On Friday, House Republican leaders failed to secure enough support to pass their plan to repeal and replace the Affordable Care Act. Reporters with Kaiser Health News and California Healthline (produced by KHN) have appeared on numerous radio and television shows in recent days to assess what’s next for the health law. Listen to what they had to say below.National Media
NPR’s All Things Considered with Mary Agnes Carey (March 25):
CNN’s Smerconish with Mary Agnes Carey (March 25):
WBUR’s On Point with Mary Agnes Carey (March 27):https://kaiserhealthnews.files.wordpress.com/2017/03/032717-on-point_carey.mp3
WAMU’s 1A with Julie Rovner (March 27):
WBUR’s Here & Now with Julie Rovner (March 27):https://kaiserhealthnews.files.wordpress.com/2017/03/032717-here-now_rovner.mp3
PBS NewsHour with Mary Agnes Carey (March 27):California Media
KCRW’s The Mixer with Anna Gorman (March 24):https://kaiserhealthnews.files.wordpress.com/2017/03/032417-kcrw_gorman.mp3
KQED’s The California Report with Pauline Bartolone (March 27):https://kaiserhealthnews.files.wordpress.com/2017/03/032717-kqed_bartolone.mp3
KPCC’s Air Talk with Chad Terhune (March 27):https://kaiserhealthnews.files.wordpress.com/2017/03/032717-kpcc_terhune.mp3
The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.
Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.
Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.
UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. “We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules,” he wrote in an email.This KHN story also ran on NPR. It can be republished for free (details).
Burns also said that “litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong.”
Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.
Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.
“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the “winners here are going to be American taxpayers.”
Burns also contends that the cases against UnitedHealth could potentially exceed $1 billion in damages, which would place them among the top two or three whistleblower-prompted cases on record.
“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.
On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.
When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.
But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.
“If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars,” Hanagami said.
David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is “deeply concerned by ongoing improper payments” to Medicare Advantage health plans.
These overpayments “undermine the finances of the overall Medicare program,” he said in an emailed statement. He said his group supports “more rigorous oversight” of payments made to the health plans.
The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.
The federal Centers for Medicare & Medicaid Services said in draft regulations issued in January 2014 that it would begin requiring that Medicare Advantage plans report any improper payment — either too much or too little.
These reviews “cannot be designed only to identify diagnoses that would trigger additional payments,” the proposal stated.
But CMS backed off the regulation’s reporting requirements in the face of opposition from the insurance industry. The agency didn’t say why it did so.
The Justice Department said in an April 2016 amicus brief in the Swoben case that the CMS decision not to move ahead with the reporting regulation “does not relieve defendants of the broad obligation to exercise due diligence in ensuring the accuracy” of claims submitted for payment.
The Justice Department concluded in the brief that the insurers “chose not to connect the dots,” even though they knew of both overpayments and underpayments. Instead, the insurers “acted in a deliberately ignorant or reckless manner in falsely certifying the accuracy, completeness and truthfulness of submitted data,” the 2016 brief states.
The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them.
This is the first in our “Vouchers Work” blog series, which provides the latest facts and figures about the Housing Choice Voucher program, the largest rental assistance program to help families with children, working people, seniors, and people with disabilities afford decent, stable housing.
President Trump and House Speaker Paul Ryan have both signaled that tax reform is their next top legislative priority. Any tax bill should keep three promises that they and other key Republican leaders have made:
(1) No absolute tax cuts for the “upper class.” In an interview shortly after his nomination, Treasury Secretary Steven Mnuchin stated:
The following is a guest post by Abdalrahman Alangari, a student from Saudi Arabia who was a foreign law intern at the Law Library of Congress for a few months in late 2016.
The Kingdom of Saudi Arabia is the largest economy among the Gulf countries. Developments in the Kingdom in recent years have transformed it into a new regional and global hub for commercial arbitration. The developments have included the establishment of the Saudi Center for Commercial Arbitration (SCCA) and the issuance of a new Arbitration Law. The Law was issued on July 7, 2012, by Royal Decree No. M/34, replacing the Arbitration Law of 1983. Since its issuance, the 2012 law has generated debate among legal practitioners. Some have endorsed the law and consider it to be a substantial step in the field of international arbitration. Others, however, have raised concerns about the practicability of its application.
Those supporting the 2012 law have argued that it eliminates some controversial provisions of the previous arbitration law of 1983. For instance, under the 1983 law, arbitrators were required to be Muslim. However, the 2012 law only requires that they must have a university degree in Sharia law (Islamic law) or a Bachelor of Laws.
The 2012 law also does not discriminate between genders. It does not specify any gender requirements for arbitrators, nor does it contain any language that prohibits a woman from serving as an arbitrator.
Another feature seen as a positive development by proponents of the law is that it promotes the separability principle of an arbitration agreement. Article 21 states that the arbitration clause in a contract shall be treated as a separate independent agreement from other terms in the contract. The nullification, revocation, or termination of the contract therefore does not entail the annulment of the arbitration clause if such a clause is valid.
In addition, under article 50 of the 2012 law, the court in charge of administering the arbitral award only has the authority to review the award and not the facts of the case. In doing so, it must ensure the award is in conformity with Sharia law and the Kingdom’s public policy.
In contrast to the 1983 law, article 29 of the 2012 law allows arbitration hearings to be conducted in a language other than Arabic. Article 29 provides that arbitration shall be conducted in Arabic, unless the arbitration tribunal or the disputed parties, agree on another language or languages.
Some legal scholars, however, have raised concerns that the 2012 law impedes the enforcement of some arbitral awards. According to article 55 of the 2012 law, Saudi courts will not enforce an arbitral award conflicting with the principles of Islamic law. For example, if the award ordered one of the parties to pay interest as a form of financial compensation, such interest is considered to be reba. Reba violates the country’s public policy since it is prohibited under Islamic law. Accordingly, the Saudi court that is in charge of implementing the arbitral award will not be able to obligate the party to pay such compensation.
The Law Library of Congress holds a variety of reference books in both Arabic and English addressing the Saudi legal system, including business and company laws. This includes books such as The Effect of Company Mergers on the Saudi Legal System (2004) (Arabic); Islamic Law and Legal System: Studies of Saudi Arabia (English) (2000); and Saudi Arabia, Keys to Business Success (1981) (English).
We have previously published two other posts on international arbitration law: International Arbitration Law in Mexico – Global Legal Collection Highlights and Arbitration in Turkey and Istanbul as a New International Arbitration Center.
Cynthia Brownfield was lucky. When her daughter, then 2 years old, tested for high levels of lead in her blood, she could do something.
Brownfield, a pediatrician in St. Joseph, Miss., got her home inspected and found lead in the windows. She got them replaced and had her pipes fixed, too. Her daughter, now 12, was probably affected, says Brownfield. But quick action minimized the exposure. Her daughter is now a healthy, fully-functioning preteen.
“We were in the financial position where we could hire a plumber and change the windows,” she said. But others — even her own patients — may not be so fortunate. This reality may have implications even more far-reaching than generally accepted.
Findings published Tuesday in JAMA break new ground by suggesting the effects of childhood lead exposure continue to play out until adulthood, not only harming an individual’s lifelong cognitive development, but also potentially limiting socioeconomic advancement. Specifically, Duke University researchers tracked a generation of kids based on data collected through a nearly 30-year, New Zealand-based investigation known as the Dunedin Multidisciplinary Health and Development Study.
They studied the development of more than 1,000 New Zealanders born between April 1972 and March 1973. Because at that time gasoline still contained lead, exposure was common, creating a sizeable sample that included people across class and gender. More than half in that data set had been tested for lead-exposure at age 11, and the study tracked brain development and socio-economic status over the years — making for “a natural time” to use them to study lead’s health effects, said Aaron Reuben, a PhD candidate in neuropsychology at Duke University, and the study’s first author.Use Our ContentThis KHN story can be republished for free (details).
By the time study participants reached age 38, a pattern emerged: Children who were exposed to lead early in life had worse cognitive abilities, based on how their exposure level. The difference was statistically significant. They were also more likely to be worse off, socioeconomically, than those who had not been exposed to lead. The study found that no matter what the child’s IQ, the mother’s IQ, or the family’s social status, lead poisoning resulted in downward social mobility. That was largely thanks to cognitive decline, according to the research.
“Regardless of where you start out in life, exposure to lead in childhood exerts a downward pull to your trajectory,” Reuben said.
Though this research was set in New Zealand, it offers insight into a problem experts said is fairly ubiquitous in the United States and across the globe. The CDC estimates that as many as half a million children between ages 1 and 5 had blood lead levels high enough to cause concern: 5 micrograms per deciliter and up. At least 4 million households across the country have children experiencing significant lead exposure.
Last year’s water crisis in Flint, Mich., brought lead exposure front and center as a public health concern. Meanwhile, a Reuters investigation published this winter found elevated lead levels in almost 3,000 communities around the country. The Centers of Disease Control and Prevention recently changed its guidelines to suggest that any childhood exposure to the chemical is harmful, and is pushing to get rid of lead poisoning in kids by 2020.
In the U.S., children at risk are typically poorer and racial minorities — in part because they more often live in older houses with lead paint. This is a stark difference from the research population, which tended to be white. However, because the study spanned a period of time in which lead was still used in gasoline, the lead exposure measured in the study spanned a wider class spectrum.
That adds greater consequence to these findings, many said.
“Kids who are poor, or who have some of these other social determinants of health that are negative — they end up with a double whammy. Whatever health consequences they have from being poor, those are added to the additional consequences of being exposed to lead,” said Jerome Paulson, an emeritus professor and pediatrician at George Washington University. Paulson has researched lead’s effects on children, although he wasn’t involved with this study.
“If you want to talk about ‘breaking out of poverty,’ kids who have lead exposure are probably going to have more difficulties,” he added.
That said, these conclusions aren’t perfect. For instance, the research doesn’t account any variation in how the children who were tested may have been previously exposed to lead, or how their continued lead exposure through adulthood may have differed. Those who worked in jobs like construction, for instance, may have had greater lead exposure than those in white-collar jobs, Paulson noted. But on the whole, he said, it makes a strong case for the long-term impact of childhood lead exposure.
Pennsylvania, Maryland and Massachusetts, which all have cities with concentrated areas of older housing, have identified lead poisoning as a major child health hazard. The CDC has also embraced “primary prevention” — testing homes for lead and removing it before people move in and risk exposure. But securing resources for lead testing, screening and abatement poses its own set of challenges.
The JAMA study illustrates, in part, one such difficulty. Lead poisoning happens over years, not overnight. So illustrating the impact, even if it’s ultimately significant, is hard to do.
“Prevention doesn’t have a lot of pizzazz. If you prevent something from happening, it’s a wonderful thing, but it’s hard to measure and take credit for,” said David Bellinger, a neurology professor at Harvard Medical School and a professor in the environmental health department of the university’s public health school, who wrote a commentary that ran alongside the JAMA paper.
And funding for such programs is often unreliable, said Donna Cooper, the executive director of Public Citizens for Children and Youth, a Pennsylvania-based nonprofit that advocates on behalf of young people. For instance, the White House’s initial budget plans would boost some lead abatement funds but slash other grants used for similar purposes. And for many states, she said, even what’s long been available isn’t enough to meet the scope of the concern.
“We have very clear CDC guidance on what should be done, and no money to back it up,” Cooper said. “It ebbs and flows with the headlines.”
State and local housing agencies will have to eliminate vouchers for 55,000 low-income families, seniors, and people with disabilities if policymakers renew Housing Choice Vouchers for the rest of fiscal year 2017 at the average funding level that the House and Senate appropriations committees approved last summer, we estimate. Even worse, 135,000 vouchers will disappear if policymakers extend the current freeze on voucher funds through September 30.
You’d think that a vaccine that protects people against more than a half-dozen types of cancer would have people lining up to get it. But the human papillomavirus (HPV) vaccine, which can prevent roughly 90 percent of all cervical cancers as well as other cancers and sexually transmitted infections caused by the virus, has faced an uphill climb since its introduction more than a decade ago.
Now, with a new dosing schedule that requires fewer shots and a more effective vaccine, clinicians and public health advocates hope they may move the needle on preventing these virus-related cancers.
In December, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended reducing the number of shots in the HPV vaccine from three to two for girls and boys between the ages of 9 and 14. The recommendation was based on clinical trial data that showed two doses was just as effective as a three-dose regimen for this age group. (Children older than 14 still require three shots.)Insuring Your Health
KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.
To contact Michelle with a question or comment, click here.
This KHN story can be republished for free (details).
The study was conducted using Gardasil 9, a version of the vaccine approved by the Food and Drug Administration in late 2014. It protects against nine types of HPV: seven that are responsible for 90 percent of cervical cancers and two that account for 90 percent of genital warts.
In addition, the new version of Gardasil improved protection against HPV-related cancers in the vagina, vulva, penis, anus, rectum and oropharynx — the tongue and tonsil area at the back of the throat.
An earlier version protected against four types of HPV.
From the start, clinicians have run into some parental and political roadblocks because the vaccine, which is recommended for preteens, protects against genital human papillomavirus — a virus transmitted through sexual contact. Many physicians are also reluctant about discussing the need for the vaccine, and for many parents, the vaccine’s cancer-prevention benefits were overshadowed by concerns about discussing sexual matters with such young kids. Yet for maximum protection, the immunizations should be given before girls and boys become sexually active.
The focus should not have been on sexually transmitted infections, some say. “You only get one chance to make a first impression,” said Dr. H. Cody Meissner, a professor of pediatrics at Tufts University School of Medicine and a member of the American Academy of Pediatrics’ committee on infectious diseases. “This vaccine should have been introduced as a vaccine that will prevent cancer, not sexually transmitted infections.”
The HPV virus is incredibly common. At any given time, nearly 80 million Americans are infected, and most people can expect to contract HPV at some point in their lives. Most never know they’ve been infected and have no symptoms. Some develop genital warts, but the infection generally goes away on its own and many people never have health problems.
However, others may develop problems years later. There are approximately 39,000 HPV-related cancers every year, nearly two-thirds of them in women. In addition to cervical cancer, more than 90 percent of anal cancers and 70 percent of vaginal and vulvar cancers are thought to be caused by the HPV virus. Recent studies show that about 70 percent of cancers in the oropharynx may also be linked to HPV.
A 2015 study published in the Journal of the National Cancer Institute estimated that earlier versions of the HPV vaccine could reduce the number of HPV-related cancers by nearly 25,000 annually, and the new version of the vaccine could further reduce the number of such cancers by about 4,000.
The vaccine is estimated to prevent 5,000 cancer deaths annually, said Dr. Paul Offit, professor of pediatrics and director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.
But compliance is an ongoing problem. “They’re not getting the one vaccine that protects against diseases from which they’re most likely to suffer and die,” Offit said, noting that deaths from pertussis and meningococcal disease, for which adolescents are also vaccinated at that age, are minuscule compared with HPV-related cancers.
In 2015, 87 percent of 13-year-olds were up-to-date with the Tdap vaccine that protects against tetanus, diphtheria and pertussis, and 80 percent had received the meningococcal vaccine, according to the Centers for Disease Control and Prevention. But just 30 percent of girls and 25 percent of boys at that age had received all three doses of the HPV vaccine. In contrast to other vaccines, however, the HPV vaccine is required only in a few states for secondary school.
Public health advocates say they think the shift to a two-dose regimen could make a big difference in the number of adolescents who get all the necessary doses of the HPV vaccine. For one thing, the fewer shots the better, in general, they say.
In addition, because the second HPV shot is supposed to be given anywhere from six months to a year after the first one, “parents can fit it into a routine regimen when people go in for their 12-year-old’s regularly scheduled visit,” said Dr. Joseph Bocchini Jr., chairman of pediatrics at Louisiana State University Health in Shreveport who is president-elect at the National Foundation for Infectious Diseases.
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