Patients in Alexandria, La., were the friendliest people Dr. Muhammad Tauseef ever treated. They’d drive long distances to see him, and often brought gifts.
“It’s a small town, so they will sometimes bring you chickens, bring you eggs, bring you homemade cakes,” he said. One woman even gave him a puppy. “That was really nice.”
Tauseef was born and raised in Pakistan. After going to medical school there, he applied to come to the U.S. to train as a pediatrician.
It’s a path thousands of foreign-born medical students follow every year — a path that’s been around for more than half a century. And, like most foreign-born physicians, Tauseef came on a J1 visa. That meant after training he had two options: return to Pakistan or work for three years in an area the U.S. government has identified as having a provider shortage. He chose to work with mostly uninsured kids at a pediatric practice in Alexandria, La.
“That was a challenge,” he said, “but it was rewarding as well, because you are taking care of people who there aren’t many to take care for.”
The U.S. medical system depends on doctors like Tauseef, said Andrew Gurman, president of the American Medical Association. He worries that President Donald Trump’s executive order on immigration, which is now on hold after a federal appeals court ruling.This story is part of a partnership that includes KERA, NPR and Kaiser Health News. It can be republished for free. (details)
“International medical graduates have been a resource to provide medical care to areas that don’t otherwise have access to physicians,” he said. “With the current uncertainty about those physicians’ immigration status, we don’t know whether or not these areas are going to receive care.”
According to the AMA, about 280,000 international medical graduates practice in the U.S. today — that’s about one in four doctors. Some are U.S. citizens who’ve gone abroad for medical school, but most aren’t.
“They don’t all have permanent visas and so a lot of them are concerned about what their status is going to be, whether they can stay, whether they can go home to visit family and still come back, and the communities they serve have similar questions,” he said.
And the care is top-notch. A study just published in the journal BMJ shows Medicare patients treated by doctors from foreign medical schools get just as good care — and sometimes better — than those treated by U.S. medical graduates.
The uncertainty is hitting medical schools at a tough time of the year. Dr. Salahuddin Kazi is in charge of recruiting top students from across the world for the University of Texas Southwestern residency program.
“Typically we have 3,000 people applying for our 61 positions — of those 3,000, at least half of them are international medical graduates,” he said.
Applicants find out their program match in March and usually start working in June. That gives them about 90 days to get a visa. Kazi worries this year that won’t be long enough, and that students from countries included in the travel ban won’t be let in.
“That would create hardship for the hospital, for us, and for our remaining residents,” he said. “They’ll have to pick up more shifts or give up vacation.”
Two-hundred and sixty people have applied for residency in the U.S. from the seven countries included in the travel ban, according to the Association of American Medical Colleges.
Tauseef left Louisiana two years ago but continues to care for low-income patients at Los Barrios Unidos Community Clinic in Dallas. Six of the 30 physicians who work at this clinic are from other countries. Tauseef said they’re all educated to do the same thing.
“As a physician, being a foreign medical graduate, U.S. medical graduate, a Muslim doctor, a non-Muslim, we are trained to look for signs and symptoms,” he said, “We do not look at anybody’s color, we are not trained to look at anybody’s religion or ethnicity.”
Tauseef, who has been in this country for 13 years, will apply for U.S. citizenship next month.
If Republicans in Congress scrap the Affordable Care Act, Carmina Bautista-Ortiz might have to go back to Mexico for health care. But she’d rather spend the time running the printing shop she and her husband own in Jurupa Valley, a city about 50 miles east of Los Angeles.
For at least 10 years, before the Affordable Care Act made it possible for them to get insurance, Bautista-Ortiz and her husband Roger had been uninsurable — she because of a heart condition known as tachycardia, he because of high cholesterol.
Bautista-Ortiz crossed the border to get tests and specialty care for her rapid heartbeat. Her husband was slapped with a $20,000 hospital bill, which Carmina spent two years negotiating down until the hospital dismissed the debt.
Three years ago, the couple was finally able to buy subsidized health coverage through the state’s Obamacare exchange, Covered California, and Bautista-Ortiz said they now spend less time worrying about how to get care.
“Our health is … basically the most important thing that we have,” said Bautista-Ortiz. “If you’re not feeling well, you’re not going to do your job the right way.”Use Our Content This story can be republished for free (details).
Under Republican-led plans to repeal the Affordable Care Act, hundreds of thousands of self-employed people in California are at risk of losing their ability to buy affordable insurance. Some business owners welcome the rollback of the law, but the smallest of California businesses — entrepreneurs and contract workers who buy insurance on their own through Covered California — have the most to lose under a repeal.
That worries small business advocates who favor the Affordable Care Act. They say putting health care coverage out of reach of the self-employed could threaten Americans’ entrepreneurial spirit and burden people who create jobs and take on financial risk.
“When you’re providing a benefit that allows folks to take that risk with a little more of a safety net … that allows more entrepreneurs to take the plunge,” said Mark Herbert, California Director for Small Business Majority, an advocacy organization that opposes repeal.
Nationally, California has one of the highest rates of small business owners who get their coverage through a health insurance exchange — 16 percent — according to a U.S. Department of the Treasury analysis of 2014 data. And Covered California officials say nearly a quarter of enrollees — 377,000 people — declared themselves “self-employed” as of December. Enrollees receive an average of $440 a month in tax credits to help offset insurance premium costs, a spokesperson for the exchange said.
Herbert said rolling back subsidized health care and the no-exclusion policy for preexisting conditions could lead entrepreneurs to abandon their endeavors for more secure jobs, or prevent them from setting up shop in the first place.
“Uncertainty is very scary,” Herbert said. “There are enough variables and challenges that small business owners face,” said Herbert.
Other self-employed people say the looming repeal of Obamacare may not make them change careers, but it would change their relationship to health care.
Charlie Murphy, a sewer pipe inspector in Marin County, says if the hefty government subsidies that help him pay his monthly premium disappeared, he’d drop his coverage, or get a skeletal policy instead.
“My focus would be more [on] something catastrophic, than [a plan that supports] health maintenance,” said Murphy, 54, who pays a fraction of a monthly premium of roughly $500. The rest is subsidized with federal money.
When Murphy signed up for health care last year, he decided it was time for a check-up, the first in seven years. He barely interacted with doctors during the previous fifteen years, which he spent uninsured.
He was surprised to hear that his blood sugar and blood pressure were higher than they should be.
“I thought I was in better health than I was,” Murphy said.
The doctor’s visit — and a break up with a girlfriend — inspired Murphy to lose 20 pounds this past year. He cut down on smoking and drinking alcohol, and learned he can “survive without cookies and pie.”
He got some mental health treatment for anxiety, too, which improved his “outlook,” he said.
Although Obamacare may have made a notable impact on his health, he said he wouldn’t pay more for insurance or abandon his career to keep the same health care access he has now.
“I like working for myself, it’s nice … Driving around with the dog,” said Murphy, who performs site visits on homes for sale, inspecting sewage systems.
Just as each individual experiences the health care system differently, small business owners’ perspectives on Obamacare also vary widely and are influenced by ideological views and how much care costs.
Sunder Ramani, who owns Westwind Media, a post-production company in Burbank, Calif., offers small group coverage to roughly a dozen employees, even though he’s not legally required to. He pays 100 percent of their premiums.
“I’ve been paying higher and higher premiums, but for what appears to be packages that are less and less attractive,” said Ramani. He is a member of the California Leadership Council of the National Federation of Independent Business, a conservative small business association which opposes the Affordable Care Act and sued to overturn the law when it was first passed.
Ramani said if his business revenue hadn’t grown over the past several years, he might have shifted more of the health cost burden onto his employees. While Obamacare may not be solely responsible for health cost increases, Ramani said, the law didn’t bring them down as much as it could have.
In California, premiums in the small group market have been going up, but recent premium hikes have been smaller than in previous years, according to data from one of California’s two insurance regulators, the California Department of Managed Health Care. Premiums grew by almost 10 percent for small employer plans in 2011, whereas this year, they rose less than 6 percent, according to the data.
Businesses with 50 or more workers have greater legal responsibilities under the Affordable Care Act. The health reform law requires them to offer employees affordable coverage or pay a penalty.
That employer mandate has created an administrative “headache” for small business owners, say the insurance agents who help them comply with new required paperwork.
What’s more, the new requirement on employers hasn’t increased the rate of people with job-based coverage, because most employers of that size already offered employee health care before Obamacare, according to researchers at the Urban Institute.
But to the individuals who run the smallest of California’s enterprises, the law gave them benefits that didn’t exist before — the guaranteed availability of insurance, and the financial support to pay for it.
The promised repeal of the federal health law, as well as other policy changes under President Donald Trump, is complicating Carmina Bautista-Ortiz’s decisions to hire more employees or offer health care to the two she currently has.
Right now, those two employees, hired late last year, are responsible for their own health care. One is covered through her husband, and Carmina suggested to the other that he find a policy on the open market.
Bautista-Ortiz plans to look into a group health policy and help her employees pay for coverage. But right now, she says, those decisions are on hold.
She’s not sure how a repeal of Obamacare would affect her business yet, but she knows it will affect her personally.
“We’re ready for the worst, and hoping for the best,” she said.
Which doctor a person happens to see at a local emergency room can have long-term consequences when it comes to opioid use.
Within the same hospital, some doctors are three times more likely to prescribe an opioid than other doctors, and patients treated by high-prescribing doctors are more likely to become long-term opioid users, according to a study published Wednesday in the New England Journal of Medicine.
“Physicians are just doing things all over the map,” says Dr. Michael Barnett, an assistant professor at the Harvard T. H. Chan School of Public Health and one of the study’s authors. “This is a call to arms for people to start paying a lot more attention to having a unified approach.”
The study looked at how many opioid prescriptions emergency physicians gave to about 377,000 Medicare beneficiaries from 2008 through 2011. The lowest-prescribing quartile of doctors prescribed opioids to just 7 percent of patients, while the highest prescribed opioids to 24 percent — more than three times as often.Use Our Content This KHN story can be republished for free (details).
Patients who saw a high-intensity prescriber were about 30 percent more likely to end up with a long-term opioid prescription of at least six months within the year following their hospital visit. They were also more likely to return to the hospital in the next 12 months with an opioid-related fall or fracture, a risk factor for seniors who take the powerful painkillers.
Overall, about one in every 48 Medicare patients prescribed an opioid in the study were likely to become a long-term opioid user.
There is a growing consensus among doctors that opioids have long been overprescribed. In 2010, there were enough prescriptions written to supply every American adult with hydrocodone for a month, according to the Centers for Disease Control and Prevention.
Part of the problem, Barnett believes, is that there isn’t enough guidance for doctors on when it’s appropriate to prescribe an opioid. Much of the evidence for when they are appropriate comes from small studies sponsored by drug companies.
“It’s kind of a grey area and there’s not very clear evidence around what you should do, so we use our own judgement. And there’s a huge gulf between what one doctor thinks and another,” Barnett explains.
Take, for example, a patient who comes to the emergency room complaining of back pain. There’s evidence that opioids are not necessary in that situation, but many doctors prescribe them anyway, said Barnett. “The world of pain treatment outside of opioids is limited and can take time to figure out. Opioids are an easy fix.”
The problem, he said, is that “even one prescription for opioids carries risks with it, that from my own experience as a provider, we tend to underestimate and under-explain to patients.”
“It is very, very plausible that well-intentioned but perhaps overly aggressive prescribing of opioids makes it likely that a patient will continue a medication long-term even if they don’t truly need it,” said Dr. David Juurlink, a professor of medicine at the University of Toronto. He was not involved in the study. “The doctors in the lowest quartile are the ones whose prescribing we should seek to be emulating.”
The study did not look at whether the opioids were correctly prescribed in each incidence. Dr. Carla Perissinotto, a geriatrician at the University of California San Francisco, worries that some of the doctors in the lowest quartile might be under-prescribing. “We have to be careful to not make assumptions too quickly and assume they’re bad prescribers, because it could be the opposite,” said Perissinotto, who also was not involved in the study.
Usually, a patient is prescribed just a handful of pills by a doctor at the emergency department to tide them over until the patient can visit his or her primary care physician.
But many primary care doctors simply refill the opioid prescription for another 30 days or longer, a phenomenon Barnett calls clinical inertia. “There’s this cognitive bias to keep going with the flow especially if the patient still feels they’re in pain.”
That can have long-term implications: One-third of people who have taken prescription opioids for at least two months say they became addicted to or physically dependent on them, a recent Washington Post-Kaiser Family Foundation survey found.
“We know there is a population of people who will potentially get addicted if they’re exposed to an opioid,” said Dr. Lewis Nelson, chair of the department of emergency medicine at Rutgers New Jersey Medical School, who was not involved with the study. “It’s a numbers game. The more people you expose, the more people you are likely to hit in that population likely to get addicted.”
Some hospitals are starting to help doctors prescribe opioids more judiciously. Many of those efforts have taken place after 2011, and therefore any changes would not be seen in the New England Journal of Medicine study.
For the past year, St. Joseph’s Regional Medical Center in New Jersey has been instructing doctors to prescribe opioids only as a last resort, said Dr. Mark Rosenberg, who runs the hospital’s emergency department and is on the board of the American College of Emergency Physicians. Rosenberg helped institute protocols that have doctors try other methods of pain relief first, such as a Novocain injection. In just over a year, the hospital has managed to reduce the number of opioid prescriptions written in the emergency room by 50 percent.
New York City and Washington state have also tried to introduce opioid prescribing guidelines into hospitals, and the ACEP expects to release new nationwide guidelines for emergency physicians in 2018.
The Trump Administration proposed a sweeping rule for the individual health insurance market today that would raise consumers’ deductibles and other out-of-pocket costs, reduce premium tax credits that help millions of people buy insurance, and make it harder to enroll in coverage.
While Congress continues to struggle with how to “repeal and replace” the Affordable Care Act, the Trump administration today unveiled its first regulation aimed at keeping insurers participating in the individual market in 2018.
“These are initial steps in advance of a broader effort to reverse the harmful effects of Obamacare, promote positive solutions to improve access to quality, affordable care and ensure we have a health system that best serves the needs of all Americans,” Tom Price, secretary of the Department of Health and Human Services said in a Twitter message.
But the new rule, which had been widely expected, was actually begun by the outgoing Obama administration. In part, it is an effort to address complaints by insurers that consumers were “gaming” the system to purchase coverage only when they were sick and then dropping it when they were healthy.Use Our Content This KHN story can be republished for free (details).
To combat that, the regulation makes it harder for patients to sign up outside of annual open enrollment periods and would allow insurers to collect past-due premiums before starting coverage for a new year. It would also shorten the annual enrollment period by half, from three months to 45 days, ending right between Thanksgiving and Christmas. And it would give insurers more flexibility in the types of plans they offer and return regulation of the size and adequacy of health care provider networks to the states.
But it remains unclear whether the action will be too little, too late to ensure insurance is available next year. That would be necessary to keep congressional Republicans’ promises that people “do not get the rug pulled out from under them” during the transition to a new program, as House Speaker Paul Ryan (R-Wis.) says frequently.
On Tuesday, Humana announced it would stop selling policies in the health exchanges at the end of this year, and on Wednesday Mark Bertolini, the CEO of Aetna, suggested his firm might follow suit, repeating GOP charges that the individual market exchanges are in a “death spiral” where only sick people buy coverage.
While Humana was not a major player in the state exchange market — it only sold policies in 11 states for 2017 — its exit could leave at least 16 counties in Tennessee, including Knoxville, with no insurance company offering policies on the health exchange, according to data from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
That alarmed Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, who has been one of the leading voices in Congress advocating a slower repeal and replace strategy.
“Yesterday’s news from Humana should light a fire under every member of Congress to work together to rescue Americans trapped in the failing Obamacare exchanges before they have no insurance options next year,” Alexander said in a statement.
Last year Aetna’s Bertolini also cited losses in the market as the reason for the company’s scaling back participation in the exchanges, although in an unrelated case, a judge’s ruling later said the decision had at least as much to do with pushing federal officials to allow Aetna to merge with Humana. On Monday that merger was officially called off after being blocked by a judge.
The new rules were greeted with cautious optimism by insurance industry trade groups.
“While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers,” Marilyn Tavenner, president and CEO of America’s Health Insurance Plans, said in a statement.
The Alliance of Community Health Plans, which represents nonprofit insurers, called the regulation “a promising first step.” But in a statement, president and CEO Ceci Connolly warned that the rule “does not resolve all of the uncertainty for plans and patients alike. Without adequate funding it will be extremely difficult to provide high-quality, affordable coverage and care to millions of Americans.”
Groups representing patients, however, were less happy with the changes. They argue that the rules could result in higher out-of-pocket costs.
Ron Pollack, executive director of the consumer group Families USA, said the new administration “is deliberately trying to sabotage the Affordable Care Act, especially by making it much more difficult for people to enroll in coverage.”
Sick people are likely to jump through any hoops required to get coverage, but healthy people are less inclined to sign up when it is more difficult. So by making it harder for healthy people to enroll, said Pollack, “they are creating their own death spiral that would deter young adults from gaining coverage, thereby driving up costs for everyone.”
And the American Cancer Society said that the new rules could hurt cancer patients in particular — for example, when they need to purchase new coverage after becoming too sick to work or moving to be closer to health providers. The proposed changes “would require documentation that is often challenging to quickly obtain,” and could “delay a patient’s treatment and jeopardize a person’s chance of survival,” said a statement from Chris Hansen, president of the society’s Cancer Action Network.
Unless the new administration changes the date, insurers must decide by May 3 if and where they will sell insurance for next year on the state exchanges.
Meanwhile, the Republican-led Congress remains in a deadlock between conservatives in the House, who want to repeal the health law as soon as possible, and moderates in the Senate like Alexander, who want to wait until there is agreement on what will replace it.
“We should just do what we said we would do,” Rep. Raul Labrador (R-Idaho) told reporters on Tuesday.
Conservatives say, at a minimum, Congress should pass the partial repeal bill it passed in 2015 that President Barack Obama vetoed. That measure would eliminate the expansion of the Medicaid program, financial help for people to purchase insurance, the penalties for not having coverage, and all the taxes that pay for the program, among other things.
“Why would it be difficult to get [the Senate] to vote for something they already voted for?” asked Rep. Mark Meadows (R-N.C.).
But congressional budget scorekeepers in January said that bill, which has no replacement provisions, could result in a doubling of premiums and 32 million more people without insurance.
And Republicans in the Senate, as well as President Donald Trump, continue to say that repeal and replace should take place simultaneously.
“I thought we were embarked on an effort to replace it,” said Sen. John McCain (R-Ariz.).
Arizona will soon send a proposal to the federal government to place a five-year lifetime limit on Medicaid coverage for adults under 65 who don’t have a disability. The government should reject the proposed time limit, which would lead to coverage losses and increase hardship among Arizona’s older, low-income residents.
With the potential this year for substantial cuts in poverty reduction programs and the Affordable Care Act’s (ACA) repeal, people without a bachelor’s degree — including working-class whites — have the most at stake, our new analysis
Trump Administration’s New Health Rule Would Reduce Tax Credits, Raise Costs, For Millions of Moderate-Income Families
The Trump Administration’s new proposed rule on health care would raise premiums, out-of-pocket costs, or both for millions of moderate-income families. If finalized as proposed, the rule would reduce the amount of health care that marketplace plans have to cover.
Poverty reduction programs play a much more critical role in the economic security of working-age adults who lack a bachelor’s degree, including working-class whites, than they play for adults with a college degree. The nation’s poverty reduction programs provide extensive support to adults lacking a college degree, including working-class whites. Working-age adults without a degree, who are sometimes described as members of the working class, are far more likely than those with a degree both to have low incomes and to be lifted out of po