Baby boomers are getting high in increasing numbers, reflecting growing acceptance of the drug as treatment for various medical conditions, according to a study published Monday in the journal Addiction.
The findings reveal overall use among the 50-and-older study group increased “significantly” from 2006 to 2013. Marijuana users peaked between ages 50 to 64, then declined among the 65-and-over crowd.
Men used marijuana more frequently than women, the study showed, but marital status and educational levels were not major factors in determining users.
The study by researchers at New York University School of Medicine suggests more data is needed about the long-term health impact of marijuana use among seniors. Study participants said they did not perceive the drug as dangerous, a sign of changing attitudes.
The study was based on 47,140 responses collected from the National Survey on Drug Use and Health.Use Our Content This KHN story can be republished for free (details).
Joseph Palamar, a professor at the NYU medical school and a co-author of the study, said the findings reinforce the need for research and a call for providers to screen the elderly for drug use.
“They shouldn’t just assume that someone is not a drug user because they’re older,” Palamar said.
Growing use of the drug among the 50-and-older crowd reflects the national trend toward pushing cannabis into mainstream culture. Over 22 million people used the drug in 2015, according to the Substance Abuse and Mental Health Services Administration. Seven states have legalized the drug for medicinal use and collect taxes from sales, according to Marijuana Policy Project, a non-profit advocacy group dedicated to enacting non-punitive marijuana policies across the United States. The drug has also proved to be a financial boon for state economies, generating over $19 million in September in Colorado.
Researchers also uncovered an increasing diversity in marijuana users. Past-year use doubled among married couples and those earning less than $20,000 per year.
More people living with medical conditions also sought out marijuana. The study showed the number of individuals living with two or more chronic conditions who used the drug over the past year more than doubled. Among those living with depression, the rate also doubled to 11.4 percent.
Palamar says the increase among the sick could be attributed to more individuals seeking to self-medicate. Historically, the plant was difficult to research due to the government crackdown on the substance. The Drug Enforcement Administration classifies the plant as a Schedule I substance, “defined as drugs with no currently accepted medical use and a high potential for abuse.”
Benjamin Han, assistant professor at the New York University School of Medicine and the study’s lead author, fears that marijuana used with prescription drugs could make the elderly more vulnerable to adverse health outcomes, particularly to falls and cognitive impairment.
“While there may be benefits to using marijuana such as chronic pain,” he said, “there may be risks that we don’t know about.”
The push and pull between state and federal governments has resulted in varying degrees of legality across the United States. Palamar says this variation places populations at risk of unknowingly breaking the law and getting arrested for drug possession. The issue poses one of the biggest public health concerns associated with marijuana, Palamar says.
But unlike the marijuana of their youth, seniors living in states that legalized marijuana for medicinal use now can access a drug that has been tested for quality and purity, said Paul Armentano deputy director of NORML, a non-profit group advocating for marijuana legalization. Additionally, the plant is prescribed to manage diseases that usually strike in older age, pointing to an increasing desire to take a medication that has less side effects than traditional prescription drugs.
The study found over half of the users picked up the habit before turning 18, and over 90 percent of them before age 36.
“We are coming to a point where state lawmakers are responding to the rapidly emerging consensus-both public consensus and a scientific consensus — that marijuana is not an agent that possesses risks that qualifies it as a legally prohibited substance,” he said.
KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.
When Ashley Hurteau, 32, was arrested in 2015, she faced a list of charges for crimes she committed to finance a drug craving she had struggled with for more than a decade.
“I wasn’t using it to get high,” she said. “I was using it to survive.”
Homeless, uninsured and addicted to heroin, Hurteau, a New Hampshire resident, had tried and failed to get help. Services came at a price she couldn’t afford.
But in 2014, Hurteau’s home state of New Hampshire expanded Medicaid. She qualified for coverage, giving her access to intensive outpatient treatment through the county’s drug court program.
New Hampshire, along with 30 other states and the District of Columbia, expanded eligibility for the state-federal low-income health insurance program under the Affordable Care Act. Hurteau is among the 1.6 million Americans who since then have had access to substance abuse services.
But a study published Monday in the journal Health Affairs found significant disparities in coverage among the states.Use Our Content This KHN story can be republished for free (details).
Researchers sought to determine the number of substance treatment services available in each state in 2014. They analyzed coverage for the four tiers of services recognized by the American Society for Addiction Medicine, which are classified as outpatient (including group and individual therapy as well as recovery support services), intensive outpatient, short- and long-term residential inpatient and intensive inpatient care for detoxification. Data was collected from the annual National Drug Abuse Treatment System Survey and state Medicaid directors.
At the time of the study, 21 states had expanded Medicaid. The federal health law required states that chose to expand their Medicaid programs to include coverage for substance abuse treatment. But it gave states control to decide the type of treatment and medication that would be covered.
Overall, the researchers found the level of Medicaid coverage for substance abuse treatment did not correlate with Medicaid expansion. Thirteen states and the District of Columbia insured each of the services in all tiers, and 26 states covered at least one service in each level of treatment.
Nine states did not provide Medicaid reimbursement for any substance abuse care in at least two levels of treatment. In particular, states shied away from covering residential interventions, which the federal government had historically chosen not to reimburse for mentally ill patients insured by Medicaid.
The expansion has forged a path for thousands to access substance abuse services. In Rhode Island, over 3,600 individuals obtained treatment through the additional coverage. From January 2015 to March 2016, nearly 63,000 people in Massachusetts received services.
Colleen Grogan, a professor at the University of Chicago and lead author of the study, said that although gaps in coverage remain, undoing the Medicaid expansion as part of the current push by Republican lawmakers and President-elect Donald Trump could have serious consequences for the nation’s efforts to address the ongoing opioid epidemic.
“If we repeal the ACA, I think that’s going to make it worse,” she said.
Deaths by overdose have quadrupled since 2000, totaling more than 28,600 fatalities in 2014, according to the Centers for Disease Control and Prevention. In North Dakota alone, the number of cases surged by 125 percent in one year. In New Hampshire, the rate rose by nearly 75 percent.
Grogan said the variety of coverage across the nation also didn’t align along political lines, pointing to the severity of substance abuse across the nation and states’ commitment to address the issue.
“It’s really hard to address the epidemic if you can’t get people connected to services,” she said.
The coverage disparity across the nation extended to medications used to manage addiction. Every state and the District of Columbia insured buprenorphine, and all but two states covered injectable naltrexone. However, only 32 Medicaid programs covered methadone, one of the most effective drugs in managing addiction, according to the American Society for Addiction Medicine.
Only 17 state programs and the District of Columbia insured both comprehensive treatment services and all addiction medications.
The large number of states paying for these drugs surprised Grogan, she said. Although relatively low rates of methadone coverage reveal residual stigma toward the medication, the overall rise in drug coverage indicates a national shift in accepting drugs as a viable treatment option for recovering addicts rather than “replacing one addiction with another.”
“We’ve moved quite a ways in accepting that medication for the rest of your life is needed,” Grogan said.
But the study also revealed several hurdles in accessing services and life-saving medication. It found many states limited access to substance abuse treatment by requiring preauthorization, imposing annual maximums or asking for patients to pay a share of the costs.
Nearly every state required preauthorization and over a third of them required copays for buprenorphine. About half the states imposed preauthorization for intensive inpatient facilities. Nearly 10 states extended the annual maximums to recovery services.
“When you have a patient that is ready to get treatment that is in withdrawal, that is the moment where you really need as few barriers as possible,” said Yngvild Olsen, chair of the public policy committee for the American Society of Addiction Medicine.
When Hurteau entered treatment, New Hampshire was streamlining the process to allow patients to access care with few hurdles. Although the study says the state is missing intensive outpatient residential treatment programs, the state expanded Medicaid under a waiver and provides comprehensive services through a substance use disorder benefits package.
Michele Merritt, policy director at New Futures, a nonprofit organization that works to address substance abuse issues in New Hampshire, said expanding Medicaid enabled the state to connect 10,000 people to treatment in 2015, she said. Prior to that, the state relied solely on grants to support their system, she said, resulting in long wait lines.
“Medicaid expansion at least in my opinion is the single most important thing New Hampshire has done to combat the opioid epidemic,” Merritt said.
The possible repeal of the ACA raises serious concerns for Grogan, Merritt and Olsen. All three women touted the importance of comprehensive services, rather than piecemeal interventions, as key to tackling the epidemic. These services cost money, Grogan admitted, but the fiscal and societal costs of neglecting the opioid epidemic outweigh the initial investment.
“I think even from a moral perspective, we know that we need to respond to people who have addiction,” Grogan said. “Especially for those that have reached a point that want help.”
Hurteau’s life has dramatically changed.
Today, Hurteau works as a volunteer and program coordinator at Safe Harbor Recovery Center. She is able to see her son, now 3, and is on track to regain custody. A recovery support group also helps her live a life of sobriety.
“I don’t know where I would be if this wasn’t available to me,” she said.
The Washington, D.C., jail has big metal doors that slam shut. It looks and feels like a jail. But down a hall in the medical wing, past an inmate muttering about suicide, there’s a room that looks like a normal doctor’s office.
“OK, deep breaths in and out for me,” says Dr. Reggie Egins to his patient, Sean Horn, an inmate in his 40s. They talk about how his weight has changed in his six weeks in jail, how his medications are working out and if he’s noticed anything different about his vision. Egins schedules an ophthalmology appointment for Horn.
Horn says before he arrived here, things were not looking good.This copyrighted story comes from NPR’s Shots blog. All rights reserved.
“I looked real bad. I was homeless, for one, and not taking my medicine,” says Horn, who has depression, high blood pressure and gout, among other things.
When he was out on the streets, Horn says, it was hard for him to get his medications or to see a doctor. So he just didn’t. He got sicker and sicker.
“I had two heart attacks and my gout flared up a whole lot of times when I was out there,” he says.
Horn is no outlier. People with a history of incarceration are typically much sicker than the general population, especially returning inmates like Horn. Studies done primarily in Ohio and Texas have found that more than 8 in 10 returning prisoners have a chronic medical condition, from addiction to asthma. Egins says a lot of it has gone untreated, for a range of reasons — because the health care system is tough to navigate, because they’re homeless and don’t have insurance, or because they don’t trust doctors.
“The first thing is that they usually have no permanent address, which means that they cannot apply for health insurance and/or there’s nowhere to receive those documents if they do,” says Egins, a family doctor who does correctional health care, splitting each week between serving patients at the D.C. jail and at Unity Health Care, a network of community health centers.
Now, being in jail is not healthy. But for a lot of people, the best health care they’ll receive is what they get behind bars. About 40 percent of inmates are newly diagnosed with a chronic medical condition while incarcerated. Outside, many only interact with doctors when they’re in the emergency room.
“Man, if there is any one single thing in the literature that is compelling, it’s that there’s a significantly higher risk of dying in the first two weeks following release from a correctional facility,” she says.
Wang says the primary causes of death after incarceration include overdose, heart disease, suicide and cancer — often treatable things, if you catch them early enough.
It’s not just a matter of getting insurance. “Insurance is necessary, but it’s not sufficient,” says Wang. “Our patients will often come with insurance, but they don’t know the first thing about how to use the health care system to their benefit.”
Behind bars, patients get three meals a day and line up to get their daily medications handed to them by a nurse.
“When they come home from prison, they have to learn to use the pharmacy, learn to get a refill, learn to make their appointments … on top of trying to get housing, get employed, figure out where to get food for the day,” she says.
So many former inmates put off getting medical care until they wind up in the emergency room, with conditions that have become a lot worse than they could’ve been. That means they are also more expensive to treat, costs that are often picked up by hospitals and taxpayers.
Wang and her colleagues are trying to make it easier for ex-inmates to manage their health care so they don’t end up in the ER. They work at the Transitions Clinic Network, which now has 14 sites across the U.S. and in Puerto Rico. They’re funded by private donations and by grants like one from the Centers of Medicare & Medicaid Innovation.
Their patients qualify for Medicaid based on income, and the clinics are reimbursed by Medicaid. The difference is that they offer more services than Medicaid typically does — like helping patients find a halfway house they can afford.
Joe McFadden has experienced how much of a difference those extra services can make. McFadden spent 40 days in solitary confinement before being released two weeks later.
“You’re just locked up like an animal. That’s not good or healthy at all,” says McFadden, who is in his 40s and was homeless and living on the streets of New Haven, Conn., when I spoke with him. “It’s not easy, coming home from being incarcerated to a world where you’re being discriminated against,” he says.
Shortly after release, McFadden ended up in the emergency room with a ballooning leg. It was a blood clot. “I thought I had pulled a muscle. It took me like a week to go in because I didn’t know the symptoms of having blood clots,” he says. He’d rarely been to the doctor before that, but now he comes in for regular visits at the Transitions clinic in New Haven. The staff there helped him find a substance abuse program, and a place where he could visit his two kids.
“Our rationale for this program is by organizing primary care in this manner, we improve public health,” Wang says. “Our patients are sicker than the general population, so by caring for them, fewer communicable diseases are transmitted, substance use is treated, etc.” She adds: “Moreover, it makes good business sense for the health system.”
In a randomized control trial looking at 200 recently released prisoners in San Francisco, Wang and her colleagues showed that bringing that population to see doctors significantly reduced emergency room visits and hospitalizations. That lessens the strain on emergency departments, and the cost burden that emergency treatment puts on the health care system.
Wang works at the New Haven clinic, which gets additional funding from the Community Foundation for Greater New Haven, the Yale-New Haven Hospital and the Substance Abuse and Mental Health Administration.
The staff starts off the morning by running through a list of the patients coming in. One patient is worried about relapsing on a drug addiction and wants to talk about options for staying clean. Another patient with an infection in his leg has finally gone to see orthopedics.
“That was a huge accomplishment. Getting him to an appointment is a feat,” says Dr. Lisa Puglisi, one of the physicians at Transitions.
The patient came to his appointment because of Jerry Smart. As a community health worker with Transitions, Smart is the clinic’s secret weapon, because patients might not trust doctors, but they do trust him.
“This population, you know, they’ve been dealing with probation, parole, dealing with correctional officers. So they don’t trust people,” says Smart.
Like all Transition’s community health workers, Smart knows what it’s like to be an ex-inmate. It’s been 30 years since he did time, but he remembers feeling judged by doctors, and thinking they didn’t care about his well being.
“A lot of these guys feel the same way. But when they meet me, I just let them know we have a great team. The physicians care about you, they care about your needs,” says Smart. “So once they buy into me, then they buy into the whole thing.”
No one wants to be sick, he says, but sometimes the whole health care system can be intimidating. He’ll go with patients to their appointments, check in with some of them regularly on the phone, and he’ll even take frantic calls at 2 a.m. about whether they should go to the emergency room or not.
Mark Baskerville, who lives in New Haven, is one of the clinic’s success stories. He’s in his mid-50s, and he’s been in and out of prison four times.
On the bus coming home, he says, “First it’s anxieties that pick up: ‘Man, am I going to do all right?’ Things are in your hands and you’re in control of it now.”
Health problems are easy to push aside, he says.
Baskerville has been living with diabetes for about 20 years, about 12 of which he spent in the correctional system. He says he had five diabetic comas while he was an inmate. But since reentering the community, he’s come for regular visits at the clinic and says he’s doing better.
“It was easy. I know what I got to do to take care of my diabetes. You got to work with your doctor,” says Baskerville.
If you don’t, he says, you’ll never be able to enjoy your freedom.
Penny Gentieu did not intend to phone 308 physicians in six different insurance plans when she started shopping for 2017 health coverage.
But a few calls suggested to Gentieu, a photographer who lives in Toledo, Ohio, that doctors listed as “taking new patients” in the health plans’ directories were not necessarily doing so.
Surprised that information about something so central to health insurance could be so poor, she contacted almost every primary care physician listed as accepting new patients in every local plan. More than three-quarters of those doctors in her part of Ohio were in fact rejecting new patients, she found.
“It’s just not fair to be baited and switched,” said Gentieu, who must find a new doctor because her physician of several years will not be in any available plans in her area next year. “It’s just so crazy that you’re presented with this big list of doctors and then you call them and you realize there’s nobody there.”This KHN story also ran in The New York Times. It can be republished for free (details).
As consumers review their coverage and shop for 2017 insurance through the federal health law’s online marketplaces during the annual open enrollment period, many of the directories they are using are outdated and inaccurate. Some doctors in the directories are not accepting new patients and some are not participating in the network, say experts, brokers and consumers. Still other physicians in the directories, who are listed as “in-plan,” charge patients thousands of dollars extra per year in “concierge fees” to join their practices.
“There continue to be inaccuracy problems,” said Justin Giovannelli, a Georgetown University professor, who studies coverage under the health law. Flawed directories are “a real barrier to accessing the care and accessing the insurance consumers have purchased.”
President-elect Donald Trump has pledged to repeal and replace the Affordable Care Act, which created the marketplaces. But insurers’ doctor lists are likely to remain a problem no matter what the law looks like, consumer advocates say.
Knowing which doctors and specialists are available within a plan is critical, as patients who visit a physician outside a plan’s network must pay much if not all of the cost.
The effect from flawed directories is even greater this year, as carriers have stopped offering coverage in many markets, meaning many consumers have only one or two insurers to choose from. The number of doctors and hospitals in plan networks also continues to shrink as insurers steer patients toward lower-cost narrow networks.
Reports of inaccuracies suggest that new federal rules to ensure reliable directories are having little effect. Starting this year, all plans sold through the marketplaces are required to “publish an up-to-date, accurate and complete provider directory” or be subject to penalties or removed from the marketplace portal.
But so far no plans have been fined or kicked off the enrollment sites for having poor doctor directories, said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which would enforce the rules. A Health and Human Services Department survey of Medicare plans for those 65 and older that was released in October found errors in nearly half of the listings in doctor directories.
Staci Doolin, a co-owner of a radon-testing company in Forsyth, Ill., consulted the Blue Cross Blue Shield of Illinois physician directory in January to make sure her primary care physician was in the network and even called the insurer to double-check.
The directory was wrong. The doctor was not in the plan.
“I thought I was good to go, and then I get this bill and it says my insurance didn’t cover anything and I owe $503,” Doolin said.
It took until September to resolve the matter — but not before the office threatened to summon a bill collector. She never recovered $100 she spent on a dermatologist who was listed in the directory but who also was not part of the plan.
No comprehensive data exists on doctor directory accuracy. The health law and HHS set standards for network adequacy but leave most enforcement up to states. States rarely test the lists for accuracy and often rely on consumers to report problems.
But third-party surveys frequently reveal big discrepancies. One recently published study showed as many as a fourth of the doctors listed in California directories last year for marketplace plans were not accepting new patients. About one doctor in 10 was not working for the listed practice.
Consumer advocates often praise California for vigorous insurance regulation. Last year, the state fined one plan $350,000 and another $250,000 for flawed doctor directories.
“I have to think it’s pretty much the same nationwide,” said Simon Haeder, an assistant professor at West Virginia University, who led the study. “Insurers have a hard time keeping these up-to-date because it costs a lot of money, and providers don’t put a lot of effort on giving insurers updated information.”
Even doctors offices are frequently unclear about whether they participate in certain plans, said insurance brokers, who assist consumers shopping for plans.
Confusion multiplies when physicians are in some networks and not others offered by the same insurer. Doctors might be part of broader plan with many choices but not part of a narrow network with nearly the same name.
“We’d have customers call up [a doctor] and they’d say, ‘We take Blue Cross PPO,’” said John Jaggi, an Illinois broker. “But they didn’t take Blue Choice Preferred PPO.” Neither the patient nor the doctor’s office knew the difference, he said.
Even when primary-care doctors are in-network and accepting new patients, they increasingly charge expensive “concierge” fees on top of the usual deductibles, co-pays and premiums required by the policy, brokers say.
The primary-care roster for two plans from Florida Blue, the Blue Cross insurer in that state, lists four physicians working for NCH Healthcare, a Naples hospital system. One practiced at Harvard University and another worked for the Cincinnati Bengals football team.
What the directory doesn’t say is that seeing those four doctors costs patients an extra $3,000 a year in addition to thousands of dollars in premiums and deductibles.
Florida Blue cannot discuss contracts with network doctors and is unaware of recent complaints about concierge fees, said company spokesman Paul Kluding.
Directories for specialty physicians may be even more difficult to navigate than those for primary care doctors.
Brian Jarvis, who lives near Dayton, Ohio, needed an orthopedist after straining an Achilles’ tendon this summer. He had to go through 17 doctors listed as accepting his marketplace plan before finding one who really did, he said.
An online tool for Florida Blue does not let consumers search for anesthesiologists, who are often outside coverage networks even when their hospital is in network. Unwittingly being put under by a non-network anesthesiologist can cost patients thousands of dollars.
Even insurers admit patients are ultimately on their own to navigate the directory thicket.
“We recommend you contact the provider to confirm that they are in your plan and that the desired service is covered,” warns the online doctor-search tool for Anthem, one of the biggest sellers of marketplace plans under the health law.
Few consumers take that advice to heart like Gentieu.
“I was shocked at how awful the state of Ohio is for handling all of this,” said Gentieu, who was concerned about having a five-year-old hip replacement monitored.
She posted results on her website and sent complaint letters to plans and the Ohio Department of Insurance. Four of the insurers did not substantially dispute Gentieu’s research.
“While our findings do not exactly match those of Gentieu, we did identify issues which are being addressed,” said Don Olson, a spokesman for Medical Mutual of Ohio, a health insurer in the state.
Gentieu found that only 15 percent of those listed as primary care doctors in one Medical Mutual network were actually primary care physicians taking new patients. Many had not accepted new patients in years. Others were specialty doctors, nurse practitioners or medical residents who had not completed their training.
Physicians often fail to tell insurers when they stop accepting patients for certain plans, Medical Mutual and other carriers said.
Like HHS, Ohio instituted new directory-accuracy rules this year for marketplace plans. But enforcing them is “consumer-driven,” said David Hopcraft, a spokesman for the Ohio Insurance Department. The state does not check the lists until consumers report inaccuracies, one doctor at a time.
“That is completely insufficient,” said Lynn Quincy, a health care specialist for Consumers Union. “Only 13 percent of the non-elderly adult population know they have a state insurance department, so clearly that’s a pretty bad setup.”
U.S. House Majority Leader Kevin McCarthy wants to repeal the Affordable Care Act first and replace it sometime later. That doesn’t sit well with Victoria Barton, who lives in McCarthy’s rural California district.
“It’s like they dangled the carrot and now they’re taking it away,” said Barton, 38, of Bakersfield, an unpaid photographer and stay-at-home mother of two.
Barton and her husband, a contract computer technician, had been uninsured for most of their adult lives until Obamacare expanded Medicaid and they were finally able to qualify for the low-income health program. This year, California’s version of Medicaid, known as Medi-Cal, paid for surgery to remedy Barton’s long-standing carpal tunnel syndrome.
When McCarthy returns later this month to his Congressional district, a mostly agricultural region in California’s Central Valley including the city of Bakersfield and Edwards Air Force Base, he will likely face many confused and frustrated constituents.
Two counties represented by the Republican leader are among the most heavily dependent on Medi-Cal in the state. Roughly half of residents are covered by the program, which added about 212,000 enrollees after Obamacare took effect.This story also ran on NPR. It can be republished for free (details).
Nearly 29,000 residents have purchased health plans through Covered California, the state’s insurance exchange, with coverage heavily subsidized by the federal government.
Some of those who favor the law, or rely on it, see a conflict between McCarthy’s stated goals as a national leader and the needs of so many of his constituents.
“Those comments he made [about repeal] just demonstrate how disconnected he is from the people he’s supposed to be representing,” said Edgar Aguilar, program manager for Community Health Initiative of Kern County, an organization that helps enroll residents in Medi-Cal and Covered California in Bakersfield.
McCarthy’s staff in Washington, D.C., said they were not available to comment.
The complexities of killing Obamacare are laid bare in the 23rd Congressional district that McCarthy represents, highlighting what other Republican politicians from less affluent areas may face.
On one hand, the district is considered a safe Republican haven — McCarthy easily defeated his Democratic challenger in November, winning about 70 percent of the vote. More than half of Kern and Tulare voters chose President-elect Donald Trump, and some of McCarthy’s constituents vocally support his promise to get rid of Obamacare.On the other hand, constituents like Barton worry about the consequences of repealing the health law without an immediate replacement. They fear losing all or part of their health coverage, or losing jobs in the health care industry.
Unemployment in Kern and Tulare counties runs between nine and nearly 11 percent, twice as high as the state average. About a quarter of residents live in poverty, according to U.S. Census data.
With Obamacare, “we’ve made this gigantic step … and then suddenly to just take it away without any rational plan in place seems totally irresponsible,” says Bill Phelps, chief of program services at Clinica Sierra Vista, a network of health care clinics serving 200,000 patients.
“They’re playing chess with the American population,” said Phelps.
Since the Affordable Care Act was signed in 2010, the health care network where Phelps works has hired more than 100 employees and opened at least four new health centers, although some clinics were planned beforehand. A repeal of the Medi-Cal expansion may require the clinic system to shed some nursing and case management jobs, clinic officials said.
“Health care is such an integral part of the economy,” said Phelps, adding that he hopes McCarthy will look into the “details” before scrapping Obamacare. “You just can’t turn off the switch.”
But McCarthy seems to want a quick repeal. He told reporters that ending the Affordable Care Act is “easier and faster” than passing an alternative policy, which would require more votes.
“I want to make sure it gets done right,” he said of replacing Obamacare in a Washington Post interview.
Others in McCarthy’s district will be glad to see Obamacare go, and as soon as possible.
“This whole system has been a disaster from Day One,” said Rodger Harmel, an insurance agent in Bakersfield. “Rates have been at an all-time high.”
Harmel says most of his Covered California clients earn too much to qualify for the federal subsidies that reduce monthly premiums. He said most are paying more now than they did before the law and didn’t need the new rules to be able to buy insurance.
“A forced coverage system is not the answer,” he said.
But health care advocates in Sacramento have sharply criticized McCarthy’s remarks, saying his plan could create “chaos” in California’s individual insurance market.
“The elimination of financial help in Covered California — even if delayed — would not just cause people to drop coverage and insurers to leave the market, but would force skyrocketing rates for those left in a smaller and sicker insurance pool,” said Anthony Wright of Health Access California, a statewide consumer advocacy coalition.
Meanwhile, Aguilar, the program manager for Community Health Initiative of Kern County, said roughly six people are referred to his organization each month by a local cancer center. They have been diagnosed with cancer or another serious illness, but don’t have insurance, he said.
For people like this, a full repeal of Obamacare without a replacement would be devastating, Aguilar said.
“It’s just horrible thinking about those people who are having the worst experience in their life and now they’re not going to have anywhere to turn in order to get the coverage they need to get their medical care,” Aguilar said.
“I’m afraid people can lose their lives without the coverage they need,” he added.
Worry about Obamacare’s repeal is not confined to residents who depend on the government for coverage.
Bakersfield resident David Tate, a 34-year-old school nurse, has a son, Lucas, who was diagnosed with acute lymphoblastic leukemia in 2009, when he was 7 months old. The boy survived after intensive chemotherapy treatments.
Tate, who then had a private market plan to cover Lucas, credited two provisions of the Affordable Care Act for giving his family security and peace of mind after Lucas’ initial treatment was over. One was a requirement to cover people with preexisting conditions. “If the ACA hadn’t been there and I needed another private plan, they would have denied him coverage,” Tate said.
The second provision prohibited insurance companies from placing lifetime limits on most benefits in most plans.
“Lucas had essentially used his lifetime maximum for treatments in that first year,” Tate said. “Could you imagine if Lucas had relapsed? We would have been completely out of benefits. We would have just been hosed.”
President-elect Donald Trump has pledged to defund Planned Parenthood, to appoint conservative Supreme Court justices who could overturn Roe v. Wade and to prohibit late-term abortions. He has also vowed to repeal and replace the Affordable Care Act, which expanded access to contraception.
The anti-abortion platform of Trump and Vice President-elect Mike Pence appeals to many conservatives around the nation but worries many women’s health providers.
We spoke to Kathy Kneer, CEO and president of Planned Parenthood Affiliates of California, about the organization’s future under the incoming administration. Planned Parenthood provides primary care, reproductive health services, sex education and abortions across the nation. The 100-year-old organization has about 650 health centers, including 115 in California.
The conversation has been edited for clarity and length.
Q: Who do Planned Parenthood centers serve in California?
We serve 850,000-plus men and women a year. Throughout the state of California, our patients are 80 percent served through the Medicaid program and the federal Title X family planning program.
Q: What sort of services do they receive?
The basic service that people come to Planned Parenthood for is reproductive health care, specifically contraception. Often times, they come because they think they are pregnant. We wish they would come for birth control first, but they [often] come for a pregnancy test. That then opens the door to discuss with the patients how we can help them with their contraceptive method.
So 97 percent of overall services [in California] are for non-abortion services. We also do annual exams. The most important feature is your breast exam to make sure you are not having early stage breast cancer. Also, we screen for STDs — and in California right now, we are having an epidemic of STDs.
Q: Are women coming in after the election making different decisions about their care than they did before?
It’s not just whether Planned Parenthood gets defunded, it’s if contraception gets defunded as a result of a repeal of the Affordable Care Act. I think that’s making women think differently about their contraceptive needs. But it’s a little too soon for us to say that women are switching or that they are coming in only for IUDs [intrauterine devices]. We had already been seeing a dramatic increase prior to the election of women electing IUDs. That’s been a trend really in the last three years and it has really taken off in the last year. Women are much more knowledgeable about it and are aware that there is an effective long-term [contraceptive] method.
Q: Are centers advising women to do anything differently because of the new administration?
We advise all women that they should come in and get screened and onto birth control before they need it … and learn how to have safe sex to protect against STDs as well as pregnancy. That has always been our mantra and that will continue to be our mantra.
Q: What do you anticipate happening with the new administration’s pledge to defund Planned Parenthood and to repeal the Affordable Care Act?
Trump is proposing to figure out how to defund Planned Parenthood. It is not clear that he really means that, because we have not seen him necessarily stand by everything he said. But the repeal of Obamacare is the biggest threat for women who are not on Medicaid. It’s very important that women understand that if you are in Covered California, you could lose access to birth control or have to pay a copay.Use Our Content This story can be republished for free (details).
The good news is that California passed a law that says insurance companies must give you a year’s supply. So if you are in Covered California and you need birth control, make sure that after January 1, you go get your new prescription and you ask for it in advance. And it will be with no copay. That way you will have a year’s supply of birth control regardless of what the Trump administration does.
I don’t believe they are going to end the family planning benefit in the Medicaid program, so women on Medi-Cal will continue to have access to it.
Q: How exactly could Trump defund Planned Parenthood, and what would that mean for the organization?
There are different pathways he could take. He could issue an executive order his first day in office to restrict the Title X federal family planning program and eliminate any providers who also provide abortion. We know that [Trump] could do that easily with a stroke of a pen. That would have two impacts. One is the loss of those federal family planning dollars, but also the loss of … a federal drug program that allows us to provide drugs at a deeply discounted rate. It would be very hard for our affiliates to make up that loss.
There is also the Medicaid program. Federal law says that states must allow any willing and eligible provider to participate in the Medicaid program. But [Republicans] can change that law in the budget reconciliation process. It’s a majority vote bill in both houses. That bill would go to the president, and if he signed it, we would be denied eligibility to participate in the federal Medicaid program.
It’s potentially very devastating. And it’s devastating for people in California. Women in California really need to understand that what happens in [Washington] D.C. around reproductive health care will impact how women access care in California.
Q: How is Planned Parenthood preparing to respond to Trump’s pledges?
At the national level, we are certainly going to see if there is any litigation that can be done. At the state level, we will be doing the same thing. Are there steps from a legal perspective we can take to really guarantee that women in California will have access to reproductive health care?
Q: What are you seeing in terms of donations here in California and nationally since the election?
Nationally, we know that they are up. But it’s also getting close to the end of the year and people are making their year-end donations. There are no private donations that can subsidize the volume of government funds spent on those services. There isn’t that much money available in terms of private donations.
Q: Is it possible the state of California would step up if the federal government cut off funding for Planned Parenthood? Are you talking to state officials?
That’s what I am starting to do. I have an appointment with the governor’s office. Our first goal is to let them know our grim assessment. We are going to talk to them about Proposition 56 [the tobacco tax that increased funds for Medi-Cal]. We were originally going to talk to the governor’s administration about making sure that some of the money is targeted to women’s reproductive health care services. We’ve had to expand that agenda to help us delay and defeat any Trump actions hostile to California.
What helps is that … family planning services are recognized to be cost-effective in the state of California by preventing unintended births. They are so cost-effective that the state … pays for undocumented women to have access to family planning services.
And if we went away, there is no place for those patients to go. Often times, [Planned Parenthood] centers are geographically located where there aren’t other providers.
KHN’s coverage in California is funded in part by Blue Shield of California Foundation.
Health coverage and immigration status are inextricably linked for many Californians.
Citizens and many lawfully-present immigrants are eligible for most health care options.
For other immigrants, insurance availability varies by status.
If you’re an unauthorized immigrant, for instance, you can’t purchase a plan from Covered California, the state health insurance exchange, or get full access to Medi-Cal, the state’s Medicaid program for low-income residents. Your children, however, may qualify for comprehensive Medi-Cal benefits even if they don’t have permanent legal status.
But President-elect Donald Trump’s promises to crack down on unauthorized immigration and rewrite the health care system have hung a cloud of uncertainty over the heads of many immigrants.
As a result, many immigrants are unsure whether they should use the health coverage they currently have — and if those options will be available to them in the future.Ask Emily
A series of columns answering consumers’ questions about California’s changing medical landscape.
Send questions for Emily to AskEmily@kff.org
“People are very scared. They’re doubting. They’re coming to us like we have all the answers, but we don’t have all the answers,” says Celia Valdez, director of outreach and education for Maternal and Child Health Access, an advocacy group based in Los Angeles County.
I don’t have the answers, either, but I’m going to pass along some information and advice for these uncertain times.
The first and most important tidbit is this: If you currently have health coverage and you need medical care, you “should use it and not wait. Seek the services you need while they’re available,” says Cary Sanders, director of policy analysis for the California Pan-Ethnic Health Network (CPEHN).
“No policies will change until at least after Jan. 20,” which is Trump’s inauguration day, adds Priya Murthy, policy and advocacy director at Services, Immigrant Rights and Education Network (SIREN) in San Jose.
“If you have a doctor’s appointment, please go to your doctor to make sure you get the proper care you need,” she says.
Should you apply?
Open enrollment for Covered California began before the election and runs through Jan. 31, 2017. You can apply for Medi-Cal any time of year if you’re eligible.
You may fear that enrolling yourself or your children for coverage can expose you to unwanted attention from immigration officials. But advocates and state officials say that’s not the case.
“If you are eligible for Medi-Cal or Covered California, you should recognize there are laws in place to protect the confidentiality of any information you provide,” says Gabrielle Lessard, senior policy attorney for the National Immigration Law Center, which is based in Los Angeles.
The state Department of Health Care Services (DHCS) says it shares Medi-Cal enrollee information only with federal health — not immigration — officials, and only “for the purpose of administering the Medicaid program.”
“DHCS takes its responsibility to safeguard personal health information seriously,” the department says.
Covered California, too, assures Californians that “the information you provide to Covered California will not be used for immigration enforcement purposes.”
The agency requires immigration details for those requesting coverage. But if you’re in the country without authorization and are applying for someone else, like your child, you don’t need to provide information about your own immigration status.
Still, after the election, advocates began to analyze California’s laws and policies to determine whether there are “vulnerabilities in the system … that could result in the sharing of a California resident’s information,” says Ronald Coleman, government affairs manager for the California Immigrant Policy Center.
If there are, advocates will ask state lawmakers to strengthen privacy and confidentiality protections, he says.
For now, don’t be afraid to enroll, Coleman says. “Until we are able to see what the Trump administration is going to do, we would urge people to continue moving forward with applications for programs they’re eligible for.”
Up in the Air
Earlier this year, state officials asked the federal government to allow Californians who are in the country illegally to purchase health insurance from Covered California. (They wouldn’t be eligible for federal tax credits, so they would have to pay the full insurance premiums on their own.)
“That will probably not move forward,” says Sarah de Guia, executive director of CPEHN.
Also earlier this year, California made full Medi-Cal benefits available to unauthorized immigrant children, using only state funding. Since then, about 153,000 of them have enrolled, the Department of Health Care Services says.
Because this program relies on state — not federal — money, advocates expect it to remain in place, at least initially.
But if Trump and Congress dramatically alter or reduce funding to the Medicaid program, that could “potentially trigger big deficits within Medi-Cal, which essentially puts many Medi-Cal programs in jeopardy,” Coleman says.
“Dreamers,” young people whose parents brought them to the U.S. illegally, are a group of immigrants with particular anxiety about their health care.
Via executive order, President Obama created the Deferred Action for Childhood Arrivals (DACA) program for that group in 2012. It defers deportation for two years, allows them to work and can be renewed.Use Our Content This story can be republished for free (details).
Young people in this category are barred from purchasing insurance from Covered California, but they can sign up for Medi-Cal if they qualify.
As of June, there were about 214,000 immigrants with DACA status in California, Lessard says.
But Trump has vowed to “immediately terminate” Obama’s executive actions on immigration.
“For the DACA youth, it’s just devastating. All questions are left unanswered. Folks are wondering, ‘Should I be exposing myself?’” Valdez says.
Because of the uncertainty, the National Immigration Law Center is advising people who are thinking of applying for DACA for the first time to wait “until we have a better understanding of how things are going to unfold,” Lessard says.
For those whose DACA status will be up for renewal soon, different groups offer different advice, but most suggest you seek the counsel of an immigration attorney or an immigrant rights group such as SIREN before moving forward with renewal.
But a related health question looms: If the DACA program ends, does that mean these young people’s access to Medi-Cal also ends?
That remains to be seen, advocates say.
“Originally we thought their Medi-Cal eligibility may be at risk. That may not necessarily be the case if DACA goes away,” Coleman says.
Twenty-year-old Yesenia, who asked to be identified by first name only, got DACA status right away in 2012. However, the Los Angeles resident didn’t sign up for full Medi-Cal benefits until last week, with the help of Maternal and Child Health Access.
For one thing, she needs her tonsils removed. For another, she’s worried about her future status. “Now with Trump, I have to get [Medi-Cal],” she says. “He says he’s going to take DACA from people.”
Yesenia figures that once she’s enrolled in full Medi-Cal benefits, “it will be harder for him to take it away than if I didn’t have it,” she says.
But that’s just a guess. Mostly, she’s just unsure and uneasy.
“I don’t know what will happen,” she says.