, as rigorous clinical trials have failed to confirm the benefits suggested by early, preliminary studies. A string of trials found no evidence that vitamin D reduces the risk of cancer, heart disease or falls in the elderly. And most scientists say there isn’t enough evidence to know if vitamin D can prevent chronic diseases that aren’t related to bones.

Although the amount of vitamin D in a typical daily supplement is generally considered safe, it is possible to take too much. In 2015, an article in the American Journal of Medicine linked blood levels as low as 50 nanograms per milliliter with an increased risk of death.

Some researchers say vitamin D may never have been the miracle pill that it appeared to be. Sick people who stay indoors tend to have low vitamin D levels; their poor health is likely the cause of their low vitamin D levels, not the other way around, said Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women’s Hospital in Boston. Only really rigorous studies, which randomly assign some patients to take vitamin D and others to take placebos, can provide definitive answers about vitamin D and health. Manson is leading one such study, involving 26,000 adults, expected to be published in November.

A number of insurers and health experts have begun to view widespread vitamin D testing as unnecessary and expensive. In 2014, the U.S. Preventive Services Task Force said there wasn’t enough evidence to recommend for or against routine vitamin D screening. In April, the task force explicitly recommended that older adults outside of nursing homes avoid taking vitamin D supplements to prevent falls.

In 2015, Excellus BlueCross BlueShield published an analysis highlighting the overuse of vitamin D tests. In 2014, the insurer spent $33 million on 641,000 vitamin D tests. “That’s an astronomical amount of money,” said Dr. Richard Lockwood, Excellus’ vice president and chief medical officer for utilization management. More than 40 percent of Excellus patients tested had no medical reason to be screened.

In spite of Excellus’ efforts to rein in the tests, vitamin D usage has remained high, Lockwood said. “It’s very hard to change habits,” he said, adding: “The medical community is not much different than the rest of the world, and we get into fads.”

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Babies Dependent On Opioids Need Touch, Not Tech

Kaiser Health News:Marketplace - August 20, 2018

Dr. Jodi Jackson has worked for years to address infant mortality in Kansas. Often, that means she treats newborns in a high-tech neonatal intensive care unit with sophisticated equipment whirring and beeping. And that is exactly the wrong place for an infant like Lili.

Lili’s mother, Victoria, used heroin for the first two-thirds of her pregnancy and hated herself for it.

“When you are in withdrawal, you feel your baby that’s in withdrawal too,” said Victoria, recalling sensations during her pregnancy. (Kaiser Health News is using her first name only because she has used illegal drugs.) “You feel your baby uncomfortable inside of you, and you know that. And then you use and then the baby’s not [uncomfortable], and that’s a really awful, vulgar thought, but it’s true. That’s how it is. It’s terrible.”

Though Victoria went into recovery before giving birth, Lili was born dependent on the methadone Victoria took to treat her opioid addiction. Treatment for infants like Lili has evolved, Jackson said.

“What happened 10, 15 years ago, is [drug-dependent] babies were immediately removed from the mom, and they were put in an ICU warmer with bright lights with nobody holding them,” said Jackson, who is a neonatologist at Children’s Mercy Hospital in Kansas City, Mo. “Of course, they are going to be upset about that! And so the risk of withdrawal is much higher.”

Jackson now leads a statewide effort to get hospitals in Kansas to use the science-based treatment methods for neonatal abstinence syndrome, as the condition is formally known. The symptoms include high-pitched screams, clenched muscles and trouble sleeping. The treatment involves keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities to ease the baby’s symptoms until she can be weaned off of them.

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It’s estimated that around 2 percent of infants are now born drug-dependent. In areas gripped by the opioid crisis, the rate is even higher.

The low-tech, high-touch treatment approach that Lili received in the first weeks of her life is one that health experts encourage hospitals everywhere to adopt as they grapple with increasing numbers of infants born with drug dependencies.

In many parts of the state, Jackson said, she’s starting from scratch.

“Many hospitals have no standard of practice. No standard approach,” Jackson said.

But improving outcomes for opioid-dependent babies will probably take more than just educating hospital staff.

Dr. Elisha Wachman, who is a neonatalogist at Boston Medical Center and teaches pediatrics at Boston University, said that providing this kind of care is a big adjustment for many hospitals.

“It really depends on the capacity of the hospital and where they house the babies for monitoring,” Wachman said. “Some of them don’t have room for the mothers to stay with the babies.”

Compounding the problem, the matter of exactly what are the “best practices” is far from settled.

For example, new research suggests that methadone may be a better recovery drug for newborns than morphine, which Wachman said is most often used, even though doctors are still unsure about morphine’s long-term effects.

“There are very few high-quality clinical trials that have been done in this population of infants,” Wachman said. “If you can imagine, this is an incredibly difficult population to study. To do a randomized, controlled trial, for instance, of opiates and neonates is incredibly challenging.”

Jackson acknowledged the challenges, but she said establishing consistent practices based on what doctors do know is an important first step toward getting answers.

Victoria used heroin during her pregnancy with her fourth child, Lili. Victoria says she could feel Lili’s distress in utero when she experienced withdrawal symptoms. Now 16 months old, Lili is doing well and her mother has been in recovery for 18 months. (Alex Smith/KCUR)

Victoria said she did everything she could to help newborn Lili get healthy in the hospital, with no idea whether they’d be together in the long term.

“I was trying not to be connected with her, because, I thought, they’re probably going to take her,” Victoria said. “I haven’t been clean that long. So I was trying to not, like, be in love with her. But I was so in love with her.” Lili is her fourth child.

Victoria has continued to show state officials that she is committed to staying off drugs. She has been allowed to raise Lili at Amethyst Place, a recovery home in Kansas City.

Lili is now a 16-month-old girl who shares her mother’s blond hair, bright eyes and big smile. Despite her difficult start in life, the toddler is in good health, and her mom has been drug-free for a more than a year and a half.

This story is part of a partnership that includes KCURNPR and Kaiser Health News.

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

Hospitals Battle For Control Over Fast-Growing Heart-Valve Procedure

Kaiser Health News:Marketplace - August 17, 2018

BALTIMORE — When Medicare in 2011 agreed to pay for a revolutionary procedure to replace leaky heart valves by snaking a synthetic replacement up through blood vessels, the goal was to offer relief to the tens of thousands of patients too frail to endure open-heart surgery, the gold standard.

To help ensure good results, federal officials limited Medicare payment only to hospitals that serve large numbers of cardiac patients.

The strategy worked. In the past seven years, more than 135,000 mostly elderly patients have undergone transcatheter aortic valve replacement, known as TAVR. And TAVR’s in-hospital mortality rate has dropped by two-thirds, to 1.5 percent.

Now, in a campaign motivated by a muddy mix of health care and business, smaller hospitals and the medical device industry are arguing that the technique should be more widely deployed. They note only about half of the nearly 1,100 hospitals offering surgical valve replacement can do TAVR. And they say current limitations discriminate against minorities and people in rural areas, forcing patients to undergo a riskier and significantly more invasive treatment — or miss getting a new valve altogether.

Hospitals that already have a TAVR franchise are fighting to stifle new competitors, saying programs that don’t do enough procedures would not provide high-quality care.

At stake is the care of thousands of patients. Half of the more than 250,000 Americans estimated each year to develop severe aortic valve stenosis — narrowing of the valve that regulates the flow of blood from the heart to the largest artery of the body — die within two years. Getting an artificial heart valve lowers that death rate to as low as 17 percent, studies show.

Also at stake is the $45,000 Medicare pays hospitals for each TAVR case — excluding the doctor’s fee. While hospitals typically make only a small profit on the procedure — partly because the device costs more than $30,000 — they benefit because each TAVR patient typically needs other cardiac services and tests that can boost the hospital’s bottom line.

In addition, offering TAVR carries a cachet that helps recruit and retain top specialists, who bring in more patients.

At a Medicare advisory committee hearing in Baltimore on July 25, both sides of the debate emphasized how they were seeking to help patients. But the economics of TAVR was ever-present given the horde of medical device and hospital officials and industry analysts in the audience.

The committee split on the issue, although a majority of members backed the continued use of volume requirements. The Centers for Medicare & Medicaid Services is expected to decide later this year whether to change its patient volume minimum for TAVR.

Dr. Jason Felger, a heart surgeon who wants his community hospital in San Angelo, Texas, to offer the procedure, said behind the fight over TAVR is protecting profit and revenue. He refers patients to hospitals more than three hours away for the procedure or, if they aren’t willing to travel, they risk their lives to undergo the conventional operation.

Hospitals that offer TAVR, he said, aren’t willing to give up the referrals they now rely on from other hospitals.

“It’s all about the money,” he said.

Improving A Hospital’s Reputation

Unlike open-heart surgery, in which the chest is cracked open to remove the unhealthy valve, TAVR involves threading a catheter tipped with a replacement valve through a blood vessel to the heart. Doctors then implant the new valve. The old valve remains but is pushed aside, and the new one takes over its work.

With this less invasive valve procedure, people can get out of the hospital within two or three days and get back to daily activities much sooner than with open-heart surgery, which typically has a six-week recovery time.

TAVR has been approved by the Food and Drug Administration for people who cannot have open-heart surgery or for whom it would be risky. These include the elderly and frail and people with complications such as kidney and lung disease. But TAVR use has expanded among younger, and less sick, patients in recent years. Within the next year, the FDA is likely to approve the procedure for all patients needing a new aortic valve, industry analysts say.

TAVR does carry risks, including stroke. Patients may also need a pacemaker after the procedure to regulate heart rhythm.

TAVR involves threading a catheter tipped with a replacement valve through a blood vessel to the heart. Doctors then implant the new valve.(Courtesy of Edwards Lifesciences Corp.)

The large majority of patients getting TAVR are 65 and over. The importance of Medicare’s blessing goes beyond its payments, since private insurers typically follow Medicare standards. Physicians seeking to expand use of TAVR point out that Medicare has no volume requirements for other major cardiac procedures.

The two largest TAVR medical device companies are divided on the issue. Edwards Lifesciences Corp. of Irvine, Calif., supports eliminating the minimum-patient requirements, while Minneapolis-based Medtronic favors keeping the status quo. The Advanced Medical Technology Association, or AdvaMed, an industry trade group, also supports the change.

About 50,000 patients are expected to have TAVR this year, and those numbers are forecast to double by 2020, according to American College of Cardiology and other major heart groups.

When Michael Vigil, 50, needed TAVR in May, he drove more than three hours from his home in eastern Wyoming to a hospital in Denver. Before the procedure, the oil-drilling contractor was constantly tired and out of breath — even after mundane chores at home. Vigil’s aortic valve had been damaged from radiation treatments for non-Hodgkin lymphoma decades before.

Vigil was sent home a day after the TAVR procedure. He was back at work the following week.

He said he felt more energized almost immediately after having the procedure.

“It’s worked so well, my wife wishes they dialed it back a little,” Vigil said.

Donnette Smith, president of the patient advocacy group Mended Hearts, said many patients don’t have good access to the procedure.

“Patients do not know of this option unless they walk through the right door of the right hospital,” said Smith of Huntsville, Ala. She had heart valve surgery in 1988.

Mended Hearts receives funding from device makers.

‘Experience Matters’

To gain Medicare approval for TAVR programs, hospitals have to perform annually 50 open-heart valve repairs, 400 angioplasties and 1,000 cardiac catheterizations — a procedure in which medical teams use skills similar to those needed for TAVR.

Doctors at larger hospitals say procedure volume is a good predictor for success. The American College of Cardiology and the Society of Thoracic Surgeons recommend hospitals be able to do at least 50 TAVRs each year within two years of startup. More than three-quarters of the 582 hospitals authorized by Medicare for TAVR meet that standard.

“Whether it’s playing the violin or performing heart surgery, experience matters,” said Dr. Thoralf Sundt, chief of cardiac surgery at Massachusetts General Hospital.

Dr. Ashish Pershad, an interventional cardiologist who performs TAVR at Banner Medical Center in Phoenix, agreed that there are access issues. But he said it’s not because of a lack of programs. Rather, he said, surgeons too often don’t refer patients for it because they make more money from doing the open-heart surgical valve replacement.

“Patients are missing out on this procedure because they are not being referred, and primary care doctors lack knowledge about it,” he said.

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Expanding Treatment Options

Doctors seeking a Medicare rule to widen access say there is little evidence hospitals that perform more TAVRs have lower mortality rates. As long as they can show low mortality and complications, they believe their hospitals should be able to offer the service.

“Our intention is not to lower the quality of outcomes by expanding to ‘low volume’ centers; but to provide excellent care to a larger population of patients,” Felger and his colleagues at Shannon Medical Center in San Angelo, Texas, wrote to the CMS advisory group.

Last year, Felger said, he sent a dozen patients to hospitals in Austin or Dallas for TAVR, while eight other patients opted for the open-heart surgery.

“I have patients tell me they would rather have the surgical procedure at their local hospital than traveling to another city,” he said. “They tell me ‘Let’s do this; if I die, I die.’”

KHN’s coverage of these topics is supported by John A. Hartford Foundation and Gordon and Betty Moore Foundation

Purdue Pharma’s Sales Pitch Downplayed Risks Of Opioid Addiction

Kaiser Health News:Marketplace - August 17, 2018

Two decades ago, Purdue Pharma produced thousands of brochures and videos that urged patients with chronic pain to ask their physicians for opioids such as OxyContin, arguing that concerns over addiction and other dangers from the drugs were overblown, company records reveal.

Kaiser Health News earlier this year posted a cache of Purdue marketing documents that show how the pharmaceutical company sought to boost sales of the prescription painkiller, starting in the mid-1990s.

Purdue turned the records over to the Florida attorney general’s office in 2002 during its investigation of the company. Additional Purdue documents from the Florida investigation detail how the company targeted patients and allayed addiction worries.

“Fear should not stand in the way of relief of your pain,” a pivotal marketing brochure said.

How America Got Hooked On A Deadly Drug

An inside look at how Purdue Pharma pushed OxyContin despite risks of addiction and fatalities.

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Purdue said it handed out thousands of copies of the brochure, which emphasized consumer power in treating pain, as well as a videotape. “The single most important thing for you to remember is that you are the authority on your pain. Nobody else feels it for you so nobody else can describe how much it hurts, or when it feels better,” the pamphlet states.

More than 1,500 pending civil lawsuits, filed mostly by state and local governments, allege that deceptive marketing claims helped fuel a national epidemic of opioid addiction and thousands of overdose deaths.

This week, the New York attorney general’s office filed another suit that accuses Purdue of operating a “public nuisance” in it sales tactics and marketing of opioids. Like many others, the suit demands compensation for addiction treatment costs and other problems. Purdue and other drugmakers have denied all allegations.

President Donald Trump said Thursday he wants the federal government to sue drugmakers in response to the addiction epidemic.

The Purdue brochure from the late 1990s spurred recent criticism from drug safety experts. Dr. G. Caleb Alexander, a physician at the Center for Drug Safety and Effectiveness at Johns Hopkins Bloomberg School of Public Health, said the sales pitch was “simply not true” and called it “a smoking gun.”

“We have learned the hard way that many patients develop opioid [addiction] when using these medicines as prescribed,” he said.

Alexander said other drugmakers also appealed to patients hoping to influence their doctors — a tactic that was relatively new in the late 1990s. But Alexander said he was “shocked” to hear that Purdue did so with OxyContin, given the risks posed by long-term use of the morphine-like narcotic.

“These drugs [opioids] are in a class of their own when it comes to the harms that they have caused,” Alexander said.

The internal Purdue documents, dating from 1996 to 2002, show that the company began marketing OxyContin to doctors in late 1995 for treating moderate to severe cancer pain. With modest sales of $49.4 million in 1996, Purdue posted a loss of $452,000 on the drug. In 1997, sales reached $146.5 million for a pretax profit of $16.5 million, the company records show.

In 1998, as Purdue hawked OxyContin for conditions such as arthritis and back pain, it decided to “increase communications” with patients, company records show.

The goal: “convince patients and their families to actively pursue effective pain treatment. The importance of the patient assessing their own pain and communicating the status to the health care giver will be stressed.”

Purdue’s six-page pamphlet for patients, provided to the Florida attorney general, was titled “OxyContin: A Guide to Your New Pain Medicine.” “Your health care team is there to help, but they need your help, too,” the pamphlet says. It says OxyContin is for treating “pain like yours that is moderate to severe and lasting for more than a few days.”

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To patients or family members worried about addiction, Purdue’s pamphlet said: “Drug addiction means using a drug to get ‘high’ rather than to relieve pain. You are taking opioid pain medication for medical purposes. The medical purposes are clear and the effects are beneficial, not harmful.”

Asked to comment this week, Purdue spokesman Robert Josephson said the company “discontinued the use of this piece many years ago.”

Dr. Michael Barnett, a physician and assistant professor at the Harvard T.H. Chan School of Public Health, said that some of Purdue’s early marketing claims may have seemed reasonable to many doctors 20 years ago.

But he faulted the medical profession for not demanding scientific evidence that opioids were in fact safe and prudent for widespread use.

“I think a lot of physicians are coming to the realization that a lot of what we were taught about pain management was pure conjecture,” he said. “I feel foolish for believing it.”

In hindsight, he said, Purdue’s sales tactics seem “almost a satire of an unscrupulous corporation that really has no interest in understanding the implications and complications of people using their drugs.”

Dr. Art Van Zee, a physician in southwestern Virginia who was among the first to recognize the ravages of OxyContin misuse, said that some people who became addicted were drug abusers.

But he added: “There clearly are people that I’ve taken care of who took it as directed orally and became opioid-addicted.”

Purdue also paid a New York City production company to shoot a videotape called “From One Pain Patient to Another,” featuring testimonials by seven patients from the Raleigh, N.C., area under the care of pain doctor Alan Spanos. Filming took place at the patients’ homes, places of work and other area locations on July 17, 1997, according to the documents.

Purdue did not pay the patients, though Spanos received $3,400 as a “physician spokesman” on that video and another, the company records state. Contacted recently by phone, Spanos would not comment. In the documents, Purdue said that the patients “participated willingly, wishing to speak out regarding the importance to them of being able to receive effective therapy for their chronic pain.”

Between January 1998 and June 2001, Purdue distributed 16,000 copies of the video to doctors, who showed them to selected patients.

Facebook Live: The Marketing Plan That Fueled An Addiction Epidemic

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The video did not mention OxyContin directly, but the Food and Drug Administration did balk at a claim in the video that fewer than 1 percent of people taking opioids became addicted. The FDA said that claim was not substantiated, according to a December 2003 General Accountability Office audit.

Purdue destroyed remaining copies of the video in July 2001, including 4,434 Spanish-language versions, according to the company records.

By then, annual OxyContin sales had topped $1 billion as Purdue pushed to “attach an emotional aspect to non-cancer pain so physicians treat it more seriously and aggressively,” according to the company’s marketing reports.

Asked about the video, Purdue spokesman Josephson said the drugmaker has not made that claim — regarding 1 percent addiction — “in more than 15 years.”

Purdue submitted the marketing records to the Florida attorney general’s office during its investigation of the company. The state settled the case in 2002 when Purdue agreed to pay $2 million to help set up an electronic prescription-tracking program.

Florida officials released the records to two Florida newspapers in 2003 after Purdue lost a court battle to keep them confidential. KHN posted some of those documents earlier this year for readers to review on its website.

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

HHS Secretary Azar Meets with Specialty and Patient Groups Regarding Drug Pricing

HHS Gov News - August 17, 2018

On Wednesday, Secretary Alex Azar met with representatives of specialty-physician and patient groups to discuss the Trump Administration’s efforts to offer new tools for Medicare Advantage plans to negotiate lower drug prices for patients.

The groups included the American Academy of Ophthalmology, the American Cancer Society’s Cancer Action Network, the American College of Rheumatology, the American Society of Clinical Oncologists, and Patients for Affordable Drugs. Secretary Azar was joined by Centers for Medicare & Medicaid Services Principal Deputy Administrator Demetrios Kouzoukas, Senior Advisor for Drug Pricing Reform Dan Best, and Advisor to the Secretary John O’Brien.

Both Secretary Azar and the organizational representatives expressed appreciation for the opportunity to share their views with each other on the recent announcement that Medicare Advantage plans will be able to use step therapy or prior authorization to negotiate lower drug prices for patients. Most of the groups with representatives in attendance have expressed concerns about the new policy.

Representatives offered their individual views on the new policy, included concerns about the complexity and challenges their organizations’ members have faced in prescribing drugs for patients covered by plans that use prior authorization or step therapy. A number of individuals also expressed their support for the administration’s attention to the issue of prescription drug pricing.

Secretary Azar emphasized the department’s interest in innovations and solutions that can address the high price of prescription drugs, and individual attendees offered a number of ideas, including noting their support for concepts put forth in President Trump’s American Patients First blueprint. He also shared his openness to solutions that may alleviate the burden that could be imposed on physicians by the new negotiation tools.

Read the President’s American Patients First blueprint.

Podcast: KHN’s ‘What The Health?’ See You In Court!

Julie Rovner

Kaiser Health News


Read Julie's Stories Kimberly Leonard

Washington Examiner


Read Kimberly's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

A federal district court judge in Texas has set Sept. 10 as the date for oral arguments in a case filed by Republican state attorneys general and governors from 20 states. Their lawsuit charges that the Affordable Care Act should be found unconstitutional following Congress’ elimination of the tax penalty for failing to have insurance. That date is less than two months before the critical midterm election that will determine which party controls Congress.

Meanwhile, a group of cities whose leaders support the health law have also filed suit. They charge that President Donald Trump has violated his constitutional duty to “take care” to “faithfully execute” laws passed by Congress in relation to the ACA. They say the damage done to the law by the Trump administration has raised health costs in their jurisdictions.

Also in court this week were Medicaid recipients from Arkansas, who say the state’s new work requirements for healthy people getting such coverage threatens their health care.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Alice Ollstein of Talking Points Memo, Margot Sanger-Katz of The New York Times and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • The timing of the arguments in the attorneys general’s ACA case — and the possibility of a quick decision — could remind midterm voters that the GOP is still vowing to get rid of the law. On the other hand, some Republicans are hoping that the case will help fire up the base, which in the past has responded well to the party’s criticisms of the law.
  • The attorneys general in Missouri and West Virginia are among those bringing the suit — and they are also challenging incumbent Senate Democrats. Their political futures could be closely tied to the suit.
  • As Arkansas’ work requirements move to a court case, the state announced that thousands of people are in danger of losing coverage because they did not report their work hours online, as required.
  • Despite the administration’s strong opposition to the ACA, officials are divided over whether to allow states to accept only a partial expansion of Medicaid under the law. That would save money for the states — who shoulder part of the cost of Medicaid — but likely would cost the federal government more because many people who ordinarily would qualify for Medicaid would instead move to the health insurance marketplace and get federal subsidies.
  • Hospitals are watching with concern the Democratic debate over setting up a national, single-payer health system. Savings that the Democrats expect from such a move would likely have to come from hospitals’ and doctors’ revenues.

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

Julie Rovner: The Washington Examiner’s “Hospitals Present a Major Roadblock to Medicare for All Act,” by Kimberly Leonard

Also, Rovner mentioned a 2009 story: The New Yorker’s “Getting There From Here” by Atul Gawande

Margot Sanger-Katz: Kaiser Family Foundation’s “An Analysis Of Out-Of-Network Claims In Large Employer Health Plans,” by Gary Claxton, Matthew Rae, Cynthia Cox and Larry Levitt

Alice Ollstein: STAT News’ “Tapered To Zero: In Radical Move, Oregon’s Medicaid Program Weighs Cutting Off Chronic Pain Patients From Opioids,” by Lev Facher

Kimberly Leonard: Pew Stateline’s “For Addicted Women, the Year After Childbirth Is The Deadliest,” by Christine Vestal

To hear all our podcasts, click here.

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