Health Care

You’ve reached a standstill with your mother and father, who are in their late 80s. You think they need some help in the home, but they vigorously refuse. You’re frustrated because you want to make their lives easier. They’re angry because they think you’re interfering in their affairs.

Can negotiation and dispute resolution techniques used in the business world help defuse these kinds of conflicts?

Yes, say a group of researchers at Northwestern University. And they’re on to something.

These experts have developed a training curriculum on negotiation and dispute resolution for social workers, care managers, and health care professionals who regularly work with resistant older adults. Materials for family caregivers are being developed, too.

Instead of avoiding difficult issues or simply telling people what to do (“You’ll need home health aides several times a week for the foreseeable future”), professionals learn to elicit what’s most important to older adults and approach arranging care as a collaboration, not an edict from on high.

“People get into so many arguments when they get older. It’s something I see every day in my work,” said Lee Lindquist, chief of geriatrics at Northwestern University’s Feinberg School of Medicine, who’s leading the project. Its goal is to de-escalate conflicts and make it easier for older people to receive needed support, she said.

In May, Lindquist and her team planned to launch another part of the project: a trial of a computer-based training program for family caregivers of people with mild cognitive impairment or early-stage dementia. The program, called NegotiAge, features avatars of older adults and allows caregivers to practice negotiation techniques under different scenarios.

“You get thrown different situations, different emotions, and you get to play the game of negotiation as often as you want,” Lindquist said. Nearly $4 million in funding for the project comes from the National Institutes of Health. After evaluating the program’s effectiveness, Lindquist hopes to make NegotiAge widely available.

In the meantime, there are several steps family caregivers can take to forestall or resolve conflicts with older parents.

Prepare

Preparation is essential for any type of negotiation, advised Jeanne Brett, professor emerita of dispute resolution and organizations at Northwestern’s Kellogg School of Management and a member of the NegotiAge team. “You want to think through answers to several fundamental questions: What issues need to be addressed? Who are the parties invested in these issues? What are the parties’ positions on each of these issues? Why do you believe they’re taking those positions? And what’s going to happen if we can’t reach an agreement?”

It’s helpful to write down answers to these questions in a planning document. Be sure to include yourself among the parties and spell out your goals for the conversations to come.

What might this look like in practice? Let’s say you want your father, who’s in his early 90s, to stop driving, because he’s started getting lost and his vision isn’t great. The people with a stake in the discussion include your father, your elderly mother, you, your two siblings, and your father’s physician.

Your mom may be concerned about your father’s safety but hesitant to raise the issue for fear of provoking an argument. One of your siblings may agree it’s time to take away the car keys, while the other may think Dad is still fine on the road. The doctor may recommend a driving evaluation and subsequently offer his professional opinion.

Look for Common Interests

Your job is to find areas where these parties’ interests intersect and work from there. Everyone wants your father to remain active and see his friends on a regular basis. Everyone wants to ensure he doesn’t injure himself or anyone else on the road. Everyone wants to respect his desire for independence. No one wants to label him incompetent.

Brett distinguishes between positions, such as “I’m not going to stop driving,” and interests, or the reasons why someone takes a position. In this case, Dad may be afraid of becoming isolated, losing autonomy, or giving up control over his affairs. But he, too, may worry about hurting somebody else unintentionally.

Negotiations have the best chance of success when they address the interests of all the parties involved, Brett noted. Don’t adopt an adversarial approach. Rather, emphasize that you’re on the same team. The goal isn’t for one side to win; it’s for people to work together to find a solution to the issue at hand.

Ask Questions

Don’t assume you know why your parent is taking a certain position (“I don’t want to go to the doctor”). Instead, ask follow-up questions, such as “Why?” or “Why not?”

If an older person snaps, “I don’t want to talk about it,” don’t back away. Acknowledge their discomfort by saying, “I understand this is difficult,” while adding, “I care about you and I want to know more.”

Lindquist favors starting difficult discussions with patients with open-ended questions: “What are some things you’re having issues with? What are you doing that you wish you could be doing differently? What would make your life easier?”

Listening carefully and making the person you’re negotiating with feel heard and respected is essential. If one of Lindquist’s patients tells her, “I make my own choices, and this is what I want,” she might respond, “I agree you’re the boss, but we’re both here to make your life better, and I’m worried about you.”

Brainstorm Strategies

Negotiations with family members are often charged with emotions that can easily spiral out of control. But don’t reciprocate if someone gets angry and lashes out.

“When you’re buying a car, if you can’t agree with the dealer you’re talking to, you can go to another dealer. When you’re in a conflict with a family member, you don’t have this option. You’ve got more stubbornness and more defensiveness about disabilities,” Brett said, “and preserving relationships is even more important.”

Redirect your focus to brainstorming strategies that can help solve the problem at hand. Get creative and put lots of options on the table. Invite your parent to respond and ask “Why?” or “Why not?” again as needed.

If you find yourself going round and round without making progress, try saying something like, “We could argue about this all afternoon, but neither one of us is going to give in. Let’s set aside our arguments and come up with five ways that you can get to activities without your car,” Brett said.

Don’t expect to agree on a strategy right away. “You can say, ‘Let’s bring in Mom and talk about this later,’ or, ‘Let’s think about this and check in with each other next week,’” Lindquist suggested, noting that many negotiations take time and can’t be rushed.

Bring In a Third Party

If all else fails, appeal to a third party. This was Brett’s strategy when her husband, who has Parkinson’s disease and compromised vision, wanted to resume driving in 2021 after recovering from a serious fall. Brett and the couple’s daughter couldn’t convince him this might be risky, but the older man, then 89, agreed to get a driving evaluation at a facility associated with a Chicago hospital. When they recommended he stop driving, he gave up the car keys.

Brett later hired a neighbor in the small town in France where they now live to ferry her husband to appointments several times a week. Twice a week, she drives him to a nearby village where he has coffee with friends. He gets out into the world and she doesn’t worry about safety — an outcome both can live with.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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NEW ORLEANS — Erin Brown recalls all too well the dreadful call he received from his mother in 2021, while in the thralls of the covid-19 pandemic: His cousin — his “brother” — had been shot six times.

Although it was not the first time gun violence had reached the then-17-year-old Brown’s social circle, that incident was different. It involved family. So it hit Brown harder, even though his cousin, then 21, survived the gunshot wounds.

Now, while Brown works toward high school graduation and a career in graphic design, he said, he stays indoors in his neighborhood, the Lower 9th Ward. The frequent accidental shootings there frighten him the most. The gunfire outside his windows makes it hard to sleep.

“We were all just quarantined, now we can’t even go outside,” said Thomas Turner, 17, Brown’s classmate at the campus of the NET: Gentilly charter school, in New Orleans’ Gentilly neighborhood. “Just because you want to shoot and stuff, I feel like that is just locking us back in our room.”

It’s an all-too-common feeling in pockets of this city — which had one of the nation’s highest rates of homicides among large cities in 2022 — and other communities across the country where shots ring out regularly. As gun violence soars nationwide, children’s health experts are advocating for such traumatic exposure to be considered what’s known as an “adverse childhood experience.”

For decades, the definition for these adverse childhood events has excluded exposure to community gun violence. That means young people exposed to shootings outside the home have been without access to the broad range of intervention efforts and support at various stages of life given to youth facing other forms of traumatic events, such as child abuse or household dysfunction, said Nina Agrawal, a pediatrician who has researched how such experiences have been handled.

“We need to start recognizing that our children are experiencing trauma and it may not show up overtly, but we have to start recognizing it and listening,” said Agrawal, who chairs the Gun Safety Committee for the New York state chapter of the American Academy of Pediatrics.

Agrawal’s young patients who have witnessed the effects of gun violence are developing chest pain, headaches, and other health concerns, a commonality among youth experiencing a lack of sleep due to gun violence paranoia, she said. The more time a child spends on high alert, the more disruptions to the immune system and brain function occur, as well as effects on mental and behavioral health, said Agrawal.

For Turner, it was the day of his grandmother’s funeral in 2021 that brought gun violence too close to home. As young children and older relatives gathered to honor her life in the Holly Grove neighborhood, shots were fired outside the church.

Turner recalled how his first instinct was to find his younger sister and mother, who were also attending the funeral. Although he is relieved that the suspect in the shooting was arrested — something locals complain is rare — Turner said he now feels as if he’s susceptible to such capricious violence while living in New Orleans.

Gun injuries, including suicides, are the leading cause of death for children and teens nationwide. But the Centers for Disease Control and Prevention does not differentiate which injuries come from stray bullets, and electronic health records don’t typically record how patients feel about their safety. So Agrawal regularly asks her patients if they feel safe at home, school, and other places.

Brown and Turner are aware of the ever-present risk, so they channel their energy into the classroom, where they recently competed, with a small group of fellow NET students, in the national Aspen Challenge, aiming to pinpoint societal solutions to curb the epidemic of gun violence and reduce the damage it causes to mental health. The group, Heal NOLA, recommended coping mechanisms such as creating artwork and encouraging anonymous story-sharing of the mental trauma through social media. They also said the normalization of gun violence needs to end.

Before debuting their proposals in competition, Turner and classmate Chainy Smith spoke at a city-sponsored public safety summit in early April about how the internet and social media further the culture of gun ownership as self-defense. They advocated for a cultural shift in which flaunting one’s gun doesn’t earn respect and popularity.

For them, mental health resources are available inside the halls of the NET, the students said, and the intimate classroom where they work on the Aspen Challenge feels like a safe space for emotional processing. But Turner, Brown, and their other classmates know that isn’t always the reality elsewhere — outside of school, they said, they’ve been told by family and other adults that they are too young to understand depression.

Terra Jerome, a student participating in the Aspen project, said that when she has spoken out about mental health she feels as if no one understands where she is coming from. “Like, you’re not getting what I’m saying,” she said.

And the veneer of safety disappears when they leave school each day.

During spring break, two students from the school died in separate shootings.

“New Orleans is very traumatized,” said Erin Barnard, the Heal NOLA faculty adviser. “Everybody seems to know that everyone’s traumatized, but then, what are we doing to get out of that?”

Brown and Turner each worry about what lies beyond for them — and for their mothers — when they leave home. Both are close to their moms. They can talk openly about mental health with them, something they realize isn’t the case for every kid.

This element of being heard is a crucial intervention, Agrawal said. She said medical research needs to further understand the effects of youth isolation, adding that she has seen how it leads to increased rates of mental health problems, from intergenerational trauma to suicidal ideation. The younger children are when exposed to gun violence, she said, the higher their susceptibility to post-traumatic stress disorder. She is advocating for intervention for children under age 5 and before they’re exposed to gun violence.

Rather than feel the all-too-common urge of retaliation, Turner and Brown reflect on the incidents from a mental health perspective, wondering what was going on in the heads of the individuals who carried out the shootings.

“It all leads back to mental health, because why is that person carrying a gun in the first place?” Turner said.

Turner said he sees things he shouldn’t have by age 17. But he said his fear may not always be visible to others when he is on the basketball court, in the gym, or at the Uptown pizza spot that employs him. He’s just trying to live his life, he said. He hopes to become a firefighter and, someday, have kids. He said he doesn’t want them to endure such mental trauma.

For now, Turner feels it is his role to get the word out that young people are hurting mentally.

“If somebody need a hug, just a hug, I don’t have to know you, I’ll give you a hug,” said Turner. “You want to talk to me and tell me anything? I’m going to sit here and listen, because I’d want someone to do that for me.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Policy analysts, Democrats, and Republicans dissatisfied with the deal agree: Federal health programs have dodged a budgetary bullet in the Washington showdown over raising the nation’s debt ceiling.

A compromise bill — approved in a bipartisan vote by the House of Representatives on Wednesday night and expected to pass the Senate before the June 5 deadline — includes some trims and caps on health spending for the next two years.

But the deal spares health programs like Medicaid from the deep cuts approved in April by the Republican-led House. The bill suspends the debt ceiling — the federal government’s borrowing limit — until January 1, 2025, after the next presidential election.

The need for Congress to act to avoid an unprecedented debt default and its rippling economic consequences gave House Republicans leverage to extract spending concessions from Democrats. But in the end the compromise bill, negotiated primarily by House Speaker Kevin McCarthy and Biden administration officials, limits health spending only slightly.

The most conservative Republicans said they are outraged at what they see as a giveaway to Democrats. “It is a bad deal,” said Rep. Chip Roy (R-Texas), one of the bill’s most outspoken opponents, during a news conference at the Capitol. “No one sent us here to borrow an additional $4 trillion to get absolutely nothing in return.”

Besides the spending limits, the main health-related concession made by Democrats is the clawback of about $27 billion in money appropriated for covid-related programs but not yet spent.

Only a portion of the money being reclaimed from covid programs is specifically health-related; money is also being returned to the federal government from programs centered on housing and transportation, for example.

Of the unspent covid funds, according to the Congressional Budget Office, the biggest single rescission is nearly $10 billion from the Public Health and Social Services Emergency Fund. The CDC would have to give back $1.5 billion. But exempted from those health-related givebacks are “priority” efforts such as funding for research into next-generation covid vaccines; long covid research; and efforts to improve the pharmaceutical supply chain.

“The deal appears to have minimal effect on the health sector,” concluded Capital Alpha Partners, a Washington-based policy strategy firm.

That would not have been the case with the House Republicans’ “Limit, Save, Grow Act,” their first offer to raise the debt ceiling and slow — in some areas dramatically — the growth of federal spending. That bill would have reduced the federal deficit by nearly $5 trillion over the next decade, including through more than $3 trillion in cuts to domestic discretionary programs, which account for roughly 15 percent of federal spending. A part of that 15 percent goes to health programs, including the National Institutes of Health, the Centers for Disease Control and Prevention, and the FDA.

The Republican bill would also have imposed nationwide work requirements on the Medicaid health program, a proposal that was vehemently opposed by Democrats in Congress and the Biden administration.

Democrats argued that such requirements would not increase work but rather would separate eligible people from their health insurance for failing to complete required paperwork. That is already happening, according to a KFF Health News analysis, as states begin to trim rolls following the end of the covid public health emergency.

The compromise bill, however, leaves untouched the major federal health programs, Medicare and Medicaid — amounting to a political victory for Democrats, who prioritized protecting entitlement programs. The deal includes no new work requirements for Medicaid.

The bill also freezes other health spending at its current level for the coming fiscal year and allows for a 1% increase the following year. It will be up to the House and Senate Appropriations Committees to determine later exactly how to distribute the funds among the discretionary programs whose spending levels they oversee.

Advocacy groups have argued that even a funding freeze hurts programs that provide needed services to millions of Americans. The result, said Sharon Parrott, president of the liberal Center on Budget and Policy Priorities, “will still be cuts overall in key national priorities when the very real impact of inflation is taken into account.”

Even less happy, however, are conservatives who had hoped the debt ceiling fight would give them a chance to take a much bigger bite out of federal spending.

“Overall, this agreement would continue America’s trajectory towards economic destruction and expanded federal control,” Kevin Roberts, president of the conservative Heritage Foundation, said in a statement.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Host Julie Rovner KFF Health News @jrovner Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

This week, KFF Health News’ weekly policy news podcast — “What the Health?” — celebrates its 300th episode with a wide-ranging discussion of what’s happened in health policy since it launched in 2017 and what may happen in the next decade.

For this special conversation, host and chief Washington correspondent Julie Rovner is joined by three prominent “big thinkers” in health policy: Ezekiel Emanuel of the University of Pennsylvania; Jeff Goldsmith, president of Health Futures; and Farzad Mostashari, CEO of Aledade.

Among the takeaways from this week’s episode:

• Since 2017, dissatisfaction has permeated the U.S. health care system. The frustrations of providers, patients, and others in the field point to a variety of structural problems — many of which are challenging to address through policymaking due to the strength of interest-group politics. The emergence of the huge, profitable “SuperMed” firm UnitedHealth Group and the rise of urgent virtual care have also transformed health care in recent years.
• As high costs and big profits dominate the national conversation, lawmakers and policymakers have delivered surprises, including the beginnings of regulation of drug prices. Even the Trump administration, with its dedication to undermining the Affordable Care Act, demonstrated interest in encouraging competition. Meanwhile, on the clinical side, a number of pharmaceuticals are proving especially effective at reducing hospitalizations.
• Looking forward, the face of insurance is changing. Commercial insurance is seeing profits evaporate, private Medicare Advantage plans are draining taxpayer dollars, and employers are making expensive, short-sighted coverage decisions. Some stakeholders see a critical need to reconsider how to be more efficient and effective at delivering care in the United States.
• The deterioration of the patient’s experience signals a major disconnect between the organizational problems providing care and the everyday dedication of individual providers: The local hospital may provide excellent service to a patient experiencing a heart attack, yet Medicare will not pay for patients to have blood pressure cuffs at home, for instance. Low reimbursements for primary care providers exacerbate these problems.

Plus, our experts — drawing on extensive experience making government and private-sector policy and even practicing medicine — name their top candidates for attainable improvements that would make a big difference in the health care system.

Further reading by the panelists from this week’s episode:

• Health Affairs’ “Nine Health Care Megatrends, Part 1: System and Payment Reform,” by Ezekiel J. Emanuel.
• Health Affairs’ “We Have a National Strategy for Accountable Care, So What’s Next?” by Sean Cavanaugh, Mandy K. Cohen, and Farzad Mostashari.
• The Health Care Blog’s “What Can We Learn From the Envision Bankruptcy?” by Jeff Goldsmith.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ ‘What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This week, a federal appeals court ruling concerning opioid manufacturer Purdue Pharma spared its owner, the Sackler family, from further civil litigation in exchange for a $6 billion settlement.

KFF Health News senior correspondent Aneri Pattani appeared on PBS NewsHour to discuss the ruling and her reporting into the ongoing distribution of more than $54 billion in opioid settlement funds.

Pattani also participated in a May 9 panel discussion on “Spotlight PA” investigating how Pennsylvania might spend the $1 billion it’s receiving through the opioid settlement.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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More than 600,000 Americans have lost Medicaid coverage since pandemic protections ended on April 1. And a KFF Health News analysis of state data shows the vast majority were removed from state rolls for not completing paperwork.

Under normal circumstances, states review their Medicaid enrollment lists regularly to ensure every recipient qualifies for coverage. But because of a nationwide pause in those reviews during the pandemic, the health insurance program for low-income and disabled Americans kept people covered even if they no longer qualified.

Now, in what’s known as the Medicaid unwinding, states are combing through rolls and deciding who stays and who goes. People who are no longer eligible or don’t complete paperwork in time will be dropped.

The overwhelming majority of people who have lost coverage in most states were dropped because of technicalities, not because state officials determined they no longer meet Medicaid income limits. Four out of every five people dropped so far either never returned the paperwork or omitted required documents, according to a KFF Health News analysis of data from 11 states that provided details on recent cancellations. Now, lawmakers and advocates are expressing alarm over the volume of people losing coverage and, in some states, calling to pause the process.

KFF Health News sought data from the 19 states that started cancellations by May 1. Based on records from 14 states that provided detailed numbers, either in response to a public records request or by posting online, 36% of people whose eligibility was reviewed have been disenrolled.

In Indiana, 53,000 residents lost coverage in the first month of the unwinding, 89% for procedural reasons like not returning renewal forms. State Rep. Ed Clere, a Republican, expressed dismay at those “staggering numbers” in a May 24 Medicaid advisory group meeting, repeatedly questioning state officials about forms mailed to out-of-date addresses and urging them to give people more than two weeks’ notice before canceling their coverage.

Clere warned that the cancellations set in motion an avoidable revolving door. Some people dropped from Medicaid will have to forgo filling prescriptions and cancel doctor visits because they can’t afford care. Months down the line, after untreated chronic illnesses spiral out of control, they’ll end up in the emergency room where social workers will need to again help them join the program, he said.

Before the unwinding, more than 1 in 4 Americans — 93 million — were covered by Medicaid or CHIP, the Children’s Health Insurance Program, according to KFF Health News’ analysis of the latest enrollment data. Half of all kids are covered by the programs.

About 15 million people will be dropped over the next year as states review participants’ eligibility in monthly tranches.

Most people will find health coverage through new jobs or qualify for subsidized plans through the Affordable Care Act. But millions of others, including many children, will become uninsured and unable to afford basic prescriptions or preventive care. The uninsured rate among those under 65 is projected to rise from a historical low of 8.3% today to 9.3% next year, according to the Congressional Budget Office.

Because each state is handling the unwinding differently, the share of enrollees dropped in the first weeks varies widely.

Several states are first reviewing people officials believe are no longer eligible or who haven’t recently used their insurance. High cancellation rates in those states should level out as the agencies move on to people who likely still qualify.

In Utah, nearly 56% of people included in early reviews were dropped. In New Hampshire, 44% received cancellation letters within the first two months — almost all for procedural reasons, like not returning paperwork.

But New Hampshire officials found that thousands of people who didn’t fill out the forms indeed earn too much to qualify, according to Henry Lipman, the state’s Medicaid director. They would have been denied anyway. Even so, more people than he expected are not returning renewal forms. “That tells us that we need to change up our strategy,” said Lipman.

In other states, like Virginia and Nebraska, which aren't prioritizing renewals by likely eligibility, about 90% have been renewed.

Because of the three-year pause in renewals, many people on Medicaid have never been through the process or aren’t aware they may need to fill out long verification forms, as a recent KFF poll found. Some people moved and didn’t update their contact information.

And while agencies are required to assist enrollees who don’t speak English well, many are sending the forms in only a few common languages.

Tens of thousands of children are losing coverage, as researchers have warned, even though some may still qualify for Medicaid or CHIP. In its first month of reviews, South Dakota ended coverage for 10% of all Medicaid and CHIP enrollees in the state. More than half of them were children. In Arkansas, about 40% were kids.

Many parents don’t know that limits on household income are significantly higher for children than adults. Parents should fill out renewal forms even if they don’t qualify themselves, said Joan Alker, executive director of the Georgetown University Center for Children and Families.

New Hampshire has moved most families with children to the end of the review process. Lipman, the state’s Medicaid director, said his biggest worry is that a child will end up uninsured. Florida also planned to push kids with serious health conditions and other vulnerable groups to the end of the review line.

But according to Miriam Harmatz, advocacy director and founder of the Florida Health Justice Project, state officials sent cancellation letters to several clients with disabled children who probably still qualify. She’s helping those families appeal.

Nearly 250,000 Floridians reviewed in the first month of the unwinding lost coverage, 82% of them for reasons like incomplete paperwork, the state reported to federal authorities. House Democrats from the state petitioned Republican Gov. Ron DeSantis to pause the unwinding.

Advocacy coalitions in both Florida and Arkansas also have called for investigations into the review process and a pause on cancellations.

The state is contacting enrollees by phone, email, and text, and continues to process late applications, said Tori Cuddy, a spokesperson for the Florida Department of Children and Families. Cuddy did not respond to questions about issues raised in the petitions.

Federal officials are investigating those complaints and any other problems that emerge, said Dan Tsai, director of the Center for Medicaid & CHIP Services. “If we find that the rules are not being followed, we will take action.”

His agency has directed states to automatically reenroll residents using data from other government programs like unemployment and food assistance when possible. Anyone who can’t be approved through that process must act quickly.

“For the past three years, people have been told to ignore the mail around this, that the renewal was not going to lead to a termination.” Suddenly that mail matters, he said.

Federal law requires states to tell people why they’re losing Medicaid coverage and how to appeal the decision.

Harmatz said some cancellation notices in Florida are vague and could violate due process rules. Letters that she’s seen say “your Medicaid for this period is ending” rather than providing a specific reason for disenrollment, like having too high an income or incomplete paperwork.

If a person requests a hearing before their cancellation takes effect, they can stay covered during the appeals process. Even after being disenrolled, many still have a 90-day window to restore coverage.

In New Hampshire, 13% of people deemed ineligible in the first month have asked for extra time to provide the necessary records. “If you're eligible for Medicaid, we don't want you to lose it,” said Lipman.

Clere, the Indiana state representative, pushed his state’s Medicaid officials during the May meeting to immediately make changes to avoid people unnecessarily becoming uninsured. One official responded that they’ll learn and improve over time.

“I’m just concerned that we’re going to be ‘learning’ as a result of people losing coverage,” Clere replied. “So I don’t want to learn at their expense.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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At least eight states this year have decided to seek federal approval to extend postpartum Medicaid coverage, leaving just a handful that have opted not to guarantee at least a year of health care for women during that critical period after pregnancy.

The new states on the list include Montana, where lawmakers in the recently ended legislative session voted for a state budget that contains $6.2 million in state and federal funds over the next two years to extend continuous postpartum eligibility from 60 days to 12 months after pregnancy. That would ensure coverage for between 1,000 and 2,000 additional parents in the state each year, according to federal and state estimates.

Maggie Clark, the program director for Georgetown University’s Center for Children and Families, has been tracking statehouse bills to expand postpartum coverage under Medicaid, the federal-state health insurance program for low-income people. What’s driving the wave is the recognition by policymakers of all political affiliations that the U.S. is in a maternal health crisis, she said. Maternal mortality rates increased during the pandemic, particularly among non-Hispanic Black women, according to the Centers for Disease Control and Prevention.

“Whether you’re conservative, liberal, or somewhere in between, people are really supportive of maternal health and helping moms and babies get a good start,” Clark said.

More than 4 in 10 births in the U.S. are covered under Medicaid. But the default postpartum coverage period is 60 days.

State by state, momentum has been building to ensure that new mothers’ medical care isn’t interrupted by loss of health care coverage. The American Rescue Plan Act made it easier for states to extend postpartum Medicaid coverage by allowing them to simply amend their Medicaid plans instead of applying for a full waiver from the Centers for Medicare & Medicaid Services.

Besides Montana, legislators in Alaska, Mississippi, Missouri, Texas, Utah, and Wyoming passed measures this year to extend postpartum Medicaid coverage from 60 days to a year. States must submit amendments to their Medicaid plans to federal officials for approval. South Dakota officials submitted a proposed amendment to the state’s Medicaid plan in March.

That amendment is pending with CMS, which has approved 12-month postpartum coverage plans for 33 states and Washington, D.C., as of May 30. New York and Vermont also have applications pending, and the states with newly passed measures are expected to submit theirs soon. It typically takes a couple of months for CMS to approve state Medicaid plan amendments to extend postpartum coverage, Clark said.

Lawmakers in Nebraska, Nevada, New Hampshire, and Wisconsin are considering measures to extend postpartum Medicaid coverage to 12 months.

Three other states considered but failed to pass legislation this year that would have authorized 12 months of postpartum Medicaid coverage: Idaho; Iowa; and Arkansas, which has the nation’s highest reported maternal mortality rate, according to the CDC.

Support in statehouses for such measures has been mostly bipartisan at a time of polarizing debate over reproductive health policy since the U.S. Supreme Court overturned Roe v. Wade last year.

Abortion has crept into the debate in some instances. The Texas House, for example, passed a 12-month postpartum coverage bill in April, only to see the measure amended in the state Senate to bar coverage for women after an abortion. After negotiations, the bill that passed said, “Medicaid coverage is extended for mothers whose pregnancies end in the delivery of the child or end in the natural loss of the child,” leading some to worry that federal officials won’t approve the amendment to the state plan.

The bill is headed to Republican Gov. Greg Abbott, who has said he supports the measure.

Extended postpartum coverage allows new parents to establish a relationship with their health provider and manage their care and chronic illnesses without a disruption in insurance coverage. Continuous care is particularly important in the first year after birth, when patients face an increased risk of post-pregnancy complications and a significant number of maternal deaths occur from suicide and substance use, said Annie Glover, a senior research scientist at the University of Montana’s Rural Institute for Inclusive Communities.

“The year that follows the delivery is a very vulnerable year for the pregnant person,” Glover said. “They have a new infant in their family, and this is a time when they probably need health care more than ever.”

It’s particularly important to provide access to mental health and substance use treatment, said Stephanie Morton, the director of programs and impact for the nonprofit Healthy Mothers, Healthy Babies: the Montana Coalition. “We know that suicide and overdose combined are a leading cause of death for new mothers,” she said.

Montana’s Republican governor, Greg Gianforte, included the postpartum coverage extension in his original budget proposal last fall. But a moment of confusion occurred on May 22 when Gianforte vetoed a bill that would have directed how certain provisions of the state budget are implemented, including the postpartum coverage extension. State health officials and the bill’s sponsor, Republican Rep. Bob Keenan, said the veto does not affect the ability of the state to extend postpartum Medicaid coverage.

“Supporting new mothers and infants by extending Medicaid coverage for up to 12 months postpartum was a top priority for the governor and his administration this session,” said state Department of Public Health and Human Services Director Charlie Brereton in an emailed statement. “We’re thankful for the Legislature’s support.”

States were not allowed to drop most beneficiaries from their programs during the covid-19 pandemic, so parents losing Medicaid coverage after the birth of a child wasn’t an issue. But states are reviewing their Medicaid rolls now that the public health emergency has ended. The Biden administration has estimated that 15 million people could lose Medicaid as a result.

That could include some people who would qualify for postpartum coverage in states whose approval of the extension is pending. But state agencies have a lot of discretion in how they redetermine Medicaid enrollment, and Clark said she expects they will do what they can to make sure new parents don’t lose coverage as part of what’s being called the Medicaid unwinding.

“We hope the state agencies would honor the wishes of the legislature,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The federal government is reconsidering a decision that breast cancer patients, plastic surgeons, and members of Congress have protested would limit women’s options for reconstructive surgery.

On June 1, the Centers for Medicare & Medicaid Services plans to reexamine how doctors are paid for a type of breast reconstruction known as DIEP flap, in which skin, fat, and blood vessels are harvested from a woman’s abdomen to create a new breast.

The procedure offers potential advantages over implants and operations that take muscle from the abdomen. But it’s also more expensive. If patients go outside an insurance network for the operation, it can cost more than $50,000. And, if insurers pay significantly less for the surgery as a result of the government’s decision, some in-network surgeons would stop offering it, a plastic surgeons group has argued.

The DIEP flap controversy, spotlighted by CBS News in January, illustrates arcane and indirect ways the federal government can influence which medical options are available — even to people with private insurance. Often, the answers come down to billing codes — which identify specific medical services on forms doctors submit for reimbursement — and the competing pleas of groups whose interests are riding on them.

Medical coding is the backbone for “how business gets done in medicine,” said Karen Joynt Maddox, a physician at Washington University School of Medicine in St. Louis who researches health economics and policy.

CMS, the agency overseeing Medicare and Medicaid, maintains a list of codes representing thousands of medical services and products. It regularly evaluates whether to add codes or revise or remove existing ones. Last year, it decided to eliminate a code that has enabled doctors to collect much more money for DIEP flap operations than for simpler types of breast reconstruction.

In 2006, CMS established an “S” code — S2068 — for what was then a relatively new procedure: breast reconstructions with deep inferior epigastric perforator flap, or DIEP flap. S codes temporarily fill gaps in a parallel system of billing codes known as CPT codes, which are maintained by the American Medical Association, a physician group.

Codes don’t dictate the amounts private insurers pay for medical services; those reimbursements are generally worked out between insurance companies and medical providers. However, using the narrowly targeted S code, doctors and hospitals have been able to distinguish DIEP flap surgeries, which require complex microsurgical skills, from other forms of breast reconstruction that take less time to perform and generally yield lower insurance reimbursements.

CMS announced in 2022 that it planned to eliminate the S code at the end of 2024 — a move some doctors say would slash the amount surgeons are paid. (To be precise, CMS announced it would eliminate a series of three S codes for similar procedures, but some of the more outspoken critics have focused on one of them, S2068.) The agency’s decision is already changing the landscape of reconstructive surgery and creating anxiety for breast cancer patients.

Kate Getz, a single mother in Morton, Illinois, learned she had cancer in January at age 30. As she grappled with her diagnosis, she said, it was overwhelming to think about what her body would look like over the long term. She pictured herself getting married one day and wondered “how on earth I would be able to wear a wedding dress with only having one breast left,” she said.

She thought a DIEP flap was her best option and worried about having to undergo repeated surgeries if she got implants instead. Implants generally need to be replaced every 10 years or so. But after she spent more than a month trying to get answers about how her DIEP flap surgery would be covered, Getz’s insurer, Cigna, informed her it would use a lower-paying CPT code to reimburse her physician, Getz said. As far as she could see, that would have made it impossible for Getz to obtain the surgery.

Paying out-of-pocket was “not even an option.”

“I’m a single mom. We get by, right? But I’m not, not wealthy by any means,” she said.

Cost is not necessarily the only hurdle patients seeking DIEP flaps must overcome. Citing the complexity of the procedure, Getz said, a local plastic surgeon told her it would be difficult for him to perform. She ended up traveling from Illinois to Texas for the surgery.

The government’s plan to eliminate the three S codes was driven by the Blue Cross Blue Shield Association, a major lobbying organization for health insurance companies. In 2021, the group asked CMS to discontinue the codes, arguing that they were no longer needed because the American Medical Association had updated a CPT code to explicitly include DIEP flap surgery and the related operations, according to a CMS document.

For years, the American Medical Association advised doctors that the CPT code was appropriate for DIEP flap procedures. But after the government’s decision, at least two major insurance companies told doctors they would no longer reimburse them under the higher-paying codes, prompting a backlash.

Physicians and advocacy groups for breast cancer patients, such as the nonprofit organization Susan G. Komen, have argued that many plastic surgeons would stop providing DIEP flap procedures for women with private insurance because they wouldn’t get paid enough.

Lawmakers from both parties have asked the agency to keep the S code, including Rep. Debbie Wasserman Schultz (D-Fla.) and Sen. Amy Klobuchar (D-Minn.), who have had breast cancer, and Sen. Marsha Blackburn (R-Tenn.).

CMS at its June 1 meeting will consider whether to keep the three S codes or delay their expiration.

In a May 30 statement, Blue Cross Blue Shield Association spokesperson Kelly Parsons reiterated the organization’s view that “there is no longer a need to keep the S codes.”

In a profit-driven health care system, there’s a tug of war over reimbursements between providers and insurance companies, often at the expense of patients, said Joynt Maddox, the Washington University physician.

“We’re in this sort of constant battle” between hospital chains and insurance companies “about who’s going to wield more power at the bargaining table,” Joynt Maddox said. “And the clinical piece of that often gets lost, because it’s not often the clinical benefit and the clinical priority and the patient centeredness that’s at the middle of these conversations.”

Elisabeth Potter, a plastic surgeon who specializes in DIEP flap surgeries, decided to perform Getz’s surgery at whatever price Cigna would pay.

According to Fair Health, a nonprofit that provides information on health care costs, in Austin, Texas — where Potter is based — an insurer might pay an in-network doctor $9,323 for the surgery when it’s billed using the CPT code and $18,037 under the S code. Those amounts are not averages; rather, Fair Health estimated that 80% of payment rates are lower than or equal to those amounts.

Potter said her Cigna reimbursement “is significantly lower.”

Weeks before her May surgery, Getz received big news — Cigna had reversed itself and would cover her surgery under the S code. It “felt like a real victory,” she said.

But she still fears for other patients.

“I’m still asking these companies to do right by women,” Getz said. “I’m still asking them to provide the procedures we need to reimburse them at rates where women have access to them regardless of their wealth.”

In a statement for this article, Cigna spokesperson Justine Sessions said the insurer remains “committed to ensuring that our customers have affordable coverage and access to the full range of breast reconstruction procedures and to quality surgeons who perform these complex surgeries.”

Medical costs that health insurers cover generally are passed along to consumers in the form of premiums, deductibles, and other out-of-pocket expenses.

For any type of breast reconstruction, there are benefits, risks, and trade-offs. A 2018 paper published in JAMA Surgery found that women who underwent DIEP flap surgery had higher odds of developing “reoperative complications” within two years than those who received artificial implants. However, DIEP flaps had lower odds of infection than implants.

Implants carry risks of additional surgery, pain, rupture, and even an uncommon type of immune system cancer.

Other flap procedures that take muscle from the abdomen can leave women with weakened abdominal walls and increase their risk of developing a hernia.

Academic research shows that insurance reimbursement affects which women can access DIEP flap breast reconstruction, creating a two-tiered system for private health insurance versus government programs like Medicare and Medicaid. Private insurance generally pays physicians more than government coverage, and Medicare doesn’t use S codes.

Lynn Damitz, a physician and board vice president of health policy and advocacy for the American Society of Plastic Surgeons, said the group supports continuing the S code temporarily or indefinitely. If reimbursements drop, some doctors won’t perform DIEP flaps anymore, she said.

A study published in February found that, of patients who used their own tissue for breast reconstruction, privately insured patients were more likely than publicly insured patients to receive DIEP flap reconstruction.

To Potter, that shows what will happen if private insurance payments plummet. “If you’re a Medicare provider and you’re not paid to do DIEP flaps, you never tell a patient that it’s an option. You won’t perform it,” Potter said. “If you take private insurance and all of a sudden your reimbursement rate is cut from $15,000 down to $3,500, you’re not going to do that surgery. And I’m not saying that that’s the right thing to do, but that’s what happens.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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SACRAMENTO — Influential health care interests are jockeying over a potential infusion of $19.4 billion into Medi-Cal, California’s Medicaid program, while also angling for a 2024 ballot initiative to permanently lock in that funding, KFF Health News has learned.

The Coalition to Protect Access to Care, which includes groups representing doctors, hospitals, insurance companies, and clinics, is lobbying Gov. Gavin Newsom and his fellow Democratic lawmakers on allocating proceeds from a tax on health insurance companies. The governor earlier this month proposed to spend nearly $820 million from renewing the Managed Care Organization, or MCO, tax to boost Medi-Cal reimbursement rates and divert $8.3 billion to the state general fund, leaving $10.3 billion up for grabs.

Each sector has its own idea of how that money should be spent, even as the health care industry presents a unified front, according to interviews with hospital leaders, health insurance executives, doctor groups, and community clinics. The coalition also wants to cement higher Medi-Cal funding into the state constitution, potentially through a ballot initiative in November 2024.

“We are actively exploring a plan to provide permanent and predictable funding, and stability, in the health care system,” said Dustin Corcoran, CEO of the California Medical Association, who confirmed talks with other industry groups and health care advocates about an initiative.

Medi-Cal, a massive safety-net program, has long failed to deliver timely, comprehensive health care and adequately meet the needs of 15.8 million low-income and disabled Californians who depend on it. Hospitals, clinics, and other health care providers say reimbursement rates fall short of the cost of their services.

“Health care has eluded patients for a long time,” Corcoran said. “This is absolutely a generational opportunity to improve Medi-Cal and ensure that patients can access care whenever they need it.”

California is among more than a dozen states that levy taxes on managed care organizations, a type of health plan, to draw in extra federal health care money for Medicaid. California adopted the tax back in 2005 and it has been renewed five times, according to state Department of Finance spokesperson H.D. Palmer. The last version, which expired in December, generated $2 billion annually.

However, the tax revenue has never been dedicated for new initiatives in Medi-Cal and Newsom wants to change that, such as by paying providers higher rates for primary care, mental health and addiction treatment, and maternity care.

While health groups and lawmakers agree on propping up Medi-Cal and raising reimbursement rates, various sectors of the health industry are positioning themselves to benefit from the portion still up for grabs. Hospitals say they are especially deserving of a large share of the $10.3 billion in revenue but have not indicated how they want the money distributed.

“It’s not that every other player isn’t important,” said Carmela Coyle, the president and CEO of the California Hospital Association, which is lobbying Newsom and lawmakers for a broad bailout even though not all hospitals need help. “But we did take the lion’s share of the hit during covid.”

Corcoran, of the California Medical Association, which represents doctors, contends that all providers who serve Medi-Cal patients should benefit, not just one type. “The tax has to deal with the entire ecosystem of health care,” he said. “You can’t just focus on a particular part of it.”

Insurers say they are still mulling over support of the tax, arguing it should benefit all Medi-Cal patients. In California, health insurance companies agreed to be taxed by the government, which brings in extra federal dollars to plug holes in Medi-Cal. Health insurers don’t get the money back directly. Instead, the money is spread across the entire health care system.

“We don’t just run around supporting new taxes. It’s not an easy decision,” said Charles Bacchi, the president and CEO of the California Association of Health Plans, which represents public and private insurers in the state. “For the health plans that have to add this tax to their premiums, it needs to be affordable for our customers.”

Newsom and lawmakers are hoping to agree on the tax by the June 15 budget deadline. However, negotiations on how to spend the money could continue well into summer and perhaps even next year.

Newsom wants to levy the tax through 2026 and spend the money over an eight- to 10-year period. But health providers and consumer advocates want it spent over roughly three years. The Newsom administration argues that stretching the money over 10 years protects against potential federal health care rule changes that could result in less revenue for California.

“We’ve spread those dollars out for a long period of time to provide sustainability and longer-term fiscal certainty to our providers,” Michelle Baass, director of the state Department of Health Care Services, which administers Medi-Cal, told lawmakers last week.

Health industry groups, community clinics, and patient advocates are pushing back, arguing there is always federal uncertainty. They say Medi-Cal, which has undergone major expansions, including to cover unauthorized immigrants, needs an infusion of money now.

“We should invest today because the need is so high,” said Francisco Silva, president and CEO of the California Primary Care Association, which represents community clinics that overwhelmingly serve low-income patients.

Anthony Wright, executive director of Health Access California, is prodding industry groups and the administration to come up with a deal addressing disparities by targeting all the money to improve patient care and promote more equitable access to doctors.

“Frankly, your experience in the Medi-Cal program is really different around the state — county by county, plan by plan,” Wright said, arguing investments must be made “in those areas where there are real problems.”

Doctors and insurance industry leaders are arguing to use the $10.3 billion for even higher Medi-Cal rates, and health plans say specifically there should be bigger rate increases for specialty care and loan forgiveness for doctors in underserved areas.

Community clinics, which offer one-stop care, want more payments that reimburse them each time a patient shows up for care rather than bundling them into one visit for one fee. And public hospitals are eyeing the revenue to offset their projected losses from caring for a disproportionate share of low-income people. The Newsom administration wants to raise Medi-Cal rates for hospital emergency room and outpatient visits, Baass told lawmakers.

If health interests can strike an agreement, it’s an opportunity for them to secure and direct billions in spending as they see fit. But the coalition could also splinter.

“It needs to be done in a way that’s fair to everybody,” said Democratic state Sen. John Laird of Santa Cruz, who sits on the budget committee. “The worry is that everybody wants a piece of it.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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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.

On Alcohol Abuse: Seeing a Double Standard

I have done quite a bit of research on alcohol-related deaths and I track reports from the Centers for Disease Control and Prevention. Now, my No. 1 question is: Why are the government and the media not holding the alcohol industry accountable for the deaths that its products cause?! The tobacco industry was held accountable for its products and now pharmacies are being held accountable for the opioid crisis. It seems to me that there’s a double standard that’s been ongoing for years, especially since alcohol-related deaths far outnumber opioid deaths. Can anyone working for the government or the media explain why I see more articles about the possible dangers of opioids or marijuana (“Legal Pot Is More Potent Than Ever — And Still Largely Unregulated,” May 9) instead of alcohol-related deaths?

— Stephen Hubbard, Independence, Missouri

This kind of mainstream #cannabis coverage is ignorant and reminiscent of the 1980's. It oversimplifies an incredibly complex topic, demonizes #marijuana, and outright ignores health benefits for millions. I'd expect more from USA Today. @DavidHilzenrath https://t.co/AlOkAlM5ac

— John Schroyer (@Johnschroyer) May 8, 2023

— John Schroyer, Denver

Veterans Deserve Choice in How They Claim VA Disability Benefits

While I appreciate KFF Health News’ interest in the ongoing debate about private sector services helping veterans navigate the Department of Veterans Affairs’ disability claims process (“Some Private Companies Charge Hefty Fees to Help Veterans With Disability Claims,” April 28), your coverage left the impression that private benefit guides generally overcharge for their services and provide little value to veterans. That is an unfair characterization, and your readers deserve additional context.

Honorable companies like Veteran Benefits Guide, where I work, are providing a needed service to veterans, helping guide them through the complex claims process and ensure they receive the full benefits they earned from their service. As a company founded by a veteran and staffed by many veterans and family of veterans, we are proud that our clients receive an average increase to annual benefits of $13,200, benefits they would not receive without our help.

Veterans service organizations (VSOs) are intended to help free of charge, but too often they are understaffed and inadequately trained. In congressional testimony, the National Association of County Veterans Service Officers, which represents county VSOs nationwide, acknowledged that it does not have enough representatives nor funding to meet veterans’ demand for assistance.

Your article described $2,800 as a “hefty” fee being charged by one private benefit guide and quoted the National Organization of Veterans’ Advocates, a group representing accredited attorneys and agents, calling for tighter regulation of the industry, but then failed to mention that those attorneys and agents often charge veterans significantly more. In fact, accredited attorneys charge between 20% and 33% of a veteran’s backpay, which can exceed $50,000 on complicated cases. In nearly every scenario, an attorney will charge multiples more than a private benefit guide and take years longer to achieve the same result.

At Veteran Benefits Guide, our focus is on ensuring Veterans submit fully developed, accurate claims to the VA, which helps get the correct rating for the Veteran the first time, avoids the need for costly appeals and speeds up the final benefits decision. Attorneys, on the other hand, are only paid to assist Veterans during an appeals process. And they are incentivized to drag out appeals, since they are paid a percentage of the Veteran’s backpay. The longer an appeal takes, the more the attorney is paid.

Veteran Benefits Guide and other honorable companies have strongly supported efforts to establish guardrails and crack down on bad actors, such as the recently introduced PLUS for Veterans Act, which would impose criminal penalties on those seeking to take advantage of veterans, establish safeguards to prevent conflicts of interest, and institute caps to prevent unreasonable fees — while still preserving the right of veterans to seek assistance from the private sector. It would have been helpful context for your readers to know that such reasonable legislation has been introduced and is being considered in Congress right now.

— Michael Licari, chief legal officer of Veteran Benefits Guide, Las Vegas

This is unacceptable #SDoHwarriors!Veterans and members of the military already face a higher than expected incidence and prevalence of #SDoH, now this???RISE @tdahlborg @pauldvet Jenn Kerfoot @JoSchneier Toni Tashiro #m…https://t.co/ffbcLONGJf https://t.co/EyFCg3xByU

— Ellen Fink-Samnick (@epflcswccm) April 28, 2023

— Ellen Fink-Samnick, Burke, Virginia

Bracing for a Wave of Denials

Patients and physicians alike are shocked by the increasing number of absurd and sometimes dangerous barriers insurance companies put in place (“Denials of Health Insurance Claims Are Rising — And Getting Weirder,” May 26). Not only are coverage denials happening after the fact, but care is also disrupted before patients have a chance to get the drugs and services they need.

Through a process called prior authorization, insurance companies force doctors to submit requests for care, and the insurance company representatives, who are not necessarily specialists or even medical doctors, have the power to determine if care is necessary or not. At best, it delays care and can force patients to wait; at worst, medical care can be outright denied.

One egregious example is UnitedHealthcare’s unprecedented prior authorization policy for most endoscopies and colonoscopies, starting on June 1. Even if you have blood in your stool or suffer severe gastrointestinal pain, you will need to get preapproval before you can receive a procedure to diagnose or treat your condition. With colorectal cancer being the second-leading cause of cancer deaths in the U.S. and Crohn’s disease and colitis affecting more than a million Americans, time is of the essence to catch problems quickly. I fear that UnitedHealthcare’s prior authorization policy will deter Americans from getting timely care and exacerbate existing disparities.

The gastrointestinal community calls on UnitedHealthcare to honor its recent promise to slash prior authorization — and rescind this absurd policy before patients suffer real harm.

— Barbara Jung, president-elect of the American Gastroenterological Association, Seattle

Denials of #health insurance claims are more & more common, boosting company profits but often defying medical standards of care…and sheer logic. https://t.co/0oA6ZuPFan

— Lindsay Resnick (@ResnickLR) May 26, 2023

— Lindsay Resnick, Chicago

Aging Takes a Village

I applaud Judith Graham for her article “How to Grow Your Social Network as You Age” (April 28), which also published April 22 in The Washington Post. It aptly highlights the importance of social connections for older adults and emphasizes that “it’s never too late to develop meaningful relationships.” I could not agree more.

We are increasingly learning about the consequences of isolation and loneliness on the emotional, physical, and cognitive health of older adults.

In the past decade, an antidote to social isolation has emerged nationwide through the “Villages Movement” whereby local “communities” of neighbors help one another to successfully age in place.

Most Villages are volunteer organizations offering a range of social activities and basic services. There are approximately 350 Villages nationwide and 74 in the Washington, D.C., metro area. While each Village operates differently, they share the mission to improve the quality of life for seniors and reduce isolation.

My work with Villages, both nationally and locally, has allowed me to witness firsthand how Villages are improving the lives of older adults. Whether they attend a Village seminar, luncheon, art tour, or bridge tournament, they are building those critical connections and having fun!

During the pandemic lockdown, our Potomac Community Village helped to reduce isolation by offering frequent Zoom programs as well as friendly phone calls and check-ins with members.

Villages are a great solution. I’d encourage readers to consider joining a Village where they can find new friends and a renewed sense of community. For more information, see vtvnetwork.org.

— Edgar E. Rivas (he, him, él), Potomac Community Village Board of Directors vice president, Village to Village Network, Potomac, Maryland

Worthwhile story, but this shot of people playing "yard petanque" Disrespects My #bocce Bing. https://t.co/XSSzrlFGFj pic.twitter.com/Ql4VpBAN9F

— Alex Heard (@alexheard) April 23, 2023

— Alex Heard, Santa Fe, New Mexico

Remote Work Alone Won’t Solve Caregivers’ Challenges

I am a health care professional and have relied upon the work of KFF’s health policy research and KFF Health News over the years. Reading a recent article you produced, “Remote Work: An Underestimated Benefit for Family Caregivers” (May 19) by Joanne Kenen, I would strongly suggest a deeper view. Below are specific points I’d love to help bring to the attention of your readership, given my extensive work in the space of caregiving, health, and the working caregiver. I am a registered nurse, family caregiver, caregiving expert, and co-founder of two organizations that have been supporting family caregivers for the past eight years.

Remote work is helpful, yes. But it’s only part of the answer. Without the adequate tools, resources, and support to work and carry the load of caring at home, working caregivers will still experience stress, burnout, hits to their productivity, loneliness, and the list goes on.

We need to take a more wholistic view and address the underlying factors of stress, and the myriad of challenges that plague every caregiver.

For example, communication challenges do not go away when working from home — not unless that working caregiver has the technology and resources to connect all the disparate communications in order to better coordinate among other family members involved in caring and with the providers involved in managing their care. Post-it notes, texts, emails, and phone calls are no way to communicate and are simply ineffective.

Having remote patient monitoring devices at home is good, but if they are not connected to a platform to better coordinate what’s happening, adjust care plans, and engage providers of care more effectively with the family caregiver at home managing the care, then work productivity, stress, and the employee’s well-being still takes a big hit, regardless of working remotely or not.

We need to go several layers deeper. Remote work is a good benefit, but it cannot stop there. Without the adequate support, technology, and tools to engage and better coordinate the mess, many working caregivers slog through every day, and the overall impacts will be far less than desired.

— Deb Kelsey-Davis, Chicago

The overlooked benefit of remote work for #caregivers: Employers and co-workers understand the need to take time off to care for a baby. But there’s a lot less understanding about time to care for anyone else. by @JoanneKenen @khnews https://t.co/Q30mLggH55 via @usatoday

— Catherine Arnst (@cathyarnst) May 17, 2023

— Catherine Arnst, New York City

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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TAMPA, Fla. — When a hemp dispensary in this Florida city started to stock edibles with certain mushroom extracts last year, state regulators quickly ordered it to stop selling the items.

The shop had been advertising fruit-flavored gummies and other products containing tiny doses of mood-altering chemicals from the mushroom Amanita muscaria. The red-capped, white-spotted fungus — rooted in popular culture through the Super Mario Nintendo game franchise, “The Smurfs,” and “Alice’s Adventures in Wonderland” — is legal for consumers to possess and eat in every state except Louisiana, according to a review of state laws.

Products with the mushroom’s extracts have cropped up at stores and online retailers from Florida to Minnesota and Nebraska to Pennsylvania. Businesses advertise a milder high compared with psilocybin, the Schedule 1 psychedelic that remains illegal at the national level, to people hoping to ease anxiety, depression, or joint pain.

But federal officials and fungi experts have urged caution, and Florida regulators have clamped down on sales in at least five counties. Some uses of the mushroom and its chemicals have led to serious side effects, including delirium with sleepiness and coma, according to Courtney Rhodes, an FDA spokesperson.

No human clinical trials have evaluated the products’ safety and effectiveness, said Heather Hallen-Adams, a faculty member at the University of Nebraska-Lincoln, who researches fungi in food.

Chillum, a hemp dispensary in the Ybor City neighborhood, stopped selling the edibles in December after regulators from the Florida Department of Agriculture and Consumer Services ordered it to do so, calling A. muscaria a dangerous ingredient. The shop returned $30,000 worth of merchandise to Psilo Mart, a Las Vegas-area supplier that says it imports the mushroom from Lithuania. The agriculture department, which regulates shops that sell products like hemp vapes, then lifted its restrictions on the dispensary.

Drew Gennuso, president of Psilo Mart, said he hasn’t heard of any “major issues” with the edibles. Chillum’s owner, Carlos Hermida, said he believes the products are safe.

“It’s so mild,” he said of the fungus’s effects. “It’s not anything where you’re going to smell the color purple.”

Hermida recently began selling the products again for between $20 and $55 — but, attempting to avoid another state order, he said Chillum added labels warning they are solely for “educational” or “spiritual” purposes and not human consumption.

Federal officials haven’t approved the fungus and its chemicals to be sold as food additives or to treat medical conditions.

The Tampa case highlights the gaps in oversight of this nascent national market despite concerns from federal officials.

“The companies are moving faster than the research,” said John Michelotti, who heads the medicinal mushrooms committee of the North American Mycological Association and founded Catskill Fungi, an upstate New York business that sells mushroom extracts.

“It’s the wild West.”

The crackdown at Chillum began in October. The Florida agriculture department collected samples of products for lab testing. Returning in December, the agency said a Psilo Mart hemp joint with A. muscaria powder had elevated levels of toxic heavy metals, department records show.

Hermida threw out his inventory of the mushroom joints, he said, and regulators ordered him to stop selling the other fungus products. They cited a state law that says food is “adulterated” if it “bears or contains any poisonous or deleterious substance which may render it injurious to health.”

The gummies with the extracts elicit a feeling of “being high and drunk,” Hermida said, while the capsules cause a “tingly body sensation” and throw off depth perception.

The mushroom is poisonous, though likely not fatal, and can be detoxified in boiling water. Consuming the raw fungus isn’t the same as using low doses of its chemicals, Hermida maintained.

The Florida Poison Information Center in Tampa gets one report a week, on average, of a hallucinogenic mushroom poisoning, but many callers don’t explain what kind they ate, and doctors don’t have a quick way to verify, said Alexandra Funk, its managing director. She said A. muscaria products should be kept away from children.

In the Tampa Bay area, medical examiners haven’t recorded any recent deaths from the mushroom. Johns Hopkins All Children’s Hospital in St. Petersburg and local AdventHealth emergency rooms haven’t seen poisonings, according to spokespeople. But there appears to be a lack of routine testing for the fungus.

The edibles sold at Chillum appealed to Antwan Towner, a 40-year-old Ybor City magician who said he struggles with anxiety. He eats half a gummy when having a bad day, he said, and it produces euphoria that lasts about four hours, then peace of mind for a week. He said he hasn’t experienced a negative reaction or hallucinations.

“It was never about getting high,” he said. “It was just about trying something that may be effective.”

There’s a “lot of anecdotal evidence” that low doses of the mushroom may be useful therapeutically, said Hallen-Adams, who chairs the toxicology committee of the North American Mycological Association.

But more data is needed to prove if it helps those with various medical conditions or if it’s simply a placebo, she said.

Last year, a Canadian company said an independent group of scientists found that its A. muscaria extract was “generally recognized as safe.”

The Toronto company, Psyched Wellness, conducted preclinical studies on its “Calm” extract, a sleep aid, said CEO Jeffrey Stevens.

Other businesses, Stevens said, haven’t invested in such research. “We have so many cowboys right now who are just saying, ‘Oh, this is a legal psychedelic mushroom, let’s just put product into the market.’”

Since early February, Florida regulators have cited five businesses in Daytona Beach, Largo, Plant City, Tallahassee, and Tamarac for selling merchandise containing A. muscaria, according to state agriculture department records. Because federal officials haven’t approved the mushroom to be used in food, the Florida agency orders businesses to stop selling these products when its inspectors find them, Aaron Keller, a spokesperson for the state agriculture department, wrote in an email.

In this emerging market with many unknowns, Hallen-Adams urged consumers to “be careful if this is something you’re going to experiment with.”

Under Chillum’s new labeling, consuming the edibles it sells is an “abuse of product,” Hermida said.

“If you want to study it, or if you want to pray to it, that’s fine with me.”

This article was produced in partnership with the Tampa Bay Times.

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SACRAMENTO – Cuando el gobernador Gavin Newsom asumió el cargo hace cuatro años, el demócrata arremetió contra los republicanos a nivel nacional ante su intento de destruir la Ley de Cuidado de Salud a Bajo Precio (ACA). La clave para su ambicioso programa de salud era restablecer la multa a los californianos sin cobertura sanitaria, que se había eliminado a nivel federal.

Era una propuesta difícil de vender para un nuevo gobernador, y Newsom necesitaba aliados fuertes entre los líderes demócratas del estado, que en aquel momento, en 2019, expresaron su preocupación por la imposición de un nuevo impuesto a los californianos que no podían permitirse el creciente costo de la atención de salud.

Los demócratas que, entonces como ahora, controlaban la legislatura estatal, finalmente apoyaron a Newsom a cambio de una promesa: el estado cobraría la multa pero usaría ese dinero para ayudar con los gastos de bolsillo de los californianos que compraran un seguro de salud en el mercado de seguros de salud estatal, Covered California.

Pero Newsom, ahora en su segundo mandato, se ha retractado de esa promesa. Su administración se aferra a los ingresos recaudados por el llamado “mandato individual”, el requisito de que hay que tener cobertura sanitaria o pagar una multa. Y su presupuesto para el próximo año fiscal, que comienza el 1 de julio y se está debatiendo en la legislatura estatal, canaliza el dinero al fondo general del estado.

Esto ha enfurecido a sus colegas demócratas, que lo acusan de romper una promesa, y de no tener en cuenta a los millones de californianos que no pueden pagar deducibles y copagos.

California comenzó a multar a los no asegurados en 2020, recaudando un estimado de $1,1 mil millones en los primeros tres años, y la administración Newsom proyecta que agregará más de $700 millones en los próximos dos años, elevando el total proyectado de cinco años a $1,8 mil millones, según el Departamento de Finanzas del estado.

Los líderes demócratas dijeron que la táctica de Newsom de retener el dinero para el fondo general es una “estafa”.

“El dinero del mandato debe dedicarse a la salud”, dijo el presidente “pro tempore” del Senado Toni Atkins a KFF Health News, argumentando que el estado debería distribuir el dinero ahora para ayudar a las personas a pagar la cobertura de salud. “No sé qué estamos esperando. Tenemos que encontrar una manera de hacer que la atención médica sea más accesible, y no hay duda de que el costo del seguro de salud es una barrera”.

Se espera que los legisladores demócratas sigan presionando a Newsom con la esperanza de llegar a un acuerdo, antes de la fecha límite del 15 de junio, para aprobar un proyecto de ley presupuestario. “Siempre pensamos que el dinero se destinaría a reducir los costos de seguro”, señaló el miembro demócrata de la Asamblea Phil Ting, presidente del Comité de Presupuesto.

En 2019, Newsom hizo campaña por el mandato individual ante el aumento de las primas de seguro, prometiendo reducir los costos de atención médica de los consumidores de Covered California mientras se diferenciaba del entonces presidente Donald Trump, que calificaba el mandato de injusto.

Los republicanos del Congreso habían retirado la penalización federal —parte de ACA— en 2017. Newsom argumentó que todavía funcionaría en California para reducir los costos de atención médica, y para alcanzar su objetivo de atención médica universal, la pieza central de su ambiciosa agenda de salud.

Newsom argumenta ahora que los subsidios federales para el seguro médico que compensan el costo de las primas mensuales son suficientes. Y, ante un déficit presupuestario estatal previsto de $32,000 millones, Newsom afirma que California no puede permitirse gastar el dinero y reducir aún más los gastos de bolsillo.

Argumenta, por ejemplo, que gastar el dinero para recortar deducibles (la cantidad que pagas por la cobertura antes de que tu seguro empiece a pagar), sería “insostenible”. Su propuesta mantendría el dinero para el fondo general del estado, y se utilizaría en lo que California necesite.

Pero los activistas de la salud que presionaron a favor de la multa, así como muchos legisladores demócratas, dicen que los fondos podrían salvar vidas y deberían distribuirse ahora.

“El mandato individual no estaba destinado a crear fondos para otros programas gubernamentales que no fueran la atención de salud”, explicó el miembro demócrata de la Asamblea Jim Wood, de Santa Rosa, presidente del Comité de Salud, en una acalorada audiencia sobre el presupuesto esta primavera. “La clara intención de la legislatura era que este dinero se destinara a la asequibilidad”.

Wood dijo que habría rechazado el plan de Newsom si hubiera sabido que los ingresos que generara se depositarían directamente en el fondo general. “No creo que lo hubiera apoyado”, dijo. “Me parece una violación de lo que pensábamos que estábamos haciendo”.

El aumento de los gastos de salud, por ejemplo en primas de seguros y deducibles, está llevando a que las personas renuncien a la atención médica. En California, un asombroso 52% de los residentes afirma haber renunciado o retrasado un tratamiento en el último año por motivos económicos, según una encuesta reciente de la organización sin fines de lucro California Health Care Foundation. (California Healthline es un servicio editorial independiente de la California Health Care Foundation).

Diana Douglas, cabildera de Health Access California, que formó parte de la coalición que respaldó el mandato de cobertura del estado en 2019, señaló que Newsom debe reconocer el aumento de los costos y gastar el dinero ahora en ayudar al acceso a la salud. “Este dinero de la multa debe usarse para ayudar a los californianos a pagar la cobertura y la atención”.

Los planes de seguro de salud ofrecidos por Covered California siguen encareciéndose. Los deducibles para un plan de seguro de nivel medio, por ejemplo, subirán a $5,400 el próximo año, según Covered California, frente a los $4,750 de este año y los $3,700 de hace dos años.

Muchos californianos que compran cobertura también posponen el tratamiento ante los altos costos. Una encuesta realizada por Covered California en 2022 reveló que el 48% de sus consumidores aplazaron atención médica importante debido al precio.

Newsom esquivó esta primavera una pregunta de KFF Health News sobre las críticas a las que se enfrenta por su presión para retener el dinero del mandato, diciendo simplemente que está “orgulloso” de haber establecido el mandato de cobertura estatal y señalando que los subsidios federales a las primas están disponibles para los californianos que compran cobertura a través de Covered California.

Su administración defendió la canalización del dinero al fondo general, diciendo que los ingresos serían devueltos a un fondo especial de salud y estarían disponibles para su uso en la asistencia sanitaria con el tiempo, si el gobierno federal recortara los subsidios premium existentes.

Funcionarios de la administración argumentan que Newsom está esencialmente pidiendo prestado el dinero, diciendo que será devuelto más tarde, aunque los legisladores dudan que vaya a cumplir esa promesa.

Los críticos y algunos legisladores demócratas dicen que retener el dinero es un doble golpe para los residentes de bajos y medianos ingresos que sufren para pagar la cobertura, y argumentan que equivale a un impuesto a los pobres. “Da la sensación de que estamos intentando ahorrar a costa de nuestras comunidades de bajos ingresos”, indicó la senadora estatal demócrata Caroline Menjivar, que representa al Valle de San Fernando.

La mayoría de los que pagan la multa son californianos de ingresos bajos y medios que ganan menos del 400% del umbral federal de pobreza, que es de $58,320 para un individuo y $120,000 para una familia de cuatro miembros, según los últimos datos disponibles de la Franchise Tax Board.

Los legisladores demócratas apoyan este año una propuesta alternativa, defendida por Health Access California, para destinar los ingresos procedentes de multar a los residentes no asegurados a aumentar los subsidios de seguros de salud para las personas de ingresos bajos y medios. De este modo, se cumpliría el acuerdo que los activistas alcanzaron el año pasado con los legisladores demócratas del estado para reducir o eliminar los gastos de bolsillo en Covered California, y erradicar por completo los deducibles en un plan de nivel medio.

“Tenemos que asegurarnos de que las personas no sólo tengan cobertura de salud, sino que también puedan permitirse utilizarla”, expresó Ronald Coleman Baeza, de la Red de Salud Pan-Étnica de California.

Aunque Newsom y sus aliados demócratas han aprobado importantes ampliaciones de la cobertura, el estado no ofrece salud para todos.

Expertos dicen que más de 2,5 millones de californianos siguen sin seguro, incluidos los inmigrantes indocumentados que ganan demasiado para tener derecho a Medi-Cal, y los legisladores están cada vez más inquietos porque no todos los residentes con seguro puedan permitirse el lujo de utilizar su cobertura.

“Hubo un claro compromiso de que estos dólares se utilizarían para reducir los costos de la atención sanitaria, y no lo hemos hecho”, afirmó la miembro de la Asamblea Pilar Schiavo, representante demócrata del Valle de Santa Clarita, que presentó un proyecto de ley que exigiría que los ingresos recaudados por el mandato individual se destinaran permanentemente a la atención de salud.

Aunque la propuesta fracasó, puede ser revivida el próximo año, y los activistas aseguran que seguirán presionando a Newsom para distribuir el dinero existente entre los clientes de Covered California.

“Tenemos que cumplir nuestras promesas”, enfatizó Schiavo. “Si tienes un seguro que no puedes permitirte usar, o tienes miedo de ir a ver al médico por lo elevada que pueda ser la factura, entonces no tienes realmente acceso ni cobertura universal”.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Si bien los médicos mayormente aplaudieron la recomendación de un panel designado por el gobierno de que las mujeres comenzaran sus mamografías de rutina para detectar cáncer de mama a partir de los 40 años, en lugar de a los 50, no todos la aprueban.

Algunos médicos e investigadores que están interesados en un enfoque más individualizado para encontrar tumores problemáticos se muestran escépticos y plantean preguntas sobre los datos y el razonamiento detrás del cambio radical del Grupo de Trabajo de Servicios Preventivos de Estados Unidos con respecto a sus pautas de 2016.

“La evidencia para que todas comiencen a los 40 no es convincente”, dijo Jeffrey Tice, profesor de medicina en la Universidad de California-San Francisco.

Tice es parte del equipo de investigación del estudio WISDOM, que tiene como objetivo, en palabras de Laura Esserman, cirujana de cáncer de seno y líder del equipo, “hacer pruebas de manera más inteligente, no probar más”. Esserman lanzó el estudio en curso en 2016 con el objetivo de adaptar las pruebas de detección al riesgo de una mujer, y poner fin al debate sobre cuándo iniciar las mamografías.

Los defensores de un enfoque personalizado enfatizan los costos de la detección universal a los 40, no en dólares, sino en resultados falsos positivos, biopsias innecesarias, sobretratamiento y ansiedad.

Las pautas provienen del Grupo de Trabajo de Servicios Preventivos de Estados Unidos, parte del Departamento de Salud y Servicios Humanos (HHS) federal, un panel independiente de 16 expertos médicos voluntarios que se encargan de ayudar a guiar a los médicos, aseguradoras de salud y legisladores.

En 2009, y de nuevo en 2016, el grupo presentó el aviso actual, que elevó la edad para comenzar la mamografía de rutina de 40 a 50 años e instó a las mujeres de 50 a 74 a hacérselas cada dos años.

Las mujeres de 40 a 49 años que “le otorgan un mayor valor al beneficio potencial que a los daños potenciales” también deberían someterse al procedimiento de detección, dijo el grupo de trabajo.

Ahora, el grupo ha publicado un borrador de una actualización de sus directrices, recomendando la detección para todas las mujeres a partir de los 40 años.

“Esta nueva recomendación ayudará a salvar vidas y evitará que más mujeres mueran debido al cáncer de mama”, dijo Carol Mangione, profesora de medicina y salud pública en UCLA, quien presidió el panel.

Pero la evidencia no es clara. Karla Kerlikowske, profesora de la UCSF que ha estado investigando la mamografía desde la década de 1990, dijo que no vio una diferencia en los datos que justificara el cambio. Dijo que la única forma en que podía explicar las nuevas pautas era un cambio en el panel.

“Son diferentes miembros del grupo de trabajo”, dijo. “Interpretaron los beneficios y los daños de manera diferente”.

Sin embargo, Mangione citó dos puntos de datos como impulsores cruciales de las nuevas recomendaciones: el aumento de la incidencia de cáncer de mama en mujeres más jóvenes, y modelos que muestran la cantidad de vidas que podrían salvar las pruebas de detección, especialmente entre las mujeres negras.

No hay evidencia directa de que evaluar a mujeres de 40 años salve vidas, dijo. La cantidad de mujeres que murieron de cáncer de mama disminuyó de manera constante desde 1992 hasta 2020, debido en parte a una detección más temprana y a mejores tratamientos.

Pero los modelos predictivos que construyó el grupo de trabajo, basados en varias suposiciones en lugar de datos reales, encontraron que expandir la mamografía a mujeres de 40 años podría evitar 1.3 muertes adicionales por cada 1,000 en esa cohorte, dijo Mangione. Lo más crítico, agregó, es que un nuevo modelo que incluye solo mujeres negras mostró que se podría salvar 1.8 por 1,000.

Un aumento anual del 2% en la cantidad de personas de 40 a 49 años diagnosticadas con cáncer de mama en el país entre 2016 y 2019 alertó al grupo de trabajo sobre una tendencia preocupante, dijo.

Mangione lo llamó un “salto realmente considerable”. Pero Kerlikowske lo llamó “bastante pequeño” y Tice lo llamó “muy modesto”: percepciones contradictorias que subrayan cuánta subjetividad está involucrada en la ciencia de las pautas de salud preventiva.

A los miembros del grupo de trabajo los designa la Agencia para la Investigación y la Calidad de la Atención Médica del HHS, y cumplen mandatos de cuatro años. El nuevo borrador de las pautas está abierto para comentarios públicos hasta el 5 de junio. Después de incorporar los comentarios, el grupo de trabajo planea publicar su recomendación final en JAMA, la revista de la Asociación Médica Estadounidense.

Cerca de 300,000 mujeres serán diagnosticadas con cáncer de mama en el país este año, y morirán más de 43,000 por este mal, según proyecciones del Instituto Nacional del Cáncer. Muchos consideran que expandir la detección para incluir a mujeres más jóvenes es una forma obvia de detectar el cáncer antes y salvar vidas.

Pero los críticos de las nuevas pautas argumentan que hay verdaderas concesiones.

“¿Por qué no empezar al nacer?”, ironizó Steven Woloshin, profesor del Instituto de Políticas de Salud y Práctica Clínica de Dartmouth. “¿Por qué no todos los días?”.

“Si no hubiera inconvenientes, eso podría ser razonable”, dijo. “El problema son los falsos positivos, que dan mucho miedo. El otro problema es el sobrediagnóstico”. Algunos tumores de mama son inofensivos y el tratamiento puede ser peor que la enfermedad, enfatizó.

Tice estuvo de acuerdo en que el sobretratamiento es un problema subestimado.

“Estos cánceres nunca causarían síntomas”, dijo, refiriéndose a ciertos tipos de tumores. “Algunos simplemente retroceden, se encogen y desaparecen, son de crecimiento tan lento que una mujer muere de otra cosa antes de que causen problemas”.

Las pruebas de detección tienden a encontrar cánceres de crecimiento lento que tienen menos probabilidades de causar síntomas, dijo. Por el contrario, las mujeres a veces descubren cánceres letales de crecimiento rápido poco después de haberse realizado mamografías que salieron normales.

“Nuestro fuerte sentimiento es que una sola talla no sirve para todos y que debe personalizarse”, dijo Tice.

WISDOM, que significa “Mujeres informadas para evaluar según las medidas de riesgo”, evalúa el riesgo de las participantes a los 40 mediante la revisión de los antecedentes familiares y la secuenciación de nueve genes. La idea es comenzar con mamografías periódicas de inmediato para las mujeres de alto riesgo mientras que esperar para las de menos.

Las mujeres negras no hispanas tienen más probabilidades de hacerse mamografías de detección que las mujeres blancas no hispanas. Sin embargo, tienen un 40% más de probabilidades de morir de cáncer de seno y de que les diagnostiquen cánceres mortales a edades más tempranas.

El grupo de trabajo espera que las mujeres negras se beneficien más de la detección temprana, dijo Mangione.

No está claro por qué las mujeres negras tienen más probabilidades de sufrir cánceres de mama más letales, pero las investigaciones apuntan a disparidades en el tratamiento.

“Las mujeres negras no obtienen un seguimiento de las mamografías tan rápido ni un tratamiento adecuado tan rápido”, dijo Tice. “Eso es lo que realmente impulsa las discrepancias en la mortalidad”.

También continúa el debate sobre la detección en mujeres de 75 a 79 años. El grupo de trabajo optó por no pedir pruebas de detección de rutina en el grupo de mayor edad porque un estudio observacional no mostró ningún beneficio, dijo Mangione. Pero el panel emitió un llamado urgente para investigar si las mujeres de 75 años o más deberían hacerse una mamografía de rutina.

Los modelos sugieren que evaluar a las mujeres mayores podría evitar 2,5 muertes por cada 1,000 mujeres en ese grupo de edad, más de las que se salvarían al expandir la evaluación a las mujeres más jóvenes, apuntó Kerlikowske.

“Siempre decimos que las mujeres mayores de 75 años deberían decidir junto con sus médicos si se hacen mamografías, según sus preferencias, valores, historial familiar y de salud”, dijo Mangione.

Tice, Kerlikowske y Woloshin argumentan que lo mismo es cierto para las mujeres de 40 años.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).