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How to Negotiate With Resistant Aging Parents? Borrow These Tips From the Business World

Kaiser Health News - Fri, 06/02/2023 - 5:00am

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.


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 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.


This story can be republished for free (details).

Categories: Health Care

The Gun Violence Epidemic Is ‘Locking Us Back in Our Room’

Kaiser Health News - Fri, 06/02/2023 - 5:00am

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.


This story can be republished for free (details).

Categories: Health Care

The Debt Ceiling Deal Takes a Bite Out of Health Programs. It Could Have Been Much Worse.

Kaiser Health News - Thu, 06/01/2023 - 7:15pm

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.


This story can be republished for free (details).

Categories: Health Care

Our 300th Episode!

Kaiser Health News - Thu, 06/01/2023 - 2:30pm
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:

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 SpotifyApple PodcastsStitcherPocket 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.


This story can be republished for free (details).

Categories: Health Care

Watch: Payback for the Opioid Crisis: How Did the Sackler Family Skirt Liability?

Kaiser Health News - Thu, 06/01/2023 - 1:25pm

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.


This story can be republished for free (details).

Categories: Health Care

As Medicaid Purge Begins, ‘Staggering Numbers’ of Americans Lose Coverage

Kaiser Health News - Thu, 06/01/2023 - 5:00am

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.


This story can be republished for free (details).

Categories: Health Care

More States OK Postpartum Medicaid Coverage Beyond Two Months

Kaiser Health News - Thu, 06/01/2023 - 5:00am

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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Categories: Health Care

How a Medical Recoding May Limit Cancer Patients’ Options for Breast Reconstruction

Kaiser Health News - Wed, 05/31/2023 - 7:30am

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.


This story can be republished for free (details).

Categories: Health Care

Health Care Coalition Jockeys Over Medi-Cal Spending, Eyes Ballot Initiative

Kaiser Health News - Wed, 05/31/2023 - 5:00am

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.


This story can be republished for free (details).

Categories: Health Care

Readers and Tweeters Weigh Marijuana’s Merits Against Those of Alcohol or Opioids

Kaiser Health News - Wed, 05/31/2023 - 5:00am

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

— 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

— 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.

— 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

— 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.

— 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 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.


This story can be republished for free (details).

Categories: Health Care

Mood-Altering Mushroom Sales Bloom Despite Safety Concerns

Kaiser Health News - Wed, 05/31/2023 - 5:00am

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.

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.


This story can be republished for free (details).

Categories: Health Care

Gobernador de California y legisladores demócratas discrepan sobre el uso de miles de millones de dólares en fondos de salud

Kaiser Health News - Tue, 05/30/2023 - 11:26am

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.


This story can be republished for free (details).

Categories: Health Care

¿Mamografías a los 40? Nueva pauta para la detección del cáncer de seno genera debate

Kaiser Health News - Tue, 05/30/2023 - 11:20am

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.


This story can be republished for free (details).

Categories: Health Care

La enfermedad cardiovascular podría matar a más adultos mayores hispanos

Kaiser Health News - Tue, 05/30/2023 - 11:14am

La enfermedad cardiovascular, la principal causa de muerte entre las personas de 65 años en adelante, se volverá más frecuente en los próximos años, afectando de manera desproporcionada a las comunidades hispana y afroamericana, y cobrando un enorme precio en la salud y la calidad de vida de los estadounidenses mayores.

Las estimaciones son desalentadoras: para 2060, se prevé que la prevalencia de la cardiopatía isquémica (una afección provocada por el bloqueo de las arterias y también conocida como enfermedad de las arterias coronarias) aumente un 31% en comparación con 2025; la insuficiencia cardíaca un 33%; los infartos un 30%; y los accidentes cerebrovasculares un 34 %, según un equipo de investigadores de Harvard y otras instituciones.

El mayor aumento se producirá entre 2025 y 2030, pronosticaron.

El dramático envejecimiento de la población de Estados Unidos y el número creciente de personas con afecciones como hipertensión, diabetes y obesidad —que aumentan el riesgo cardíaco— se espera que contribuyan a este escenario alarmante.

Debido a que estos factores de riesgo son más comunes entre las poblaciones hispana y afroamericana, probablemente haya más enfermedad cardíaca y muerte en estos grupos, predijeron los investigadores. (Los hispanos pueden ser de cualquier raza o combinación de razas).

“Las disparidades en la carga de la enfermedad cardiovascular solo se exacerbará” a menos que se realicen esfuerzos específicos para fortalecer la educación en salud, ampliar la prevención y mejorar el acceso a terapias efectivas, escribieron los autores de un editorial adjunto, de la Universidad de Stony Brook en Nueva York y el Centro Médico de la Universidad de Baylor en Texas.

“Cualquiera sea el enfoque que hayamos tenido antes sobre el manejo del riesgo de enfermedad [cardiovascular] en los estadounidenses negros e hispanos, debemos redoblar nuestros esfuerzos”, dijo Clyde Yancy, jefe de cardiología y vicedecano de diversidad e inclusión en la Facultad de Medicina Feinberg de la Universidad Northwestern de Chicago, que no participó en la investigación.

Por supuesto, los avances médicos, las políticas de salud pública y otros cambios podrían alterar las perspectivas de las enfermedades cardiovasculares en las próximas décadas.

Más del 80% de las muertes cardiovasculares ocurren entre adultos de 65 años o más. Durante más de una década, el número total de muertes cardiovasculares en este grupo de edad ha aumentado de manera constante, a medida que hay más adultos mayores.

Y el progreso previo en la reducción de las muertes por enfermedades cardíacas y accidentes cerebrovasculares se ha visto socavado por el aumento de la cintura de los estadounidenses, la mala dieta y la falta de actividad física.

Entre las personas de 65 años en adelante, las muertes cardiovasculares se redujeron un 22% entre 1999 y 2010, según datos del Instituto Nacional del Corazón, Pulmón y Sangre, gracias a nuevos tratamientos y a una fuerte disminución del tabaquismo, entre otras iniciativas de salud.

Luego, entre 2011 y 2019, las muertes aumentaron un 13%.

La pandemia de covid-19 también se ha sumado al número de muertes, ya que las infecciones por coronavirus causan complicaciones graves, como coágulos de sangre, y millones de personas mayores vulnerabes evitan buscar atención médica por temor a infectarse.

“La pandemia puso al descubierto las inequidades en salud en curso”, y eso ha impulsado una nueva ola de investigación sobre las disparidades entre varias afecciones médicas y sus causas, dijo Nakela Cook, cardióloga y directora ejecutiva del Patient-Centered Outcomes Research Institute, una organización independiente autorizada por el Congreso.

Uno de los exámenes más detallados hasta el momento, publicado en JAMA Cardiology en marzo, examinó las tasas de mortalidad en poblaciones hispanas, negras no hispanas y blancas no hispanas desde 1990 hasta 2019 en los 50 estados y el Distrito de Columbia.

Este trabajo mostró que los hombres afroamericanos siguen teniendo el mayor riesgo de morir por enfermedades cardiovasculares, especialmente en los estados del sur a lo largo del río Mississippi y en el norte del Medio Oeste.

Si bien los estilos de vida individuales son en parte responsables de la carga desigual de las enfermedades cardiovasculares, la declaración científica de 2017 de la American Heart Association (AHA) sobre la salud cardiovascular de los afroamericanos señala que la “discriminación racial percibida” y el estrés relacionado están asociados con la hipertensión, la obesidad, la inflamación persistente y otros procesos clínicos que aumentan el riesgo de enfermedad cardiovascular.

Otras minorías raciales y étnicas que experimentan adversidades en su vida cotidiana también se ven afectadas, señalaron varios expertos. Sin embargo, estudios recientes de muertes cardiovasculares no incluyen a algunos de estos grupos, incluidos los estadounidenses de origen asiático y los estadounidenses nativos.

¿Cuáles son las implicaciones para el futuro? Alain Bertoni, internista y profesor de epidemiología y prevención en la Facultad de Medicina de la Universidad de Wake Forest, señaló variaciones significativas en los resultados de salud cardiovascular según la ubicación geográfica, y dijo: “Es posible que necesitemos diferentes soluciones en diferentes partes del país”.

Gregory Roth, coautor del artículo de JAMA Cardiology y profesor asociado de cardiología en la Facultad de medicina de la Universidad de Washington, pidió un esfuerzo renovado para educar a las personas en estas comunidades vulnerables sobre los “factores de riesgo modificables”: presión arterial alta, colesterol alto, obesidad, diabetes, tabaquismo, actividad física inadecuada, dieta poco saludable y sueño insuficiente. La American Heart Association tiene sugerencias en su sitio web para promover la salud cardiovascular en cada una de estas áreas.

Michelle Albert, cardióloga y actual presidenta de la AHA, dijo que se debe prestar más atención en la educación médica a los “determinantes sociales de la salud”, incluidos los ingresos, la educación, la vivienda, los entornos del vecindario y las características de la comunidad, para que fuerza laboral de la atención sanitaria esté mejor preparada para abordar las necesidades de salud no satisfechas en las poblaciones vulnerables.

Natalie Bello, cardióloga y directora de investigación de hipertensión en el Smidt Heart Institute en el Centro Médico Cedars-Sinai en Los Ángeles, dijo: “Realmente necesitamos ir a las comunidades vulnerables y llegar a las personas en sus lugares para aumentar su conocimiento de los factores de riesgo y cómo reducirlos”.

Esto podría significar desplegar trabajadores de salud comunitarios de manera más amplia o expandir programas innovadores como los que llevan a los farmacéuticos a las barberías afroamericanas para educar sobre la presión arterial alta, sugirió.

“Ahora, más que nunca, contamos con las terapias y tecnologías médicas para tratar las afecciones cardiovasculares”, dijo Rishi Wadhera, cardiólogo y jefe de sección de política de salud e investigación de equidad en el Centro Smith para la Investigación de Resultados en Cardiología en Beth Israel Deaconess. Centro Médico de Boston.

Lo que se necesita, agregó, son esfuerzos más vigorosos para garantizar que todos los pacientes mayores, incluidos los de comunidades desfavorecidas, estén conectados con médicos de atención primaria y reciban pruebas de detección y tratamiento adecuados para los factores de riesgo cardiovascular, y atención de alta calidad basada en evidencia en el caso de insuficiencia cardíaca, un ataque al corazón o un derrame cerebral.

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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Categories: Health Care

Cardiovascular Disease Is Primed to Kill More Older Adults, Especially Blacks and Hispanics

Kaiser Health News - Tue, 05/30/2023 - 5:00am

Cardiovascular disease — the No. 1 cause of death among people 65 and older — is poised to become more prevalent in the years ahead, disproportionately affecting Black and Hispanic communities and exacting an enormous toll on the health and quality of life of older Americans.

The estimates are sobering: By 2060, the prevalence of ischemic heart disease (a condition caused by blocked arteries and also known as coronary artery disease) is projected to rise 31% compared with 2025; heart failure will increase 33%; heart attacks will grow by 30%; and strokes will increase by 34%, according to a team of researchers from Harvard and other institutions. The greatest increase will come between 2025 and 2030, they predicted.

The dramatic expansion of the U.S. aging population (cardiovascular disease is far more common in older adults than in younger people) and rising numbers of people with conditions that put them at risk of heart disease and stroke — high blood pressure, diabetes, and obesity foremost among them — are expected to contribute to this alarming scenario.

Because the risk factors are more common among Black and Hispanic populations, cardiovascular illness and death will become even more common for these groups, the researchers predicted. (Hispanic people can be of any race or combination of races.)

“Disparities in the burden of cardiovascular disease are only going to be exacerbated” unless targeted efforts are made to strengthen health education, expand prevention, and improve access to effective therapies, wrote the authors of an accompanying editorial, from Stony Brook University in New York and Baylor University Medical Center in Texas.

“Whatever focus we’ve had before on managing [cardiovascular] disease risk in Black and Hispanic Americans, we need to redouble our efforts,” said Clyde Yancy, chief of cardiology and vice dean for diversity and inclusion at Northwestern University’s Feinberg School of Medicine in Chicago, who was not involved with the research.

Of course, medical advances, public health policies, and other developments could alter the outlook for cardiovascular disease over the next several decades.

More than 80% of cardiovascular deaths occur among adults 65 or older. For about a dozen years, the total number of cardiovascular deaths in this age group has steadily ticked upward, as the ranks of older adults have expanded and previous progress in curbing fatalities from heart disease and strokes has been undermined by Americans’ expanding waistlines, poor diets, and physical inactivity.

Among people 65 and older, cardiovascular deaths plunged 22% between 1999 and 2010, according to data from the National Heart, Lung, and Blood Institute — a testament to new medical and surgical therapies and treatments and a sharp decline in smoking, among other public health initiatives. Then between 2011 and 2019, deaths climbed 13%.

The covid-19 pandemic has also added to the death toll, with coronavirus infections causing serious complications such as blood clots and millions of seniors avoiding seeking medical care out of fear of becoming infected. Most affected have been low-income individuals, and older non-Hispanic Black and Hispanic people, who have died from the virus at disproportionately higher rates than non-Hispanic white people.

“The pandemic laid bare ongoing health inequities,” and that has fueled a new wave of research into disparities across various medical conditions and their causes, said Nakela Cook, a cardiologist and executive director of the Patient-Centered Outcomes Research Institute, an independent organization authorized by Congress.

One of the most detailed examinations yet, published in JAMA Cardiology in March, examined mortality rates in Hispanic, non-Hispanic Black, and non-Hispanic white populations from 1990 to 2019 in all 50 states and the District of Columbia. It showed that Black men remain at the highest risk of dying from cardiovascular disease, especially in Southern states along the Mississippi River and in the northern Midwest. (The age-adjusted mortality rate from cardiovascular disease for Black men in 2019 was 245 per 100,000, compared with 191 per 100,000 for white men and 135 per 100,000 for Hispanic men. Results for women within each demographic were lower.)

Progress stemming deaths from cardiovascular disease in Black men slowed considerably between 2010 and 2019. Across the country, cardiovascular deaths for that group dropped 13%, far less than the 28% decline from 2000 to 2010 and 19% decline from 1990 to 2000. In the regions where Black men were most at risk, the picture was even worse: In Mississippi, for instance, deaths of Black men fell only 1% from 2010 to 2019, while in Michigan they dropped 4%. In the District of Columbia, they actually rose, by nearly 5%.

While individual lifestyles are partly responsible for the unequal burden of cardiovascular disease, the American Heart Association’s 2017 scientific statement on the cardiovascular health of African Americans notes that “perceived racial discrimination” and related stress are associated with hypertension, obesity, persistent inflammation, and other clinical processes that raise the risk of cardiovascular disease.

Though Black people are deeply affected, so are other racial and ethnic minorities who experience adversity in their day-to-day lives, several experts noted. However, recent studies of cardiovascular deaths don’t feature some of these groups, including Asian Americans and Native Americans.

What are the implications for the future? Noting significant variations in cardiovascular health outcomes by geographic location, Alain Bertoni, an internist and professor of epidemiology and prevention at Wake Forest University School of Medicine, said, “We may need different solutions in different parts of the country.”

Gregory Roth, a co-author of the JAMA Cardiology paper and an associate professor of cardiology at the University of Washington School of Medicine, called for a renewed effort to educate people in at-risk communities about “modifiable risk factors” — high blood pressure, high cholesterol, obesity, diabetes, smoking, inadequate physical activity, unhealthy diet, and insufficient sleep. The American Heart Association has suggestions on its website for promoting cardiovascular health in each of these areas.

Michelle Albert, a cardiologist and the current president of the American Heart Association, said more attention needs to be paid in medical education to “social determinants of health” — including income, education, housing, neighborhood environments, and community characteristics — so the health care workforce is better prepared to address unmet health needs in vulnerable populations.

Natalie Bello, a cardiologist and the director of hypertension research at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles, said, “We really need to be going into vulnerable communities and reaching people where they’re at to increase their knowledge of risk factors and how to reduce them.” This could mean deploying community health workers more broadly or expanding innovative programs like ones that bring pharmacists into Black-owned barbershops to educate Black men about high blood pressure, she suggested.

“Now, more than ever, we have the medical therapies and technologies in place to treat cardiovascular conditions,” said Rishi Wadhera, a cardiologist and section head of health policy and equity research at the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center in Boston. What’s needed, he said, are more vigorous efforts to ensure all older patients, including those from disadvantaged communities, are connected with primary care physicians and receive appropriate screening and treatment for cardiovascular risk factors, and high-quality, evidence-based care in the event of heart failure, a heart attack, or a stroke.

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 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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Categories: Health Care

Many People Living in the ‘Diabetes Belt’ Are Plagued With Medical Debt

Kaiser Health News - Tue, 05/30/2023 - 5:00am

Delores Lowery remembers vividly the day in 2016 when she was working in a weaving plant near her home in Bennettsville, South Carolina, and the world around her seemed to go dim.

She turned to her co-workers. “And I asked, I said, ‘Why y’all got it so dark in here? They said, ‘Delores, it’s not dark in here.’ I said, ‘Yes, it is. It’s so dark in here.'”

She landed in the hospital. Her A1C level, which shows the average percentage of sugar in someone’s blood over the past few months, was 14%.

A reading of 6.5% or higher indicates diabetes.

Lowery’s home in Marlboro County is at the heart of what the Centers for Disease Control and Prevention calls the “Diabetes Belt” — 644 mostly Southern counties where rates of the disease are high.

And of those counties, NPR found that more than half have high levels of medical debt. That means at least 1 in 5 people have medical debt in collections.

That’s much higher than the national rate, which is 13%, according to the Urban Institute, a social-policy nonprofit. In Marlboro County, 37% of people have medical debt in collections.

NPR measured the overlap of Diabetes Belt counties and high medical debt counties by merging the institute’s medical debt database with the CDC’s list of Diabetes Belt counties.


Urban Institute economist Breno Braga said medical debt, like diabetes, is concentrated in the South.

“The single most important predictor of a county’s medical debt is the prevalence of chronic conditions. So it’s basically the share of the population that has disease, such as diabetes, hypertension, and other types,” he said.

That finding is from an analysis conducted by the Urban Institute for KFF Health News and NPR as part of an investigation into medical debt published last year. The investigation found, among other things, that 100 million people in the U.S. have some kind of health care debt, a burden that can be devastating for people with chronic illnesses such as diabetes and cancer.

Lowery has been dealing with both the medical and financial challenges of Type 2 diabetes, and much more. The years since her diagnosis have been extremely difficult, with one life-changing event having overwhelming health and financial consequences.

In 2017, she came home one day to find her daughter, Ella Shantrica, on the floor, stabbed to death. The body of her granddaughter, 8-year-old Iyana, was found 12 days later in a nearby creek. In February, a man was found guilty of the killings and sentenced to life in prison.

In an interview in the front room of that tidy single-family home in Bennettsville, Lowery said it took time before she could bring herself to return to the house.

“Every day, 24 hours a day, that incident is in my head,” she said. “It will never, ever go away.”

She credits her church’s pastor with helping her go back to the house, which she shares with grandson Tyreon, a teenager on the autism spectrum. With her daughter gone, Lowery said, she is Tyreon’s sole caregiver.

Paying for diabetes care along with bills for food and housing has been a constant financial strain that eventually put her in debt.

“The cost of living was so extremely high in trying to raise my grandson that I just got behind,” she said.

Many Americans are facing similar hardships. In addition to NPR’s findings, research from the American Diabetes Association said people with the disease have more than twice the medical expenses annually as those without the disease.

“Because diabetes is a chronic illness, there are always six-month appointments,” said Donna Dees, who lives in Georgia and was diagnosed with Type 2 diabetes in 2008. “Every six months, go to the doctor, you’ve got lab work. So that’s how the costs keep building up and building up.”

Dees built up thousands of dollars in medical debt and got help from RIP Medical Debt, a nonprofit group that says it has wiped out more than $8 billion in medical debt.

Lowery will tell you that she gets high-quality and compassionate health care from a local provider. But the financial challenge of living with diabetes has put her health into decline.

A drug that once helped her, Ozempic, is now too costly for her. She said the medicine had been helping bring her diabetes under control. She was getting it delivered to her home, but she didn’t meet her copays, and the bills piled up as unpaid debt. Soon, the deliveries stopped and Lowery tried to renew the prescription at the local pharmacy.

“I went to get it and the woman told me, ‘I don’t think you’re going to be able to afford this.’ I said, ‘Why not?’ She said, ‘Because it’s seven hundred and some dollars.'”

Worse, as the drug’s profile skyrocketed in recent months as a treatment for weight loss among celebrities, demand increased and a shortage developed.

Lowery said this year that she hadn’t been able to get Ozempic for several months and that her diabetes was getting worse. Her insurance company has been of no help.

“Nobody is willing to work with me with Ozempic. I don’t know what to do,” Lowery said. “They won’t send me the medicine.”

She and her provider even talked about getting physician samples, but given Ozempic’s growing popularity, that didn’t work.

A Changing Economy

In Lowery’s hometown, others are struggling too.

More than 1 in 3 residents of the surrounding county have medical debt in collections, and 1 in 3 live in poverty.

It wasn’t always this way, locals told NPR. The area once hummed with manufacturing companies, restaurants, and other amenities. There were plenty of good jobs to go around.

But one by one, employers moved out. Today, downtown Bennettsville is pretty quiet. South Carolina as a whole has nearly 100,000 fewer manufacturing jobs than it did in 2000.

“Bennettsville used to be a more thriving community years ago,” said Lowery’s health care provider, nurse practitioner Pat Weaver. “With a lot of our plants leaving for, you know, overseas in the last 15-20 years really made a devastating impact. We used to have a hospital here and now we no longer have that. It is very poor.”

Weaver works for CareSouth, a nonprofit health center that has a federal government designation as a safety-net provider.

As she walks the halls of the clinic, checking on colleagues and patients, she says that of the 3,300 appointments she takes every year, more than 90% of the people she treats have Type 2 diabetes.

She and others point to Bennettsville’s changing economic fortune as a source of health problems in the community. Half the households in the city have an income of less than $32,000. Lower-income residents often can’t or don’t choose the kinds of healthy meals that would help them control their diabetes, she said.

“The fast foods don’t help at all, and a lot of people just eat it every day, and that’s a problem. It truly is,” Weaver said. “But we have programs to help them. We even have a program where we take patients to the grocery store and we teach them what to buy.”

CareSouth takes other steps, too, to fight the effects of poverty and disease in Bennettsville. The center has a sliding-fee scale based on ability to pay and an in-house pharmacy that uses a federal program to keep drug prices down.

For Lowery, having a medical provider like Weaver has been a lifeline. “She’s seen me through so much,” Lowery said. “She tried different medicines to get my diabetes intact.”

Finding Weaver came at a time when her family’s murders threw her into depression, her finances spiraled out of control, and her diabetes worsened. Weaver, she said, helped get her into counseling.

“When she found out what had happened, I honestly believe in my heart that she cried just like I cried,” Lowery said. “She did so much for me.”

South Carolina’s Choice on Medicaid

While there is no easy solution for Lowery, who is over 65 and enrolled in Medicare, the Urban Institute and others say a simple policy change could prevent others from getting to such a difficult stage in their disease and finances: Expand Medicaid.

“Seventy-nine out of the 100 counties with the highest levels of medical debt are in states that have not expanded Medicaid under the ACA,” the Urban Institute’s Braga said, referring to the Affordable Care Act.

Also known as Obamacare, the ACA offered states the option to expand their health insurance programs for the poor.

South Carolina is one of 10 states that have declined to do so, and where NPR identified more than two dozen counties that fall within the Diabetes Belt and have high rates of medical debt. There’s evidence from other states that people became healthier and owed less money to medical providers after Medicaid expansion.

A Boston University researcher looked at health centers just like CareSouth — more than 900 of them serving nearly 20 million patients.

The centers in states that did expand Medicaid reported better diabetes control than those in states that didn’t expand the program, and the effect was quick — within three years of the expansion.

Those improvements happened consistently among Black and Hispanic patients, who have higher rates of diabetes.

A study in Louisiana found that people who gained Medicaid coverage after an expansion there had reduced medical debt.

Lowery said that going forward she will continue to rely on her faith and her church community to help her through the tough times.

Still, she worries about the possible worsening of her diabetes and the financial stress of daily life.

“I wish things would get better,” she said. “I think I would sleep a little better, because sometimes it’s kind of hard for me to try to keep some food on the table.”

This article is from a partnership with NPR, where it was edited by Robert Little and Kamala Kelkar and produced by Meg Anderson; the photos were edited by Virginia Lozano.

About This Project

“Diagnosis: Debt” is a reporting partnership between KFF Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country. 

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status for KFF Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KFF Health News on a survey of its clients to explore links between medical debt and housing instability. 

KFF Health News journalists worked with KFF public opinion researchers to design and analyze the “KFF Health Care Debt Survey.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KFF Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

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.


This story can be republished for free (details).

Categories: Health Care

Mammograms at 40? Breast Cancer Screening Guidelines Spark Fresh Debate

Kaiser Health News - Tue, 05/30/2023 - 5:00am

While physicians mostly applauded a government-appointed panel’s recommendation that women get routine mammography screening for breast cancer starting at age 40, down from 50, not everyone approves.

Some doctors and researchers who are invested in a more individualized approach to finding troublesome tumors are skeptical, raising questions about the data and the reasoning behind the U.S. Preventive Services Task Force’s about-face from its 2016 guidelines.

“The evidence isn’t compelling to start everyone at 40,” said Jeffrey Tice, a professor of medicine at the University of California-San Francisco.

Tice is part of the WISDOM study research team, which aims, in the words of breast cancer surgeon and team leader Laura Esserman, “to test smarter, not test more.” She launched the ongoing study in 2016 with the goal of tailoring screening to a woman’s risk and putting an end to the debate over when to get mammograms.

Advocates of a personalized approach stress the costs of universal screening at 40 — not in dollars, but rather in false-positive results, unnecessary biopsies, overtreatment, and anxiety.

The guidelines come from the federal Department of Health and Human Services’ U.S. Preventive Services Task Force, an independent panel of 16 volunteer medical experts who are charged with helping guide doctors, health insurers, and policymakers. In 2009 and again in 2016, the group put forward the current advisory, which raised the age to start routine mammography from 40 to 50 and urged women from 50 to 74 to get mammograms every two years. Women from 40 to 49 who “place a higher value on the potential benefit than the potential harms” might also seek screening, the task force said.

Now the task force has issued a draft of an update to its guidelines, recommending the screening for all women beginning at age 40.

“This new recommendation will help save lives and prevent more women from dying due to breast cancer,” said Carol Mangione, a professor of medicine and public health at UCLA, who chaired the panel.

But the evidence isn’t clear-cut. Karla Kerlikowske, a professor at UCSF who has been researching mammography since the 1990s, said she didn’t see a difference in the data that would warrant the change. The only way she could explain the new guidelines, she said, was a change in the panel.

“It’s different task force members,” she said. “They interpreted the benefits and harms differently.”

Mangione, however, cited two data points as crucial drivers of the new recommendations: rising breast cancer incidence in younger women and models showing the number of lives screening might save, especially among Black women.

There is no direct evidence that screening women in their 40s will save lives, she said. The number of women who died of breast cancer declined steadily from 1992 to 2020, due in part to earlier detection and better treatment.

But the predictive models the task force built, based on various assumptions rather than actual data, found that expanding mammography to women in their 40s might avert an additional 1.3 deaths per 1,000 in that cohort, Mangione said. Most critically, she said, a new model including only Black women showed 1.8 per 1,000 could be saved.

A 2% annual increase in the number of 40- to 49-year-olds diagnosed with breast cancer in the U.S. from 2016 through 2019 alerted the task force to a concerning trend, she said.

Mangione called that a “really sizable jump.” But Kerlikowske called it “pretty small,” and Tice called it “very modest” — conflicting perceptions that underscore just how much art is involved in the science of preventive health guidelines.

Task force members are appointed by HHS’ Agency for Healthcare Research and Quality and serve four-year terms. The new draft guidelines are open for public comment until June 5. After incorporating feedback, the task force plans to publish its final recommendation in JAMA, the Journal of the American Medical Association.

Nearly 300,000 women will be diagnosed with breast cancer in the U.S. this year, and it will kill more than 43,000, according to National Cancer Institute projections. Expanding screening to include younger women is seen by many as an obvious way to detect cancer earlier and save lives.

But critics of the new guidelines argue there are real trade-offs.

“Why not start at birth?” Steven Woloshin, a professor at the Dartmouth Institute for Health Policy and Clinical Practice, asked rhetorically. “Why not every day?”

“If there were no downsides, that might be reasonable,” he said. “The problem is false positives, which are very scary. The other problem is overdiagnosis.” Some breast tumors are harmless, and the treatment can be worse than the disease, he said.

Tice agreed that overtreatment is an underappreciated problem.

“These cancers would never cause symptoms,” he said, referring to certain kinds of tumors. “Some just regress, shrink, and go away, are just so slow-growing that a woman dies of something else before it causes problems.”

Screening tends to find slow-growing cancers that are less likely to cause symptoms, he said. Conversely, women sometimes discover fast-growing lethal cancers soon after they’ve had clean mammograms.

“Our strong feeling is that one size does not fit all, and that it needs to be personalized,” Tice said.

WISDOM, which stands for “Women Informed to Screen Depending On Measures of risk,” assesses participants’ risk at 40 by reviewing family history and sequencing nine genes. The idea is to start regular mammography immediately for high-risk women while waiting for those at lower risk.

Black women are more likely to get screening mammograms than white women. Yet they are 40% more likely to die of breast cancer and are more likely to be diagnosed with deadly cancers at younger ages.

The task force expects Black women to benefit most from earlier screening, Mangione said.

It’s unclear why Black women are more likely to get the most lethal breast cancers, but research points to disparities in cancer management.

“Black women don’t get follow-up from mammograms as rapidly or appropriate treatment as quickly,” Tice said. “That’s what really drives the discrepancies in mortality.”

Debate also continues on screening for women 75 to 79 years old. The task force chose not to call for routine screening in the older age group because one observational study showed no benefit, Mangione said. But the panel issued an urgent call for research about whether women 75 and older should receive routine mammography.

Modeling suggests screening older women could avert 2.5 deaths per 1,000 women in that age group, more than those saved by expanding screening to younger women, Kerlikowske noted.

“We always say women over 75 should decide together with their clinicians whether to have mammograms based on their preferences, their values, their health history, and their family history,” Mangione said.

Tice, Kerlikowske, and Woloshin argue the same holds true for women in their 40s.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the 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.


This story can be republished for free (details).

Categories: Health Care

California Governor and Democratic Lawmakers at Odds Over Billions in Health Care Funds

Kaiser Health News - Tue, 05/30/2023 - 5:00am

SACRAMENTO, Calif. — When Gov. Gavin Newsom took office four years ago, the Democrat went after Republicans on the national stage as they sought to gut the Affordable Care Act. Key to his ambitious health care agenda: reinstating the fine on Californians who don’t have health coverage, which had been eliminated at the federal level.

It was a tough sell for a new governor, and Newsom needed strong allies among state Democratic leaders, who at the time, in 2019, voiced concern about essentially levying a new tax on Californians unable to afford the rising cost of health care. Democrats, who, then as now, controlled the state legislature, ultimately backed Newsom in exchange for a promise: The state would levy the fine but use that money to provide financial assistance to offset out-of-pocket costs for Californians purchasing health insurance on the state exchange, Covered California.

But Newsom, now in his second term, has since backed off that promise. His administration is holding on to revenue raised from the so-called individual mandate — the requirement that people have health coverage or pay a fine. And his proposed budget for the upcoming fiscal year beginning July 1, which is being debated in the state legislature, funnels the money to the state’s general fund.

That is infuriating fellow Democrats who accuse him of breaking a promise and disregarding the millions of Californians who can’t afford their deductibles and copays.

California began fining the uninsured in 2020, raising an estimated $1.1 billion over the first three years — and the Newsom administration projects it will bring in more than $700 million more over the next two years, bringing the projected five-year total to $1.8 billion, according to the state Department of Finance. Democratic leaders said Newsom’s tactic of holding back the money for the general fund is a “rip-off.”

“Money from the mandate should stay in health care,” Senate President Pro Tem Toni Atkins told KFF Health News, arguing the state should be distributing money now to help people afford health coverage. “I don’t know what we’re waiting for. We’ve got to figure out a way to make health care more accessible, and there’s no question that the cost of health insurance is a barrier.”

Democratic lawmakers are expected to continue ratcheting up pressure on Newsom in hopes of reaching a deal by their June 15 deadline to pass a budget bill. “We’ve always felt that the money is meant to bring insurance costs down,” said Democratic Assembly member Phil Ting, chair of the Budget Committee.

Newsom in 2019 stumped for the individual mandate amid concerns over rising insurance premiums, vowing to reduce Covered California consumer health care costs while setting himself apart from then-President Donald Trump, who was attacking the insurance mandate as unfair. Congressional Republicans had gutted the federal penalty — part of the Affordable Care Act — in 2017. Newsom argued it would still work in California to lower health care costs, and to help him achieve his goal of universal health care — the centerpiece of his ambitious health care agenda.

Newsom now argues that federal health insurance subsidies that offset the cost of monthly premiums are sufficient. And, in the face of a projected $32 billion state budget deficit, Newsom says California cannot afford to spend the money and further reduce out-of-pocket costs. He argues spending the money to slash deductibles, for instance, “would be “unsustainable.” His proposed budget would instead keep the money for the state’s general fund, to be used for anything California wants to spend it on.

But health care advocates who lobbied in favor of the fine, as well as many Democratic lawmakers, say the funds could be lifesaving and should be distributed now.

“The individual mandate was not intended to create funds for other government programs outside of health care,” said Democratic Assembly member Jim Wood, of Santa Rosa, chair of the Assembly Health Committee, at a heated budget hearing this spring. “The clear intent of the legislature was that this money was meant to go to affordability.”

Wood said he might have rejected Newsom’s plan if he had known the revenue it generated would be deposited directly into the general fund. “I don’t think I would have supported it,” he said. “It just feels like a violation of what we thought we were doing.”

Soaring out-of-pocket health care costs, for insurance premiums and deductibles for instance, are leading people to forgo health care. In California, a staggering 52% of residents report having skipped or delayed treatment in the past year for financial reasons, according to a recent survey by the nonprofit California Health Care Foundation. (KFF Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)

Diana Douglas, a lobbyist with Health Access California, which was part of the coalition that backed the state’s coverage mandate in 2019, said Newsom must recognize soaring costs and spend the money now on affordability assistance. “This penalty money should be used to help Californians afford coverage and care.”

Health insurance plans offered by Covered California are continuing to get more expensive. Deductibles for a midtier insurance plan, for example, will jump to $5,400 next year, according to Covered California, up from $4,750 this year and just $3,700 two years ago.

And even many Californians who are purchasing coverage are putting off treatment in the face of high costs. A survey by Covered California in 2022 found that 48% of its consumers delayed important medical care due to cost.

Newsom this spring dodged a question by KFF Health News about the criticism he is facing over his push to retain the mandate money, saying simply he’s “proud” to have established the state coverage mandate and noting that federal premium subsidies are available for Californians purchasing coverage via Covered California. His administration defended the push to funnel money into the general fund, saying revenues would be repaid to a special health fund and be available to use on health care eventually, if the federal government cuts back existing premium subsidies. Administration officials argue that Newsom is essentially borrowing the money and say it’ll be repaid later — though lawmakers have expressed concern that he’ll never make good on that promise.

Critics and some Democratic lawmakers say holding back the money is a double whammy for low- and middle-income residents who are struggling to pay for coverage, and argue that it amounts to a tax on the poor. “It feels like we’re trying to save it on the backs of our low-income communities,” said Democratic state Sen. Caroline Menjivar, who represents the state’s San Fernando Valley.

Democratic lawmakers this year are backing an alternative proposal, championed by Health Access California, to spend revenue from fining uninsured residents on increasing health insurance subsidies for low- and middle-income people. They would be making good on a deal advocates secured with state Democratic lawmakers last year to reduce or eliminate out-of-pocket costs in Covered California and scrap deductibles entirely for a mid-tier plan.

“We need to make sure people not only have health coverage, but that they can also afford to actually use it,” said Ronald Coleman Baeza, a health care lobbyist with the California Pan-Ethnic Health Network.

Although Newsom and his Democratic allies have passed major expansions in coverage, the state does not have universal health care. Experts say more than 2.5 million Californians remain uninsured, including unauthorized immigrants who earn too much to qualify for Medi-Cal, and lawmakers are growing increasingly agitated that not all residents who are insured can afford to use their coverage.

“There was a clear commitment that these dollars were going to be used to bring down heath care costs, and we haven’t done it,” said Assembly member Pilar Schiavo, a Democrat representing the Santa Clarita Valley, who introduced a bill that would require any revenue raised from the individual mandate be permanently set aside for health care. Though it died this year, it can be revived next year, and advocates say they will continue pressing Newsom to distribute the existing money to Covered California consumers.

“We need to keep our promises,” Schiavo said. “If you have insurance that you can’t afford to use, or you’re afraid to go see the doctor because of how high that bill might be, then you don’t truly have access or universal coverage.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the 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.


This story can be republished for free (details).

Categories: Health Care

Denials of Health Insurance Claims Are Rising — And Getting Weirder

Kaiser Health News - Fri, 05/26/2023 - 5:00am

Millions of Americans in the past few years have run into this experience: filing a health care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”

It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.

And so, the law tasked the Department of Health and Human Services with monitoring denials both by health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out-of-pocket or, faced with that prospect, forgoing needed medical help.

A recent KFF study of ACA plans found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s turndowns hit an astonishing 80% in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.

Sometimes, the insurers’ denials defy not just medical standards of care but also plain old human logic. Here is a sampling collected for the KFF Health News-NPR “Bill of the Month” joint project.

  • Dean Peterson of Los Angeles said he was “shocked” when payment was denied for a heart procedure to treat an arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute. After all, he had the insurer’s preapproval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim had been rejected because he had “asked for coverage for injections into nerves in your spine” (he hadn’t) that were “not medically needed.” Months later, after dozens of calls and a patient advocate’s assistance, the situation is still not resolved.
  • An insurer’s letter was sent directly to a newborn child denying coverage for his fourth day in a neonatal intensive care unit. “You are drinking from a bottle,” the denial notification said, and “you are breathing on your own.” If only the baby could read.
  • Deirdre O’Reilly’s college-age son, suffering a life-threatening anaphylactic allergic reaction, was saved by epinephrine shots and steroids administered intravenously in a hospital emergency room. His mother, utterly relieved by that news, was less pleased to be informed by the family’s insurer that the treatment was “not medically necessary.”

As it happens, O’Reilly is an intensive-care physician at the University of Vermont. “The worst part was not the money we owed,” she said of the $4,792 bill. “The worst part was that the denial letters made no sense — mostly pages of gobbledygook.” She has filed two appeals, so far without success.

Some denials are, of course, well considered, and some insurers deny only 2% of claims, the KFF study found. But the increase in denials, and the often strange rationales offered, might be explained, in part, by a ProPublica investigation of Cigna — an insurance giant, with 170 million customers worldwide.

ProPublica’s investigation, published in March, found that an automated system, called PXDX, allowed Cigna medical reviewers to sign off on 50 charts in 10 seconds, presumably without examining the patients’ records.

Decades ago, insurers’ reviews were reserved for a tiny fraction of expensive treatments to make sure providers were not ordering with an eye on profit instead of patient needs.

These reviews — and the denials — have now trickled down to the most mundane medical interventions and needs, including things such as asthma inhalers or the heart medicine that a patient has been on for months or years. What’s approved or denied can be based on an insurer’s shifting contracts with drug and device manufacturers rather than optimal patient treatment.

Automation makes reviews cheap and easy. A 2020 study estimated that the automated processing of claims saves U.S. insurers more than $11 billion annually.

But challenging a denial can take hours of patients’ and doctors’ time. Many people don’t have the knowledge or stamina to take on the task, unless the bill is especially large or the treatment obviously lifesaving. And the process for larger claims is often fabulously complicated.

The Affordable Care Act clearly stated that HHS “shall” collect the data on denials from private health insurers and group health plans and is supposed to make that information publicly available. (Who would choose a plan that denied half of patients’ claims?) The data is also supposed to be available to state insurance commissioners, who share with HHS the duties of oversight and trying to curb abuse.

To date, such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete, according to Karen Pollitz, a senior fellow at KFF and one of the authors of the KFF study. Federal oversight and enforcement based on the data are, therefore, more or less nonexistent.

HHS did not respond to requests for comment for this article.

The government has the power and duty to end the fire hose of reckless denials harming patients financially and medically. Thirteen years after the passage of the ACA, perhaps it is time for the mandated investigation and enforcement to begin.

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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Categories: Health Care

A Catch-22 for Clinics: State Bans Limit Abortion Counseling. Federal Title X Rules Require It.

Kaiser Health News - Fri, 05/26/2023 - 5:00am

State abortion bans in Tennessee and beyond, which constrain women’s health care, have put family planning clinics at risk of losing their federal funding.

The conflict involves the Title X family planning program, which provides services to low-income people, including minors. As of 2021, more than 3,200 clinics used federal grants to supply free or low-cost contraception, testing for sexually transmitted infections, screening for breast and cervical cancer, and pregnancy-related counseling.

Federal regulations for the program, which was established more than 50 years ago to reduce unintended pregnancies, say participating clinics must offer pregnant women information about terminating pregnancies and abortion referrals on request. But following those rules puts medical providers at odds with state laws banning abortion, some of which threaten jail time, fines, or the loss of medical licenses if they help someone end a pregnancy.

President Joe Biden’s administration at the end of March cut off Tennessee’s Title X funds after determining the state health department — which oversees its clinics and was awarded $7.1 million last year — violated federal rules by not counseling patients about abortion. “Continued funding is not in the best interest of the government,” two U.S. Department of Health and Human Services officials wrote to Tennessee officials on March 20. The state had more than 100 Title X clinics as of March, according to an HHS directory.

In 2022, the federal government awarded Title X grants to roughly 90 entities, a mix of state and local governments and private organizations. Those grantees distribute funds to public or private clinics.

Federal law prohibits clinics from using Title X money to pay for abortions. However, HHS requires clinics to offer pregnant women information about prenatal care and delivery, infant care, foster care, adoption, and pregnancy termination.

In states where abortion is generally illegal, that could mean directing patients to providers in other states. But Tennessee told family planning clinics they could discuss only services that were legal in the state — effectively cutting off any talk about abortion.

Tennessee allows abortions only under limited circumstances, including to save a pregnant person’s life. State health department policies for family planning “are consistent with state law,” said Jade Byers, a spokesperson for Republican Gov. Bill Lee. Tennessee allocated state funds to replace the federal money.

Whitney Rice, director of Emory University’s Center for Reproductive Health Research in the Southeast, said failing to provide timely information and referrals for abortion “could contribute to further delays in people’s ability to access that care,” especially because women may need to travel long distances for it.

The clash over the federally funded clinics is part of the widening fallout from the Supreme Court’s June 2022 decision in Dobbs v. Jackson Women’s Health Organization ending the constitutional right to an abortion.

In Idaho, which has a near-total abortion ban, two Planned Parenthood clinics with Title X funding recently stopped giving patients abortion information and halted out-of-state referrals, according to a lawsuit Planned Parenthood and the American Civil Liberties Union filed in April against Idaho’s attorney general.

State law prohibits providers from assisting in performing or attempting to perform an abortion, and violators risk having their medical license suspended.

The clinics’ decision came after Idaho Attorney General Raúl Labrador, in a March 27 letter, said Idaho law prohibits providers from “referring a woman across state lines to access abortion services.”

That interpretation is “preventing medical professionals from providing full information to their patients,” said Mack Smith, spokesperson for Planned Parenthood Great Northwest, Hawaii, Alaska, Indiana, Kentucky.

Though Labrador later withdrew the letter, Planned Parenthood clinics there still are not referring patients out of state for abortions, Smith said.

Before Labrador’s letter, the lawsuit states, Planned Parenthood staff would furnish general information about pregnancy options, a list of abortion providers in other states and organizations that help defray patients’ abortion and related costs, and a flyer about Idaho’s abortion law. Staff would also occasionally help patients schedule care outside of Idaho. Now, “Planned Parenthood providers no longer do so.”

“When my patients require abortions, I am now forced to tell them that I am unable to help them and that I cannot say anything about their abortion options in other states,” Caitlin Gustafson, a physician who had practiced at an Idaho Planned Parenthood clinic, said in a legal declaration.

Kimberley Harris, a visiting assistant professor at Texas Tech University School of Law, said clinicians in states with strict bans worry about referring patients to other states because a prosecutor could interpret that as “aiding and abetting an abortion.”

Facilitating medication abortion in particular could “pose potential risk to health care providers,” Harris said, because a patient they refer to obtain pills out of state might then take them in a state where abortion is illegal. Medication abortion accounts for most abortions in the U.S. and involves taking a series of pills during the first 10 weeks of pregnancy.

“The federal regulation might require me to provide counseling and provide information,” Harris said of clinicians. “But if you’re telling providers that they may lose their license, or they might go to jail, or they might face a huge fine? Rightfully, they’re going to be concerned.”

As senior HHS officials travel the country, they are getting an earful about the issue.

HHS spokesperson Tara Broido said that, increasingly, “providers and patients have raised concerns about the impact that the Dobbs decision has had on access” to pregnancy counseling and referrals.

KFF Health News asked Broido which grantees have not been following the counseling and referral requirements. She declined to say.

People who use Title X’s services are disproportionately women. A report from HHS’ Office of Population Affairs said roughly two-thirds of 1.7 million patients in 2021 had family incomes at or below the poverty line. Thirty-six percent were uninsured, more than two times the national uninsured rate for adults.

The Office of Population Affairs and the Centers for Disease Control and Prevention jointly recommend family planning services that clinics are expected to follow. They include pregnancy testing and counseling.

The Title X program has been whipsawed before.

In 2019, the Trump administration barred Title X clinics from making abortion referrals. And the administration said abortion providers couldn’t share physical space with Title X clinics. The number of participating clinics subsequently dropped sharply — from 3,825 sites in 2019 to 3,031 the following year. With fewer clinics, the number of people receiving free or low-cost family planning services through the program plummeted from 3.1 million in 2019 to 1.5 million in 2020.

The Biden administration in 2021 overturned many of the Trump policies. The Biden rules remain in effect, but several states sued to block them. That litigation is ongoing.

Sarah Parshall Perry, a senior legal fellow at the conservative Heritage Foundation think tank, anticipates additional challenges to Title X rules because “states have an interest in defending their own laws and their ability to enforce their own laws.”

In Texas, which prohibits abortion with few exceptions, the nonprofit Every Body Texas oversees 154 Title X family planning clinics.

Its providers are still counseling pregnant women about options, but “that’s not to say it hasn’t been made very, very difficult,” said Stephanie LeBleu, the group’s acting Title X director.

LeBleu said the approach to counseling “can look different” from clinic to clinic. For example, clinics in rural Texas “have to be a lot more cautious about how they share information with their clients,” LeBleu said. Sometimes that means making a “referral to the referral” — such as directing patients to organizations like All-Options, which operates a national pregnancy options hotline.

ask for information on pregnancy options, “our clinics refer clients to other resources,” Karen M. Landers, chief medical officer for the Alabama Department of Public Health, said in a statement. The department declined to say what those resources are and whether clinicians worry about being prosecuted under Alabama law for providing abortion counseling or referrals.

“Clients are additionally informed of the legality of pregnancy termination in the state,” Landers wrote.

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.


This story can be republished for free (details).

Categories: Health Care
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