Why Giving Birth Is Safer in Britain Than in the U.S.
The U.S. and the U.K. used to have the same rate of women dying in pregnancy and childbirth. Now, Britain’s is almost three times lower. Here’s what they’re doing right.
For Every Woman Who Dies In Childbirth In The U.S., 70 More Come Close
by Renee Montaigne - NPR - May 10. 2018
Samantha Blackwell was working her way through a master's degree at Cleveland State University when she found out she was pregnant.
"I was 25, in really good health. I had been an athlete all my life. I threw shot put for my college, so I was in my prime," she says with a laugh.
Though it wasn't planned, Blackwell's pregnancy was embraced by her large and loving family and her boyfriend, who would soon become her husband. Her labor was quick, and she gave birth to a healthy baby boy.
Yet just days after she was discharged, Blackwell was back in the hospital, in a medically induced coma, fighting a runaway infection that left her hovering between life and death.
"It was like 'I fell asleep at that hospital and woke up the next day' kind of thing," she says. She was in a coma for more than a month.
Blackwell's story of reaching the brink of death is one that happens much too often, say researchers.
Over the past year, NPR and ProPublica have been investigating why American mothers die in childbirth at a far higher rate than in all other developed countries.
A mother giving birth in the U.S. is about three times as likely to die as a mother in Britain and Canada.
In the course of our reporting, another disturbing statistic emerged: For every American woman who dies from childbirth, 70 nearly die. That adds up to more than 50,000 women who suffer "severe maternal morbidity" from childbirth each year, according to the Centers for Disease Control and Prevention. A patient safety group, the Alliance for Innovation on Maternal Health, came up with an even higher figure. After conducting an in-depth study of devastating complications in hospitals in four states, it put the nationwide number at around 80,000.
"It's referred to as the tip of the iceberg because for every woman we lose, there are lots of other women that we come very close to losing," says obstetrician Peter Bernstein, the director of the Maternal-Fetal Medicine division at Montefiore Medical Center in New York.
But surviving can come with a cost.
"An experience that we would hope and expect would be natural, beautiful, uplifting, becomes one that's terrifying," Bernstein says. "Women can wind up losing their uterus and therefore becoming infertile. They can wind up with kidney problems. They can have heart attacks. They can have brain damage from all the blood that they've lost."
And that is just a partial list of what can go wrong. Also on that list: Women develop pregnancy-induced high blood pressure known as pre-eclampsia, which can lead to a stroke and organ failure; parts of the placenta can be left behind, which can lead to infection; and a woman giving birth is more prone to blood clots that can be life-threatening.
The cost, though, is not just medical. The treatment for these complications can become an ongoing financial burden, and the trauma suffered from physical complications can lead to persistent emotional and psychological pain.
It is still rare for childbirth to involve truly severe complications, but in the U.S., say researchers, many of these worst-case scenarios need not have happened at all.
Samantha Blackwell doesn't remember much about her ordeal. It began 11 days after giving birth, when she sat up in bed with a terrible pain. By the time she got to the emergency room, her medical records show, she was in septic shock from a massive infection. For weeks, her doctors couldn't promise her family that she would live.
"They just knew that it was bad," she says, "to a point of 'expect the worst. We don't know if she's going to come out of this.' "
When Blackwell did emerge from her coma, she discovered she had undergone an emergency hysterectomy, a last-ditch effort to stop the infection that had originated in her uterus.
"I don't think I'm the type to overreact"
In the U.S., the rate of severe complications from childbirth has been rising faster than the rate of women who died. The rate of women nearly dying almost tripled between 1993 and 2014, according to the CDC. To help explain those dire statistics, experts point to risk factors that have increased in recent years: American women are giving birth at older ages and are more likely to have problematic conditions like obesity, high blood pressure and diabetes.
Early in our reporting, NPR and ProPublica launched an online call-out asking for stories of deaths and near deaths due to childbirth, and the tales of catastrophic complications and deaths poured in, ultimately more than 5,000 in all.
Alicia Nichols was among the thousands who wrote about their own experience. At 39, she and her husband had been trying hard to have a baby. She finally succeeded in getting pregnant through in vitro fertilization and gave birth in March 2017, just after she turned 40.
At her home outside of Boston, in a spacious, airy room strewn with baby toys, Nichols spoke of an easy pregnancy. It was how many stories we heard began. The birth, though, was different: a painful 42 hours of labor, until the baby's "failure to descend" led to an emergency cesarean section.
Then, after healing well for four weeks, she was surprised to feel a gush of blood.
"I was rocking Diana in my rocking chair here in the living room, and when I stood up, blood [had] soaked through me onto the chair," she says.
Her first reaction was to call an ambulance. "I don't think I'm the type to overreact. It was just so foreign to me," she says.
In the emergency room, the obstetrics resident who came over quickly chalked it up to natural postpartum bleeding, something that didn't merit the ultrasound Nichols was requesting.
"I felt that she was just dismissing me, annoyed, a new mother being paranoid of some blood. I felt like she was not listening at all," Nichols says.
Throughout our NPR/ProPublica investigation, we heard many variations on the perception by postpartum mothers that their physical concerns were not taken seriously. In Nichols' case, she was familiar with a medical environment. She worked as an aesthetician and office administrator for a plastic surgeon in the same building as her obstetrician.
In the weeks following her first scare, her obstetrician assured Nichols — in both an office visit and on phone calls — that the episodes of bleeding were most likely the beginning of her menstrual period.
For her part, Nichols pointed out to her doctor that she had never experienced a period like that.
"I had no cramping," she says. "It was just bright red blood. And, we all know, we're women. I don't want to be graphic, but we know it's different."
It was before dawn two months after giving birth, that Nichols — up with baby Diana — had another episode of sudden bleeding.
By chance, her own doctor was on call that early morning and picked up the phone. She remembers him saying, "You're going to be fine. Check back later in the day if this continues."
Instead, she went to his office right after it opened.
"I got on the elevator, and the minute the elevator door opened, that's when I began to hemorrhage," she says.
The obstetrician immediately called an ambulance, but Nichols was already in the midst of a life-threatening emergency.
"I remember putting my hand down, and when I lifted up my hand, it was just, my whole left hand. I remember seeing my wedding ring, just blood. My left hand was soaked with blood," she says.
According to her medical records, Nichols lost nearly half the blood in her body.
As a last resort — as in the case of Samantha Blackwell in Cleveland — Nichols' doctors in Boston performed an emergency hysterectomy.
In an addendum attached to Nichols' records 24 hours later, her obstetrician stuck with his original theory about her bouts of bleeding. He wrote "patient came to office with onset of first period that seemed heavier than average," and she "suddenly hemorrhaged."
Though NPR received written permission for Nichols' obstetrician to share details of her case, he declined to be interviewed for this story.
But a pathology report included in her records found an entirely different cause for Nichols' on-and-off bleeding. The pathologist's diagnosis was placental site vessel subinvolution, or VSI.
That essentially means that the enlarged blood vessels in the lining of the uterus, which had sent nutrition and oxygen to the developing fetus, had failed to return to their pre-pregnancy state. They stayed enlarged and intermittently bled into Nichols' uterus.
Though rare, VSI can be detected early with a scan and treated before leading to a life-threatening hemorrhage.
Obstetrician Elliott Main, a national leader in the movement to reform maternal health care, says that because most mothers do well during and after pregnancy, obstetricians and nurses strongly tend to expect the best and often are not prepared for the worst.
"That sets up the opportunity for what we call the twin demons of denial and delay. Denial that it's actually something serious," says Main, "leading to delay before you get the care that's going to make the difference."
Indeed, NPR and ProPublica found a medical system that bases care on the idea that it's rare for a woman to die in childbirth. It's a system in which funding and resources are dedicated mostly at saving babies.
The price tag of life-threatening complications
Severe complications due to childbirth are not common in the U.S., where nearly 4 million babies are born each year.
Yet bringing down the rate of these complications would not only spare tens of thousands of mothers from nearly dying, but it would also bring down the cost of health care, points out obstetrician Barbara Levy. She oversees health policy at the American College of Obstetricians and Gynecologists.
"Severe morbidity is expensive. ICU care is expensive. Transfusions are expensive. Dialysis is expensive," she says. "We can actually save money by putting processes in place that reduce risk."
The cost of Samantha Blackwell's long hospital stay, rehabilitation and home care soared to nearly $540,000.
Because she was younger than 26, she was covered by her mother's insurance, which paid for most of that.
But the experience was still financially devastating.
Blackwell couldn't return to her job at Men's Wearhouse for months. Her husband, DeVon, spent so much time at the hospital that he lost his job at a car dealership. And Samantha Blackwell's mother never left her bedside. Cynthia Murphy is still thankful that the K-Mart distribution center where she worked gave her a two-month leave, even though it was unpaid.
"I would have moved from my house, lived on the street. I really would not have cared at that time," Murphy says. "Samantha was my No. 1 priority."
Alicia Nichols, whose hemorrhage led to an emergency hysterectomy, measures her financial burden by what she estimates it would take to have another baby via surrogate: at least $80,000.
No single study has tallied the total cost of America's high rate of severe complications. But there are clues that it runs into the billions. A report in the American Journal of Obstetrics and Gynecology found the cost of caring for mothers suffering from pre-eclampsia is more than a billion dollars each year.
And the federal Agency for Healthcare Research and Quality put a dollar figure on the average cost of a hysterectomy related to childbirth complications: In 2014, it was more than $95,000.
"I was just a wreck"
And then, of course, there is the human cost.
"I have a lot of anger. I do. I know that my obstetrician feels terrible that things went this way, but it just makes me so angry," says Alicia Nichols, "because I know I'm not the only one. There are so many women out there."
In Nichols' case, her troubles did not end with the massive hemorrhage. Just days later, while she and her baby were resting at her parents' home in Cape Cod, Nichols began feeling dizzy.
And this time, at a local hospital, the doctor paid close attention to her complaint.
"He knew my history, and he said something's not adding up," she recalls.
The results of a test that helps identify the presence of blot clots worried this new doctor enough to call for a CT scan, which proved his suspicion.
"He came back, and he's like, 'I'm sorry, you're not going home, you have multiple pulmonary emboli in both your right and left branches,' " she says.
Nichols remembers her shock at looking at the scan: "It was like someone splattered paint into my lungs."
Six days later, Nichols left the hospital with an anti-clotting drug, and a new fear: anticoagulants come with a risk of bleeding, leading her to imagine a nightmare scenario in which she hemorrhaged again.
"So I was just a wreck at that point," says Nichols, who is now being treated for post-traumatic stress disorder.
"It's funny, I remember speaking with the critical care pulmonologist, and I was sort of having a pity party and was just devastated," she says. "I said I'm so unlucky. And he said, 'No, you should go buy a lottery ticket, because you shouldn't be alive right now.' "
It is a common theme among the thousands of women we've heard from: Their trauma, both physical and emotional, is hard to shake and impossible to forget.
And that anxiety radiates out to the families who also survived a terrible time.
Two full years after Samantha Blackwell's son was born, she spoke of how she is continually reminded of the high fever from the raging infection that nearly killed her. That reminder comes from her mother, who nearly lost a daughter.
"My mom, I make fun of her, because she checks my temperature with her hand," says Blackwell. "Every time she hugs me goodbye, her hand is on my forehead."
https://www.npr.org/2018/05/10/607782992/for-every-woman-who-dies-in-childbirth-in-the-u-s-70-more-come-close?
Despite Attacks on Obamacare, the Uninsured Rate Held Steady Last Year
by Margot Sanger-Katz - NYT - May 22, 2018
Last year, Trump administration officials declared Obamacare “dead,” pulled enrollment ads offline, distributed social media videos critical of the law and sent signals that the law’s requirement to buy health insurance was no longer in effect.
But the number of Americans with health insurance stayed largely unchanged. The results of a big, government survey on health insurance status were published Tuesday, and they show that the uninsured rate remained basically flat at 9.1 percent in the first year of the Trump presidency.
The numbers suggest a surprising resilience of the health law, and its expansion of insurance coverage, even in the face of efforts that the law’s defenders call “sabotage.”
The new statistics come from the Centers for Disease Control and Prevention, which monitors the number of Americans with and without health insurance every quarter. Some smaller private surveys, from Gallup and the Commonwealth Fund had shown the uninsured rate rising last year. But the C.D.C. research includes a larger sample size, and is generally regarded as a more definitive study. Tuesday’s study contains data from the entire calendar year of 2017.
Among states that expanded their Medicaid programs under the Affordable Care Act, the uninsured rate actually fell last year. Among states that didn’t expand, it rose a little.
Overall, Obamacare has substantially reduced the number of Americans without insurance. According to the report, 19.3 million fewer people were living without health insurance in 2017 compared with 2010, when the Affordable Care Act passed Congress.
New health insurance options aren’t the only thing that has changed since the passage of the Affordable Care Act. A strengthening economy has nudged more Americans into the work force, increasing people’s access to health insurance at work.
Obamacare has shown other signs of hardiness. This year, the Trump administration slashed the program’s advertising budget by 90 percent, and withdrew key subsidies from insurance companies, leading to premium increases for some customers. But every market had at least one insurer that continued to offer plans on the Obamacare marketplaces, and sign-ups dipped only slightly.
That does not mean that the insurance trends will hold forever. There are several reasons the uninsured rate may rise in the future:
- In the face of rising premiums, it is likely that some who do not qualify for federal subsidies have dropped coverage this year.
- Several states are trying to set up work or other “community engagement”requirements for some Medicaid beneficiaries. A few will impose such rules this year. States requesting such changes estimate they will result in a declining number of residents covered by Medicaid.
- The Trump administration is working on regulations to allow more loosely regulated insurance plans into the market. These plans could prove appealing to some people who are currently uninsured. But they could cause prices to rise for insurance plans with all of the Obamacare consumer protections, prompting other people to drop their coverage. According to an estimate from the Urban Institute, about 2.6 million fewer people may have comprehensive coverage next year.
- The tax penalty for people who decline to obtain insurance will disappear entirely next year. That change alone is likely to cause several million fewer Americans to have insurance. Early filings by insurance carriers suggest the change will cause another round of big price increases. And economists at the Congressional Budget Office estimate that the policy’s disappearance will also cause fewer people eligible for government help from even investigating such options.
The combination of those changes is likely to mean some backsliding. But last year’s data suggest that Obamacare’s policies have helped create options that are appealing to many Americans who would have gone without insurance in the years before its passage.
'I'VE BEEN A PAIN IN THE REAR FOR THE REPUBLICAN PARTY': A CONVERSATION WITH RICHARD PAINTER
The former Bush ethics lawyer and current Senate hopeful talks about single-payer health care, his beef with the NRA, and why he's running as a Democrat.
by David Perry - Pacific Standard - May 17, 2018
A few weeks ago, Richard Painter shocked the Minnesota political establishment by declaring that he would run for the United States Senate as a Democrat. Painter was the White House ethics lawyer under President George W. Bush and has become widely known as a centrist Republican commentator, in his own writing and on media outlets such as MSNBC. He's now a professor of corporate law at the University of Minnesota. It was no surprise when he announced an exploratory committee to compete for the Senate seat vacated by Al Franken earlier this year, but no one seems to have guessed that he'd switch parties.
Painter's campaign reflects the dilemma that center-right Republicans find themselves in thanks to the Trumpification of their party. They can run as anti-Trump Republicans and probably lose their primaries. Even if they win, then what? No reasonable person can look at the Senate under Majority Leader Mitch McConnell and imagine the GOP exercising significant oversight of the executive branch. On the other hand, can a lifelong Republican win the trust of Democratic primary voters? Moreover, is Painter's shift conditional? Will he continue to support Democratic positions if he doesn't win?
Right now, in addition to his long-running criticisms of President Donald Trump, Painter is challenging Minnesota Senator Tina Smith from the left on health care, the environment, and corporate partnerships, especially over the new NFL stadium in Minneapolis. Smith was lieutenant governor of Minnesota before Governor Mark Dayton appointed her to replace Al Franken after the latter's resignation last December.
I recently sat down with Painter in a suburban coffee shop in Eagan, Minnesota. We talked about his decision to run as a Democrat, his core philosophy of government, and the grave threat that Painter says Trump and his Republican enablers pose to the future of American democracy.
I have a paper trail that goes back to at least 1994. I've been writing, and that's what professors do. I challenge people to find an issue that I've really made a substantial change on. I recognize new evidence, for example, of even worse behavior in the banking sector than what I talked about in 1994. But because I worked for President Bush as the ethics lawyer, people assume that somehow everything else that was going on [then] was things that I would agree with.
So you haven't always been in lockstep with everything in the Republican Party platform?
There are quite a lot of differences. I have tended to speak out on the issues that are in the purview of my professional expertise—business ethics, corporate ethics, and government ethics. Until recently, I didn't get into what I think is the best health-care system, weighing in on abortion or something. In the past year or two, I started to weigh in on a lot of issues. People assume that, because the Republican president that I worked for had a different position on those issues, that back then I had a different position. That's just not the case. The whole paper trail is there. Search it and find it.
I'd love to hear more about your recent decision to run as a Democrat for the Senate, especially when everyone else was assuming you'd run as a Never-Trump Republican. Can you take me into that decision?
You got two problems with the Republican Party.
One is that the Trump White House has made it abundantly clear that they would spend enormous amounts of money to oppose anybody who doesn't support President Trump. I think it's going in an authoritarian direction with no oversight.
Problem No. 2 is that, when I actually go to take public positions on issues, and you go down the issues, the Republican Party has moved dramatically from where they were in earlier times. On environmental issues, on women's reproductive health, on a military spending, we can go through issue after issue after issue where the Republican Party—and it's a trend that started in 1980 with [President Ronald] Reagan, but it's accelerated even it it weren't for Trump—I'm running on a platform that's very different.
I grew up in Illinois. If you were in Chicago, you were a Democrat. You get out to the suburbs and central Illinois, you're a Republican. Hillary Clinton grew up as a Goldwater girl, she grew up in the 'burbs, that's just the way it was. I grew up there, then I went back to be a law professor at the University of Illinois, [so] of course I signed up to be a member of the Republican Party.
Let's talk a little about those issues. You've come out for single-payer health care, and even used the issue as a way to attack Senator Smith from her left. What does single payer mean to you? If you had the power to create a health-care system, what would you do?
I think it's in the interest of the consumer and also the small business owner to ask the question: How do we get the highest-quality health care for the best price? And also [how to] not have health-care issues interfere with the ability to start businesses? Right now, when you connect the employment relationship with health care, that means the big business has an enormous advantage over the small business. It makes no sense to connect those two. Why should health care be linked to your job?
So what's the better solution?
The advantage of having a single-payer system is that there's negotiating power vis-Ã -vis providers, drug companies, medical device companies. So I'm looking at it from an efficiency vantage point. I want best quality for best price.
Debates around the best kind of single-payer usually identify one of three models. There's Medicare for All. There's the public option model. And there's the Obamacare exchanges plus subsidies model.
I like Medicare for All. The advantage of Medicare for All, and we might not be able to do it right away, [but in] the ideal system, your employer would have nothing to do with your health care, just like your employer has nothing to do with your kids' education. Your employer doesn't send your kids to school. Your kids' health care shouldn't depend on your employer. So we separate that relationship.
And of course that may relieve the employer of a lot of expense, so we may have to raise taxes to do it, OK! You gotta find the money somewhere, but employers then would not have to pay this extra amount of money [on health care]. We would separate out the employment relationship from health care and use tax revenue, but does it matter whether I pay higher taxes or I have to pay an insurance company?
That's issue No. 1. Two is negotiating power to cut costs. You remove all those insurance company execs who are making a lot of money. Granted, this single-payer [system] is gonna have to pay people, but I don't think you'd pay them as much as the big insurance companies.
It's not a stock option-based system.
You don't have the stock and the stock options and the advertising and the legal costs and everything. A lot of the costs that are in the current system are the insurance companies competing against the other. The time it takes for consumers to compare all these different options—you say competition is good, but it's time comparing insurance options. What you should be doing is comparing doctors.
Now let's talk about the drug companies and medical device companies.
You've been critical of Senator Smith on her support for repealing the Obamacare medical device tax and her support from the chief executive officer of the medical device company Medtronic.
We've made enormous advances, but at a certain point, Americans are paying for most of it. The rest of the world gets the medical devices and the drugs for maybe a third of the prices we do. A lot of the money is going to stock options and the investors and the executives, not going to research and development.
So what's the solution?
I think the single payer negotiates with the drug companies. It's negotiating power, it's the ability to get those prices down. To say, for this medical device, this is the price that's being paid; for this drug, this is the price we're gonna pay. Which is exactly what Canada is doing and every other country is doing, all the industrialized countries. In the United States, we're paying two or three times as much.
Let's talk about connections between health care and other issues of workers and work. What are your thoughts around these more fundamental issues of labor, economic well-being, the Supplemental Nutrition Assistance Program, and food security? Where do you fall on these positions?
First of all you take health care out of the equation [by instituting single payer], so people don't have to worry about that. That's going to help a lot. Then we talk about what's left. Certainly childhood nutrition, that's the kind of thing the government ought to be spending on. I am very much focused on government doing what government should do and do it well. So: Nutrition for children [is] absolutely critical. We ought to be doing a lot more than we currently do with SNAP, like school lunches and breakfasts and other meals for children. That's a useful role for government.
What about minimum wage? Fight for 15? Universal basic income? Where do you fall on that?
I think everyone ought to be to get up to at least $15 an hour. Now, how do you get there? Do you require every employer to pay $15 an hour, or do you have exceptions, but then through additional support from the government, like negative income tax, you get the person up to $15? Quite frankly, the wage you really need to support a family is $20 an hour. So I'd rather rephrase that question to: How do you get to $20, but realize that there are gonna be parts of the country where if you say it's even $15, then the employer doesn't hire the person. I'd rather the employer hires someone at $12 or $13 and top it off.
But I think most markets will support $15, so I don't think we're going to have a lot of exceptions. To get it to $20 we're gonna have to be more aggressively using subsidies. But taking health care out of the picture as an expense is gonna make a huge difference.
So philosophically, it sounds like you're pretty aggressive in terms of using using the power of government to set tax policy, to set minimum wages, to create subsidies, and otherwise to intervene pretty strongly to bring everyone up to a basic level.
I would tend to have more spending on education and health care and food assistance—critical functions of government. I'm going to be exercising a lot of scrutiny over both defense spending and large-scale infrastructure projects. I wanna see roads repaired. I wanna see bridges repaired. I wanna see more mass transportation, particularly electric busses. I'm gonna be looking very carefully at very large-scale rail projects.
Speaking of big government projects, you have criticized the Vikings stadium as a bad deal that exemplifies the way big businesses blackmail local and state governments. Do you see it as a major issue?
[In] too many of these public-private partnerships, the private guys make out really well, they do campaign contributions, which then makes sure the public side doesn't get out really well. Everyone knows what happened with the football stadium. But if Congress said we're not going to allow states to use tax-deductible municipal bonds, we could put a stop to this blackmail by NFL owners, or Amazon, or Donald Trump. He doesn't get a handout.
I guess I didn't expect to hear a systemic critique of public-private partnerships coming from you.
I'm pro-business! But business ought to make its own money.
You're not into a rigged game?
I've written on public-private partnerships going back to the South Sea Company of 1720! It was a big scandal. Members of Parliament were all invested in the South Sea Company. Public-private partnerships were mercantilism. That's what Adam Smith rebelled against. If you really understand Adam Smith, if you really believe in free enterprise, you don't believe the government should be subsidizing business. Businesses should rise or fall on their own merits. What Adam Smith didn't like was these boondoggles, and we continue to have them, and Trump was the master of them. He bled the city of New York on every deal he did, and other businesses would have to pay the taxes.
OK, let's talk about Trump. Presumably part of what got you into this race right now is your concern about ethics and what Trump is doing in Washington.
Oh, it's a disaster. It's everything from not letting Muslims into our country—goes against the First Amendment. Attacks on the press—goes against the First Amendment. Talks about the lying press, really is very similar to the rhetoric of the 1932 German presidential election. It is scary rhetoric. Lack of respect for the judiciary, says that a judge is biased against him because the judge is of Mexican heritage. That's the way people talked about Jewish judges in Germany in the 1930s.
So you're elected senator, what's the first thing you do?
First, they have to have hearings in both houses. I'm going to want to be on the Senate Judiciary Committee and have hearings and find out what's going on. We are well past the point where we were in 1973 [Watergate] with respect to clear evidence of abuse of power, obstruction of justice, and other illegal activities. Congress looks terrible; these hearings should have started a year ago. And then let's see where it goes. We should know whether the Trump Organization is borrowing money from the Russians. This isn't something [Robert] Mueller should have to chase down, but the Senate Judiciary Committee should be doing. And then we can talk about where we go from there once we get the facts.
On your website, you've taken a pro-choice position on the basis of a principle of individual liberty. What about drug decriminalization? And how does that fit into your call for a sensible regulatory system around guns?
Abortion is an easier one because it's contained to the woman and the family. Government needs to completely stay out of abortion and the end-of life-decisions, and obviously the question of who you marry. These are things that obviously should be none of government's business. That's the position of the Republican Party prior to 1980. Those are the easier ones.
What about marijuana?
On drugs, on marijuana, it clearly ought to be at the state level. The federal government should not be getting involved. We should approach it like we did alcohol, as they did after the end of Prohibition. The states need to figure out how to deal with the impaired driving issue, and when they feel comfortable, they can go ahead and legalize.
The other drugs, the more harmful drugs, there's still some federal role in, but there's still too much criminalization as opposed to treatment: long prison sentences [that are] extremely expensive, and there are racial disparities with the prison sentences. I'd focus on treatment and prevention. The emphasis should shift.
And guns?
I hate the National Rifle Association. I wrote an op-ed on the NRA on 2012, right after Sandy Hook, called "The NRA Protection Racket." Oh boy, they got mad at me. I would certainly have a license-and-registration system similar to what we have for cars. When you get into more high-powered weapons—obviously you need a different driver's license to drive a truck.
So as a legal expert, you don't see a constitutional problem with building a strong regulatory system?
No. Remember, the Second Amendment refers to a well-regulated militia. What's going on is not a well-regulated militia. So any reading of the Second Amendment context would permit everything we're talking about here.
Last question: You're running now as a Democrat. You're running to get a nomination of a party that you haven't been a part of. You're running against a lieutenant governor who by all accounts has done a good jobhelping Governor Dayton shepherd Minnesota to a much better place than where it was eight years ago. What happens if you lose, or if you don't get the nomination? Are you going to continue to be a Democrat? To vote for Democrats and support Democrats?
I don't see Republicans on the ballot for federal office, this year, in any state, who should get support. They have all fallen in line behind President Trump. I think it's critical to our democracy. This isn't about being a Democrat; I'm an American before party. I've been a pain in the rear for the Republican Party, and if I were to continue to be involved in the Democratic Party, I will continue to be a pain in the rear on campaign finance, health care, the environment. I'm not interested in party loyalty issues. I'm interested in policy, in issues, and the right thing to do.
https://psmag.com/news/how-did-richard-painter-become-a-democrat
Vermont becomes first state to allow imported drugs from Canada
BY RACHEL ROUBEIN AND BROOKE SEIPEL - The hill - May 16, 2018
Vermont Gov. Phil Scott (R) on Wednesday signed a law permitting the import of prescription drugs from Canada into the state.
Proponents of the law, which has been opposed by President Trump's health officials as well as pharmaceutical companies, believe it will help fight rising drug prices. It was widely supported in Vermont's Democratic-controlled state legislature.
The law must still be certified by the Department of Health and Human Services (HHS).
The move puts the state at odds with the Trump administration. HHS Secretary Alex Azar on Monday called the idea of importing drugs from another country a "gimmick."
Drug companies have also criticized such plans, with the lobbying group Pharmaceutical Research and Manufacturers of America (PhRMA) maintaining that "patient safety must be our top priority."
“Lawmakers cannot guarantee the authenticity and safety of prescription medicines when they bypass the FDA-approval process, and the Canadian government does not inspect or take responsibility for the legitimacy of prescription medicines shipped to the U.S.," PhRMA said in a statement.
"The burden of combating illicit drugs would fall on local law enforcement officials, who lack the capacity to inspect even a small percentage of increased counterfeit drugs, but who have witnessed their impact in communities across the state,” it added.
In the past, President Trump has supported drug importation from overseas, which was a plank of his health-care reform proposal as president-elect.
The Vermont law is built on model legislation from the National Academy for State Health Policy (NASHP). Eight states proposed similar legislation this year, but Vermont’s is the first to be signed into law.
Specifically, the law lets a wholesaler in the United States import drugs from a wholesaler in Canada. According to NASHP’s website, prescription drugs cost 30 percent less in Canada.
Several other states allow individuals to import drugs from other countries, but not wholesalers. Trish Riley, NASHP’s executive director, argues that requiring wholesalers to import the drugs is a key distinction that provides assurances the drugs coming into the state would be safe.
“Our model legislation assures safety and savings by buying drugs through the existing supply chain, so that all the checks and balances are in place to assure safety,” she said.
Vermont Sen. Bernie Sanders (I) proposed a similar law last year.
Vermont Legislators Pass A Drug Importation Law. So What?
by Shefali Luthra - KHN - May 18, 2018
This week, Vermont passed a first-in-the-nation law that would facilitate the state’s importation of prescription drugs wholesale from Canada. It represents the state’s effort to tackle head-on the issue of constantly climbing drug prices.
Other states, including Louisiana and Utah, have debated similar legislation and are watching Vermont’s progress closely.
After all, the issue of drug importation polls well across the political spectrum and has been endorsed by politicians ranging from candidate Donald Trump, before he became president, to liberal firebrand Sen. Bernie Sanders (I-Vt.).
So how much impact might a state law like this actually have?
Trump has since stepped back from his campaign position, and the White House did not include drug importation in its proposal last week to bring down drug prices.
And cautions abound that importation may not actually save that much money as questions swirl about whether the policy undermines drug safety standards.
Kaiser Health News breaks down the challenges that lie ahead for importation champions, and what it shows about the future of the drug pricing fight.
States need federal approval to launch any kind of importation program.
Just having a law like Vermont’s on the books is not enough to legalize importation. The next step is for the state to craft a proposal outlining how its initiative would save money without jeopardizing public health. The proposal, in turn, is then subject to approval by the federal Department of Health and Human Services.
HHS has had yea-or-nay power over state importation programs since at least 2003, because of a provision included in the law creating Medicare Part D. But it’s never actually approved such a plan. And — despite mounting political pressure — there’s little reason to think it will do so now.
In the past weeks, HHS Secretary Alex Azar has come out strongly against importation, calling it a “gimmick” that wouldn’t meaningfully bring down prices.
He also has argued that the U.S. government cannot adequately certify the safety of imported drugs.
HHS declined to comment beyond Azar’s public remarks.
Importation backers — including the National Academy for State Health Policy (NASHP), which helped craft Vermont’s bill and has worked with state lawmakers — hope he’ll reverse these positions. But few are optimistic that this will happen.
“I don’t expect that Vermont alone will be able to bring sufficient pressure to bear on Secretary Azar to convince him to change his mind,” said Rachel Sachs, an associate law professor at Washington University in St. Louis, who tracks drug-pricing laws.
A state’s importation program would also require buy-in from Canadian wholesalers. What’s in it for them?
Perhaps not much. Canadian wholesalers might stand to lose financially.
After all, pharmaceutical companies that market drugs in the United States might limit how much they sell to companies that have supply chains across the border. They could also raise their Canadian list prices.
“Almost inevitably, Canadians would cease getting better prices,” said Michael Law, a pharmaceutical policy expert and associate professor at the University of British Columbia’s Center for Health Services and Policy Research. “If I were a [Canadian] company, I wouldn’t want that to occur — and [drugmakers] could take steps to limit the supply coming north. … It probably results in [Canadians] getting higher prices.”
Trish Riley, NASHP’s executive director, dismissed this concern, saying some Canadian wholesalers have indicated interest in contracting with Vermont.
Vermont would still have to prove to HHS that its proposal would yield “substantial” savings. This won’t be easy.
In fact, some analysts suggest savings would be limited to a narrow slice of the market.
Importation could bring down the price of some generics and off-patent drugs by increasing competition, suggested Ameet Sarpatwari, a lawyer and epidemiologist at Harvard Medical School who studies drug pricing.
Many generic drugs have also seen substantial price hikes in recent years — but curbing these costs is only part of the equation.
“It’s not a panacea for the drug-pricing reform or high drug prices as a whole,” Sarpatwari said.
Branded drugs, which drive much of the American problem with prescription price tags, are distributed by a single company and, therefore, that company has greater control over supply and pricing pressure.
Drug safety looms over the debate.
The worry, according to critics, is that American regulators can’t effectively determine whether imported drugs meet the same safety standards as those sold directly in the United States. A year ago, a bipartisan group of former Food and Drug Administration commissioners made that very argument in a letter to Congress.
Azar has argued this same point, as has the influential pharmaceutical industry, represented by the Pharmaceutical Research and Manufacturers of America.
“Lawmakers cannot guarantee the authenticity and safety of prescription medicines when they bypass the FDA approval process,” said Caitlin Carroll, a PhRMA spokeswoman, in a statement released on Vermont’s law.
This position, though, draws skepticism.
In cases of drug shortages or public health emergencies, the United States has imported drugs. And many Canadian and American drugs are made and approved under similar standards, Law noted.
“In terms of general safety, it is kind of nonsense. … We share plants,” he said. “The idea that Canadian drugs are somehow unsafe is a red herring.”
An argument in favor of plans like Vermont’s focuses on the idea that because the state would import drugs wholesale — rather than enabling individuals to shop internationally — it would be able to address concerns about safety or quality, Riley said.
Plus, Sarpatwari suggested, the government has resources to track drugs that come from Canada, especially if a drug were recalled or ultimately found to have problems.
“Our technology is catching up with our ability to do effective monitoring,” he said. “Particularly when it’s coming from a well-regulated country, I think there is less fear over safety.”
States have been leading the charge on addressing the drug price issue, but their efforts reach only so far.
The federal government has taken little action to curb rising drug prices — though HHS now says it plans to change that.
So far, state legislatures have been pushing for laws to penalize price gouging, promote price transparency or limit what the state will pay.
But state initiatives often require federal permission.
Vermont’s law, which is arguably meaningless without HHS’ say-so, is just one example.
Sarpatwari pointed to a request from Massachusetts to develop a drug formulary for its Medicaid insurance program — theoretically giving the state more leverage to negotiate cheaper prices by reducing how many drugs it’s required to cover.
That proposal also is contingent upon approval from HHS. The administration has been publicly silent, though some news reports suggest it leans toward rejecting the request.
Meanwhile, Sachs said Vermont’s law, and others like it, will challenge the White House to show its mettle in taking on drug costs.
“We’re seeing explicit actions by the states to put pressure back on the federal government,” Sachs said. “The administration is publicly committed to lowering drug prices. It is being asked to make decisions which will, in some ways, show how much it really is attempting to accomplish that goal.”
As an Insurer Resists Paying for ‘Avoidable’ E.R. Visits, Patients and Doctors Push Back
by Reed Abelson, Margot Sanger-Katz and Julie Crewel - NYT - May 20. 2018
Jim Burton was lifting a box in his garage last August when he felt a jolt in his back.
“It dropped me to my knees instantly,” he said. He thought he’d slipped a disk. His friend, an emergency medical technician, urged him to go to the hospital.
At the emergency room, Mr. Burton, a 37-year-old resident of Lexington, Ky., was found to have a back sprain, with no signs of other serious injury, and was sent home.
He soon got another surprise. His health insurer, Anthem, refused to pay medical bills totaling $1,722, saying his care in the emergency room had not been needed “right away to avoid a serious risk to health.”
To rein in emergency medicine costs, Anthem is reviving an old, contentious tactic: pushing back on patients who visit the emergency room for ailments deemed minor.
Anthem denied thousands of claims last year under its “avoidable E.R. program,” according to a sample of emergency room bills analyzed by the American College of Emergency Physicians. The program, which Anthem has been rolling out in a handful of states in recent years, reviews claims based on the final diagnosis of patients.
Emergency room physicians say that, last year, the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room. Anthem says it is now reviewing such records before issuing denials.
The company says the policy goal is to reduce use of the emergency department, one of the most expensive places to receive medical care. Anthem recommends that patients with sprains and upper respiratory infections instead consider a visit to a primary care doctor or an urgent care center.
“The costs of treating non-emergency ailments in the E.R. has an impact on the cost of health care for consumers, employers and the health care system as a whole,” Jill Becher, a company spokeswoman, said in an email.
But doctors and consumer advocates argue that the policy forces patients to diagnose their own illness, and may discourage people with serious problems from seeking care. Patients, doctors and hospitals have been pushing back in the form of opinion pieces, political lobbying and even humorous videos ridiculing the idea that people can be their own doctors. Members of Congress have written to Anthem expressing displeasure, and state lawmakers have drafted bills to bar the practice.
The criticism seems to have had an effect: For now, Anthem appears to be denying fewer claims — though it also expanded its policy to several more states.
“Avoidable visits” are the latest conflict among doctors, hospitals, insurance companies and patients over emergency rooms. And the Anthem policy is just one way that patients seeking emergency care can be stuck with unexpected costs. Some doctors, who fail to sign contracts with insurance companies, are sending patients direct bills for their services.
“It’s the place where the incentives in health care break down,” said Zack Cooper, a health economist at Yale University, who has studied patterns in out-of-network bills. “You’ve ended up with this death struggle between insurers, hospitals and emergency room physicians, and patients get caught in the middle.”
The emergency room, which functions as the front door to most hospitals, contributes a substantial portion to the nation’s enormous health costs. The program by Anthem, the nation’s second-largest insurer, tries to reduce those costs by changing patient behavior. Other insurers are watching carefully. Anthem points to estimates that as many as 5 percent of visits are unnecessary.
“E.R.s are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care,” Ms. Becher said.
Anthem began testing its policy in Kentucky in 2015. That’s when Jason Salyers, now 32, who works in the financial aid office of a community college, started having episodes in which he couldn’t breathe. When he went to the emergency room, he was treated for a panic attack. Two days later, he returned, fearful he was having a heart problem.
His pulse, he recalls, was above 150 beats per minute.
“I thought I was dying and I needed to go to the E.R.,” he said.
His second visit was covered because his diagnosis was breathing trouble. Anthem denied payment for his first visit, classified as a panic attack. He appealed, and eventually Anthem paid.
Under federal law, insurers can’t limit coverage of emergency care if a “prudent layperson” would think he or she were experiencing a medical emergency. That standard was established in the 1990s, and the Affordable Care Act expanded the standard to apply to all workplace and individual insurance plans in 2010.
Nearly every state has a similar standard. But the definition of the rule may be a little murky, said Mark Hall, a professor at the Wake Forest University School of Law, who studied the state laws in 2004. So far, state insurance commissioners have received some complaints about the Anthem policy, but no enforcement actions have been taken. Anthem says it follows the standard.
“I could see how this approach could easily start to violate the spirit of the law,” Mr. Hall said. “But on the other hand, there has to be some system in place to make these determinations.”
Consumer advocates argue that Anthem’s approach of reviewing the final diagnosis — even if most bills end up being paid — could cause lasting harm by making patients hesitate to seek treatment.
Karen Englert, the government relations director at the Missouri branch of the American Heart Association, said her organization has worked for years to teach women to look for early, unconventional signs of a heart attack, like indigestion, nausea or arm pain. “For some women, those are absolutely the precursors to a heart attack,” she said. “We can’t look inside ourselves to know this is what I have. And patients shouldn’t be expected to — they aren’t doctors.”
Ms. Englert, who uses Anthem insurance and is a heart patient herself, says she vividly recalls opening a letter from Anthem notifying her of the policy.
Last summer, Anthem expanded the program into some of its plans in Missouri and Georgia.
In 2016, Sandra Rivera of Jackson, Mo., had a series of small strokes during an operation to repair her aorta. Last year, she woke up in the middle of the night with chest pain and heart palpitations, and drove herself to the emergency room.
It wasn’t a heart attack, it turned out. Anthem sent her a letter, saying the visit would be covered, but if she went back again with a similar complaint, it wouldn’t pay the bill.
“I’m a heart patient, and it’s not like I was having a stomachache,” said Ms. Rivera, 48. Still, the letter worked. Worried about another bill, she said that she had a few more episodes of chest pain in the following months that she didn’t have checked out at the emergency room. “That’s pretty scary,” she said.
Mr. Burton, the man whose claim was denied after his back sprain, kept fighting his bill. Anthem eventually paid.
Anthem’s new policy appears to still be in flux.
At the start of this year, Anthem announced it would begin making more exceptions: patients who live far from an urgent care facility, those who are under 15, those who receive certain treatments in the emergency room, and those admitted to the hospital, for example. These people will automatically have their visits covered, even if they have an “avoidable” diagnosis.
In Kentucky and Missouri, data from emergency room physicians show that last year’s spike in denials has been followed by a rapid decline. But Anthem has expanded the policy to four more states — Indiana, Ohio, New Hampshire and Connecticut — and has sent letters to affected customers notifying them of the change. Anthem said it could not comment on the data provided by the doctors.
In Missouri, the state legislature passed a bill Friday to shield patients from the dysfunction of the emergency department. The legislation will prevent insurance companies from rejecting bills solely on the basis of a final diagnosis. The bill will also force doctors who didn’t sign insurance contracts into binding arbitration with insurers, to avoid surprise bills.
“The whole idea is just to protect the consumer,” said Paul Wieland, the chairman of the State Senate’s insurance and banking committee. “Because the consumer does not need to be caught up in the fight between the insurance company and the providers.”
https://www.nytimes.com/2018/05/19/upshot/anthem-insurer-resists-paying-emergency-room-visits-if-avoidable.html
Don’t Put That in My Heart Until You’re Sure It Really Works
by Haider Warraich - NYT - May 20, 2018
Atrial fibrillation, a condition affecting three million to six million Americans, is caused by irregular contractions of the heart and results in an increased risk of stroke and death. Over the past two decades, cardiologists have increasingly treated it with a procedure called catheter ablation, in which small plastic catheters are used to create scars in the damaged heart tissue to prevent the aberrant electrical signals from spreading. Many have touted catheter ablation, which can cost well above $20,000, as a “cure” for atrial fibrillation.
Yet a new randomized controlled trial, the gold standard of clinical research, has produced disappointing results. The study, called the Cabana trial, found that the procedure was no more effective than much cheaper medications at reducing mortality, cardiac arrest, major bleeding and stroke.
These results come on the back of another prominent trial published last year, which showed that stents used to relieve blockages in patients with stable chest pain provided no benefit over medications.
In the furor over the Cabana results, which have been presented at a scientific conference but not yet published, many have argued that the underlying data suggests that catheter ablation does help some people. But a different kind of study will be needed to confirm that. The fact is that years after catheter ablation hit the market, we shouldn’t have this many questions about it.
The bar for approval of medical devices is too low. There is no reason we shouldn’t require, as we almost always do for drugs, a randomized placebo-controlled trial showing improvements in “hard” outcomes like mortality before approving them.
Unfortunately, the United States may soon make it even easier for medical devices to reach the patient’s bedside. The Food and Drug Administration is considering requiring less upfront research and instead adding increased oversight after a device has been introduced into the market. The argument is that this will spur technological innovation and perhaps help terminally ill patients. However, loosening regulations could extract a steep cost from patients and the health system.
Recently, an employee from a company that makes a small heart pump called Impella emailed me asking how the use of this device could be increased: “How would you approach a physician to adopt this therapy?”
The Impella has been placed in more than 50,000 patients’ hearts, though we still have no randomized controlled trial data on its efficacy. Each device costs roughly $25,000. I replied, “I think a device such as an Impella will always be underutilized until there is a randomized controlled trial which shows improvements in hard clinical outcomes.” Was the company interested in doing an RCT, I asked.
I never heard back.
After a device has reached the market, companies have little incentive to do a high-quality trial. Why risk a study showing that your device’s benefit doesn’t exceed its harms when cardiologists are already implanting it?
Physicians have become major drivers of the overuse of devices and procedures like these. Doctors are rewarded on a fee-for-service basis, meaning the more that they do, the more they are paid.
This is especially true of doctors performing procedures such as catheter ablation. Last year, five cardiologists at Ohio State University made almost $2 million (twice what the Buckeyes’ president made).
In this environment, despite their best intentions, physicians cannot be expected to be completely disinterested stewards for their patients.
Some argue that regulations are making it too hard for good ideas to come to fruition. But if anything, over time I have become warier of “good ideas.”
The F.D.A. recently approved a new kind of stent to relieve blockages. These stents would dissolve in about three years, the theory being that patients would prefer this to having metal placed inside them. And indeed they started showing up in clinics demanding these vanishing stents.
But longer-term studies showed that while these stents were disappearing, many were disappearing into blood clots, causing an increased risk of heart attacks compared with conventional stents. The manufacturer quickly shut down the program.
It is much more difficult to study the efficacy of devices than that of drugs, because the former involves invasive procedures. It’s one thing to give patients a placebo pill to swallow; it’s much harder to pretend to implant a stent. But these so-called sham procedures are necessary if we’re going to find out whether devices work, especially for treating symptoms that are susceptible to the placebo effect.
We know what lax regulations can do. Europe’s historically loose regulatory environment exposed so many patients to harm from devices like exploding stomach balloons and deadly breast implants that regulators there have done a complete turnaround, moving toward very strict criteria.
A perfect storm of conflicted physicians, loose regulations and a culture that celebrates shiny, expensive and invasive treatments has led to the fetishization of medical devices. But if the F.D.A. won’t act, change is still possible.
The most important lever protecting patients and the economy from wasteful devices and procedures is manned by the same hand that signs the checks — insurance companies. Even if the F.D.A. approves a device, insurers can stop paying or reduce how much they pay for it. The Centers for Medicare and Medicaid Services, for example, has recently proposed reducing reimbursements for the Impella.
Transforming how doctors and hospitals are paid, from a fee-for-service model to a system in which payments are tied to the health of the patient, would also discourage the use of devices of questionable efficacy. Devising such alternate payment models was part of the mandate of the Affordable Care Act. However, progress in transitioning to these payments has been slow, and most health care continues to be paid for by quantity rather than quality.
In the meantime, we need the F.D.A. to do its job and ensure that devices that can careen patients and the health care system toward bankruptcy are actually making people healthier.
Bill Of The Month: Audience Reacts To Big Bill For Tiny Screws
by Terry Byrne - KHN-NPR - May 19, 2018
It's a club no one wants to join, but many Americans these days find themselves automatically eligible for the "Bill of the Month" club.
Kaiser Health News and NPR began collecting people's health care bills for examination early this year. We have waded through roughly 500 submissions, choosing just one each month to decode and dissect. (If you'd like to submit your story or bill, you can do it here.)
But the crowdsourced investigation has given voice to numerous others on social media — health care consumers and industry players alike. With each installment, hundreds of people have weighed in.
The most recent feature about Sherry Young's experience, "Sticker Shock Jolts Oklahoma Patient: $15,076 For Four Tiny Screws," has so far has generated nearly 6,800 shares on Facebook, scores of tweets and lively discussions on both Redditand LinkedIn.
Readers and listeners aren't merely bellyaching. Discussions quickly veer toward solutions: demanding more transparency and exploring a single-payer health care system.
Among highlights from Twitter:
A reminder from Kansas City Direct Primary Care to ask for itemized receipts.Michael Yoder, Conway, Ark., tweets that the jacked-up bill for screws argues for universal Medicare coverage.
Dr. Kevin Neal, of Jacksonville, Fla., tweeted that Sherry Young's bill for the screws wasn't unique.
A medical device executive who was mentioned in the story about the $15,076 surgical screws, Steve Lichtenthal, vice president of business development at Orthopaedic Implant Co., based in Reno, Nev., shared the link and received at least 8,300 views. He invited commenters and colleagues on LinkedIn to join in an offline forum. As of Thursday, two had expressed interest.
LinkedIn
And Canadians continue to offer insider perspective from the outside. Plucked from one of many Facebook threads:
"When health is considered a for-profit commodity, this is exactly what will happen in an unregulated system."It's sad, but not surprising."What many of us who live outside of the US wonder (I'm Canadian), is why you put up with a health-care system that treats you as a financial resource, rather than as a human being?"
— Richard Bott, Port Coquitlam, British Columbia
And on Twitter, @TrainerGloria pointed out how Sherry Young's case illustrates the differences between health care in Canada and the U.S.
What Barbershops Can Teach About Delivering Health Care
by Aaron Carroll - NYT - May 21, 2018
Heart disease is the most common killer of men in the United States, and high blood pressure is one of the greatest risk factors for heart disease. Despite knowing this for some time, we have had a hard time getting patients to comply with recommendations and medications.
A recent study shows that the means of communication may be as important as the message itself, maybe even more so. Also, it suggests that health care need not take place in a doctor’s office — or be provided by a physician — to be effective.
It might, as in this study, take place in a barbershop, an institution that has long played a significant social, economic and cultural role in African-American life. A setting that fosters both confidentiality and camaraderie seems like a good place to try reaching men to talk about hypertension.
Years ago, researchers ran an experiment in which they trained barbers to check blood pressure and refer people with high levels to physicians. One group received this intervention; a control group received pamphlets handed out by barbers. Blood pressure values were only minimally improved in the intervention group. This was thought to be because even when patients were referred to primary care physicians, those doctors rarely treated their condition appropriately.
The more recent study went further, removing physicians almost entirely from the process. The control group consisted of barbers who encouraged lifestyle modification or referred customers with high blood pressure to physicians. In the intervention group, barbers screened patients, then handed them off to pharmacists who met with customers in the barbershops. They treated patients with medications and lifestyle changes according to set protocols, then updated physicians on what they had done.
The results were impressive. Six months into the trial, systolic blood pressure (the higher of the two blood pressure measures) in the control group had dropped about 9 mm Hg (millimeters of mercury) to 145.4, which is still high.
In the intervention group, though, blood pressure had dropped 27 mm Hg to 125.8, which is close to “normal.” If we define the goal of blood pressure management to be less than 130/80, more than 63 percent of the intervention group achieved it, compared with less than 12 percent of the control group.
It gets better. The rate of cohort retention — measuring how many of the patients remained plugged into the study and care throughout the entire process — was 95 percent.
The barbershop customers were part of a population that is traditionally hard to reach. More than half of participants lived in households earning less than $50,000 a year, and more than 40 percent in households earning less than $25,000. On average, they were overweight or obese, about a third smoked, and more than a fifth had diabetes. Yet the improvement in blood pressure was more than three times thatof the average of previous pharmacist-based interventions seeking to improve blood pressure, and many of those had focused on populations easier to reach.
One reason this trial succeeded where others failed is that it adapted its intervention to overcome barriers. When barbers weren’t consistently screening customers by measuring their blood pressure, pharmacists stepped in to do that. When labs slowed things down, pharmacists brought measuring tests to the barbershops.
The larger implications of this study shouldn’t be ignored. Getting barbers involved meant health messages came from trusted members of the community. Locating the intervention in barbershops meant patients could receive care without inconvenience, with peer support. Using pharmacists meant that care could be delivered more efficiently.
Of course, this study is limited by the usual sorts of questions. Who will pay for this in the real world? Who would do the training necessary to scale it up? Who would be responsible?
But those concerns reflect the shortcomings of our current health care system, not those of the study. Health care reimbursement in the United States usually focuses on the clinical encounter, at a physician office or hospital. This reflects a belief that care is best offered there, even when evidence says otherwise. Coverage and payment focus on the individual patient, not on the community, even when research shows that the latter is more effective. Care often requires the participation of a physician, even when studies prove that it can be delivered well in many cases by midlevel practitioners.
It’s important to remember that we have the health care system we do because of history and economics, not because of studies that show it’s optimally designed. Changes are most often made within the current framework; those that buck the system are usually met with more resistance.
Retail clinics may provide better access, but many professional organizations oppose them. Lifestyle changes may do more to improve health than drugs. But getting the system to recognize that diet and exercise might prevent diabetes, for example — and to pay for that intervention — requires huge efforts and decades of time.
If we really want to improve health on a large scale, especially with populations distrustful of the health care system, it seems we need to go to where they are; to use people they trust to deliver messages; and to allow care to occur without much of the infrastructure usually demanded for billing. Such efforts may not be traditional, but they may deliver much better results.
Group suing LePage administration to expand Medicaid responds
by Joe Lawlor - Portland Press Herald - May 20, 2018
An advocacy group that is suing the LePage administration for failing to expand Medicaid, even after voters overwhelmingly approved it, filed legal briefs in court Friday countering recent assertions by the governor that he can’t implement the expansion until the Legislature allocates funds for it.
In a 21-page brief filed in Kennebec County Superior Court, Maine Equal Justice Partners argued that there’s enough money in place to implement the expansion this year, and that the LePage administration is flouting the law by not making any moves to expand Medicaid. Republican Gov. Paul LePage is a staunch opponent of Medicaid expansion and he has vetoed several attempts by the Legislature to do so, although the governor can’t veto a law approved by referendum.
Maine Equal Justice Partners led the Medicaid expansion campaign that resulted in voters approving a referendum in November – 59 percent to 41 percent – to expand the program that provides insurance to low-income Mainers.
If the lawsuit is successful, the LePage administration would be compelled to expand Medicaid. Medicaid expansion is a cornerstone of the Affordable Care Act, and so far 32 states, including Maine, and the District of Columbia have approved expansion.
“This court can, and must, resolve this case without delving into any dispute about what funds are (or are not yet) appropriated to fund the Medicaid program,” according to the court filing.
In the brief, attorneys for Maine Equal Justice Partners argued that the administration cannot fail to implement laws it doesn’t like. The LePage administration was supposed to file documents with the federal government – called a State Plan Amendment – in April to begin implementing Medicaid expansion and have the program ready for residents to enroll in by July, but failed to do so, the brief says. Medicaid is a blended federal-state program that uses federal and state dollars, but is operated by the states under federal rules.
“Submission of a (State Plan Amendment) does not require any funds not already available,” according to Maine Equal Justice Partners’ court filing. “And it is no defense to the current action that there may come a time in the future where either the executive or the legislative branch might need to act to ensure there continue to be sufficient allocated funds within the Medicaid program to pay a particular required benefit.”
But the LePage administration argued in a court filing on May 14 that the Maine Department of Health and Human Services “plainly lacks legal authority” to spend money on Medicaid expansion without the Legislature making a specific allocation for the expansion.
“Until (the Legislature) adequately funds it, there is nothing we can do,” LePage said in a statement Thursday. “Before we can proceed with expansion, DHHS needs both the staff to implement it and the money to pay the bills that will come due when the State Plan Amendment is approved” by the federal government.
About 70,000 Maine adults who earn up to 138 percent of the federal poverty limit – $25,100 for a family of four – would be eligible for Medicaid once expansion is approved.
Lawmakers approved an initial $3.8 million expenditure in April to enable DHHS to hire additional staff and cover administrative costs of expansion. However, that funding was caught up in a partisan standoff when the Legislature adjourned on May 2 before funding a number of bills.
Fully funding Medicaid expansion would cost about $45 million in state money in the first full year of implementation, according to the nonpartisan Office of Fiscal and Program Review, and would increase to $55 million by 2021.
Accepting Medicaid expansion would also unlock more than $500 million per year in federal funds that would begin coming to Maine to cover health care costs for enrollees.
If the court case is not resolved by this year, the issue will fall to the next governor. LePage is leaving office in January, and several Democrats, Republicans and independents are vying to replace him.
No comments:
Post a Comment