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For Kurdish Americans in Nashville, a Beloved Leader’s Death Prompts Vaccine Push

Kaiser Health News - 1 hour 37 min ago

On a sloppy spring day in mid-March, hundreds of Kurdish Americans gathered in a field outside Nashville, Tennessee, under a sea of black umbrellas. Some of the men carried a stretcher to an open grave, where a yellow backhoe waited.

This story is part of a partnership that includes WPLN, NPR and KHN. It can be republished for free.

In accordance with Muslim tradition, the body of Imad Doski — a prominent community leader — was buried within 24 hours of his death. He was another casualty of covid-19.

“It hit people. They saw it happen to one of them,” said Faiza Rashid, a nurse practitioner at the Amed Family Clinic, the Kurdish-run medical practice in town. “It hit home.”

Doski’s death just six weeks ago became a wake-up call for many in Nashville’s Kurdish community — the largest in the U.S. The community has been growing and thriving since a wave of Kurdish refugees started arriving 30 years ago, fleeing Saddam Hussein and the Gulf War.

Doski was part of that early wave of immigrants, and he helped start the Salahadeen Center, which serves as a mosque, religious school and community center for Nashville-area Kurds.

Doski’s untimely death — he was in his mid-50s and relatively healthy — persuaded many Kurds to be more open to the idea of vaccination, according to Rashid. After his death, the Salahadeen Center worked with the city health department to schedule on-site vaccination events.

Questions About Vaccination During Ramadan

Immigrants were expected to have more vaccine hesitancy than most Americans.

But as Kurdish residents in Nashville have started to come around, new questions emerge. A top concern is how the vaccine interacts with the religious obligations of the month of Ramadan, which runs through mid-May.

Many Muslims are careful not to break their daily sunrise-to-sunset fast, and some interpret that as refraining from anything that enters the body. The local imam weighed in, saying the vaccine does not count as nutrition. Other Muslim leaders around the world have also found ways to make an exception for the vaccine.

There’s also concern that if the post-vaccination side effects become fairly severe, such as a fever, Muslims might have to break their fast to hydrate. This is typically allowed when someone gets sick during Ramadan, but the whole day has to be made up later in the year.

Nurse practitioner Redor Abdullah said he’s been telling Muslims who hold more conservative interpretations not to risk waiting on the vaccine, even for a few more weeks.

“I would recommend you get it and make up your fast another day,” he said. “It’s better than getting the virus.”

Some Refugees Have Had Traumatic Experiences With Health Care

Nashville’s public health department has had to lean on health care workers in the Kurdish community because it doesn’t have Kurdish workers of its own.

At the Salahadeen Center vaccination events, the people giving the shots are mostly white and English-speaking, with one standout exception: Sumaya Muhamed, a pre-med college student who is Kurdish American. She’s been trained to give covid shots because she also works part time at a pharmacy.

“About 70% of the people who go to Salahadeen are just Kurdish-speaking, so they would all be at my table, because nobody else knew how to help them,” she said.

Their need for cultural assistance goes beyond practical questions about safety. Muhamed explains that many of them are sorting through past trauma related to time spent in refugee camps, and the medical care they received there.

Most of the older Kurds in the Nashville area arrived in the U.S. as refugees, after years spent waiting in various refugee camps. While there, vaccinations were not a choice. And they weren’t always seen as safe. Muhamed said many developed infections.

“I don’t blame them,” Muhamed said of first-generation arrivals. “I would be asking the same thing if I went through that too.”

Speaking Kurdish and Being Patient Can Help

Her own mother, Suad Abdulla, has been among the hesitant, or at least those who have been slow to get a covid shot. These days, Abdulla works as an English-language instructor in Nashville’s public schools, but as a child she lived in refugee camps in Turkey and has scars from vaccinations on both arms.

“They were not switching syringes [between patients]. They were just putting it over the fire to sanitize it and use[d] the same needle to inject us with the vaccinations,” she said.

At this point, it’s not a question for Abdulla of whether covid is a serious threat. She knows it is: Her uncle spent weeks in the hospital with a severe case.

Still, she felt reluctant to get the vaccine and concerned that there could be long-term side effects that aren’t yet known.

“We want to be fully knowledgeable with what we are putting in our body,” she said. “We want solid data to give us evidence that this will work and won’t cause adverse effects that are worse than the virus itself.”

And yet, daughter Sumaya, with her pre-med knowledge and her pharmacy work experience, kept talking to her about it, explaining how the vaccines work and emphasizing how effective they’re proving to be.

It took a while to convince her — many weeks after teachers first became eligible to get their vaccine in Tennessee. “But eventually she gave in, thankfully,” Muhamed said.

Half-kidding, her mother said she would take the vaccine on one condition — that her daughter give it to her. So Muhamed saw her opening and, at a recent Salahadeen Center event, gave her mom the first dose before she could change her mind.

This story is part of a partnership that includes WPLN, NPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Salesforce, Google, Facebook. How Big Tech Undermines California’s Public Health System.

Kaiser Health News - 1 hour 37 min ago

SACRAMENTO, Calif. — California Gov. Gavin Newsom has embraced Silicon Valley tech companies and health care industry titans in response to the covid-19 pandemic like no other governor in America — routinely outsourcing life-or-death public health duties to his allies in the private sector.

This story also ran on Protocol. It can be republished for free.

At least 30 tech and health care companies have received lucrative, no-bid government contracts, or helped fund and carry out critical public health activities during the state’s battle against the coronavirus, a KHN analysis has found. The vast majority are Newsom supporters and donors who have contributed more than $113 million to his political campaigns and charitable causes, or to fund his policy initiatives, since his first run for statewide office in 2010.

For instance, the San Francisco-based software company Salesforce — whose CEO, Marc Benioff, is a repeat donor and is so tight with the governor that Newsom named him the godfather of his first child — helped create My Turn, California’s centralized vaccine clearinghouse, which has been unpopular among Californians seeking shots and has so far cost the state $93 million.

Verily Life Sciences, a sister company of Google, another deep-pocketed Newsom donor, received a no-bid contract in March 2020 to expand covid testing — a $72 million venture that the state later retreated on. And after Newsom handed another no-bid testing contract — now valued at $600 million — to OptumServe, its parent company, national insurance giant UnitedHealth Group dropped $100,000 into a campaign account he can tap to fight the recall effort against him.

Newsom’s unprecedented reliance on private companies — including health and technology start-ups — has come at the expense of California’s overtaxed and underfunded public health system. Current and former public health officials say Newsom has entrusted the essential work of government to private-sector health and tech allies, hurting the ability of the state and local health departments to respond to the coronavirus pandemic and prepare for future threats.

“This outsourcing is weakening us. The lack of investment in our public health system is weakening us,” said Flojaune Cofer, a former state Department of Public Health epidemiologist and senior director of policy for Public Health Advocates, which has lobbied unsuccessfully for years for more state public health dollars.

“These are companies that are profit-driven, with shareholders. They’re not accountable to the public,” Cofer said. “We can’t rely on them helicoptering in. What if next time it’s not in the interest of the business or it’s not profitable?”

Kathleen Kelly Janus, Newsom’s senior adviser on social innovation, said the governor is “very proud of our innovative public-private partnerships,” which have provided “critical support for Californians in need during this pandemic.”

State Health and Human Services Secretary Dr. Mark Ghaly echoed the praise, saying private-sector companies have filled “important” roles during an unprecedented public health crisis.

The state’s contract with OptumServe has helped dramatically lower covid test turnaround times after a troubled start. Another subsidiary of UnitedHealth Group, OptumInsight, received $41 million to help California rescue its outdated infectious disease reporting and monitoring system last year after it crashed.

“Not only are we much better equipped on all of these things than we were at the beginning, but we are also seeing some success,” Ghaly said, “whether it’s on the vaccination front, which has really picked up and put us in a place of success, or just being able to do testing at a broad scale. So, I feel like we’re in a reasonable position to continue to deal with covid.”

The federal government finances most public health activities in California and significantly boosted funding during the pandemic, but local health departments also rely on state and local money to keep their communities safe.

In his first year as governor, the year before the pandemic, Newsom denied a budget request from California’s 61 local public health departments to provide $50 million in state money per year to help rebuild core public health infrastructure — which had been decimated by decades of budget cuts — despite warnings from his own public health agency that the state wasn’t prepared for what was coming.

After the pandemic struck, Newsom and state lawmakers turned away another budget request to support the local health departments driving California’s pandemic response, this time for $150 million in additional annual infrastructure funding. Facing deficits at the time, the state couldn’t afford it, Newsom said, and federal help was on the way.

Yet covid cases continued to mount, and resources dwindled. Bare-bones staffing meant that some local health departments had to abandon fundamental public health functions, such as contact tracing, communicable disease testing and enforcement of public health orders.

“As the pandemic rages on and without additional resources, some pandemic activities previously funded with federal CARES Act resources simply cannot be sustained,” a coalition of public health officials warned in a late December letter to Newsom and legislative leaders.

Newsom has long promoted tech and private companies as a way to improve government, and has leaned on the private sector throughout his political career, dating to his time as San Francisco mayor from 2004 to 2011, when he called on corporations to contribute to his homelessness initiatives.

And since becoming governor in January 2019, he has regularly held private meetings with health and tech executives, his calendars show, including Facebook CEO Mark Zuckerberg, Google CEO Sundar Pichai and Apple CEO Tim Cook.

“We’re right next door to Silicon Valley, of course, so technology is our friend,” Newsom wrote in his 2013 book, “Citizenville,” arguing that “government needs to adapt to this new technological age.”

With California’s core public health infrastructure already gutted, Newsom funneled taxpayer money to tech and health companies during the pandemic or allowed them to help design and fund certain public health activities.

Other industries have jumped into covid response, including telecommunications and entertainment, but not to the degree of the health and technology sectors.

“It’s not the ideal situation,” said Daniel Zingale, who has steered consequential health policy decisions under three California governors, including Newsom. “What is best for Google is not necessarily best for the people of California.”

Among the corporate titans that have received government contracts to conduct core public health functions is Google’s sister company Verily.

Google and its executives have given more than $10 million to Newsom’s gubernatorial campaigns and special causes since 2010, according to state records. It has infiltrated the state’s pandemic response: The company, along with Apple, helped build a smartphone alert system called CA Notify to assist state and local health officials with contact tracing, a venture Newsom hailed as an innovative, “data-driven” approach to reducing community spread. Google, Apple and Facebook are sharing tracking data with the state to help chart the spread of covid. Google — as well as Facebook, Snapchat, TikTok, Twitter and other platforms — also contributed millions of dollars in free advertising to California, in Newsom’s name, for public health messaging.

Other companies that have received lucrative contracts to help carry out the state’s covid plans include health insurance company Blue Shield of California, which received a $15 million no-bid contract to oversee vaccine allocation and distribution, and the private consulting firm McKinsey & Co., which has received $48 million in government contracts to boost vaccinations and testing and work on genomic sequencing to help track and monitor covid variants. Together, they have given Newsom more than $20 million in campaign and charitable donations since 2010.

Private companies have also helped finance government programs and core public health functions during the pandemic — at times bypassing local public health departments — under the guise of making charitable or governmental contributions, known as “behested payments, in Newsom’s name. They have helped fund vaccination clinics, hosted public service announcements on their platforms, and paid for hotel rooms to safely shelter and quarantine homeless people.

Facebook and the Chan Zuckerberg Initiative, the philanthropic organization started by Facebook founder Mark Zuckerberg and his wife, Priscilla Chan, have been among the most generous, and have given $36.5 million to Newsom, either directly or to causes and policy initiatives on his behalf. Much of that money was spent on pandemic response efforts championed by Newsom, such as hotel rooms and child care for front-line health care workers; computers and internet access for kids learning at home; and social services for incarcerated people leaving prison because of covid outbreaks.

Facebook said it is also partnering with the state to deploy pop-up vaccination clinics in hard-hit areas like the Central Valley, Inland Empire and South Los Angeles.

In prepared statements, Google and Facebook said they threw themselves into the pandemic response because they wanted to help struggling workers and businesses in their home state, and to respond to the needs of vulnerable communities.

Venture capitalist Dr. Bob Kocher, a Newsom ally who was one of the governor’s earliest pandemic advisers, said private-sector involvement helped California tremendously.

“We’re doing really well. We got almost 20 million people vaccinated and our test positivity rate is at an all-time low,” Kocher said. “Our public health system was set up to handle small-scale outbreaks like E. coli or hepatitis. Things work better when you build coalitions that go beyond government.”

Public health leaders acknowledge that private-sector participation during an emergency can help the state respond quickly and on a large scale. But by outsourcing so much work to the private sector, they say, California has also undercut its already struggling public health system — and missed an opportunity to invest in it.

Take Verily. Newsom tapped the company to help expand testing to underserved populations, but the state chose to end its relationship with the company in January after county health departments rejected the partnership, in part because testing was not adequately reaching Black and Latino neighborhoods. In addition to requiring that residents have a car and Gmail account, Verily was seen by many local health officials as an outsider that didn’t understand the communities.

It takes years of shoe leather public health work to build trusted relationships within communities, said Dr. Noha Aboelata, founder and CEO of the Roots Community Health Center in the predominantly Black and Latino neighborhood of East Oakland.

“I think what’s not fine is when these corporations are claiming to be the center of equity, when in fact it can manifest as the opposite,” she said. “We’re in a neighborhood where people walk to our clinic, which is why when Verily testing first started and they were drive-up and you needed a Gmail account, most of our community wasn’t able to take advantage of it.”

To fill the gap, the clinic worked with Alameda County to offer old-fashioned walk-up appointments. “We’re very focused on disparities, and we’re definitely seeing the folks who are most at risk,” Aboelata said.

The state took a similar approach to vaccination. Instead of giving local health departments the funding and power to manage their own vaccination programs with community partners, it looked to the private sector again. Among the companies that received a vaccination contract is Color Health Inc., awarded $10 million to run 10 vaccine clinics across the state, among other covid-related work. Since partnering with California, Color has seen its valuation soar to $1.5 billion — helping it achieve “unicorn” start-up status.

As the state’s Silicon Valley partners rake in money, staffing at local health departments has suffered, in part because they don’t have enough funding to hire or replace workers. “It is our biggest commodity and it’s our No. 1 need,” said Kat DeBurgh, executive director of the Health Officers Association of California.

With inadequate staffing to address the pandemic, the state is falling further behind on other basic public health duties, such as updating data systems and technology — many county health departments still rely on fax machines to report lab results — and combating record-setting levels of sexually transmitted diseases such as syphilis.

“We’ve put so many resources into law enforcement and private tech companies instead of public health,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. “This is having a devastating impact.”

Dr. Karen Smith, former director of the state Department of Public Health, left the state in July 2019 and now is a consultant with Google Health, one of Big Tech’s forays into the business of health care.

She believes Silicon Valley can improve the state’s crumbling public health infrastructure, especially when it comes to collecting and sharing data, but it can’t be done without substantial investment from the state. “Who the heck still uses fax? Public health doesn’t have the kind of money that tech companies have,” said Smith, who said she wasn’t speaking on behalf of Google.

Without adequate funding to rebuild its infrastructure and hire permanent workers, Smith and others fear California isn’t prepared to ride out the remainder of this pandemic — let alone manage the next public health crisis.

Statewide public health advocacy groups have formed a coalition called “California Can’t Wait” to pressure state lawmakers and Newsom to put more money into the state budget for local public health departments. They’re asking for $200 million annually. Newsom will unveil his latest state budget proposal by mid-May.

“We’re in one of those change-or-die moments,” Capitol health care veteran Zingale said. “Newsom has been at the vanguard of the nation in marshaling the help of our robust technological private sector, and we’re thankful for their contributions, but change is better than charity. I don’t want to show ingratitude, but we should keep our eyes on building a better system.”

KHN data editor Elizabeth Lucas and California politics correspondent Samantha Young contributed to this report.

Methodology: How KHN compiled data about political spending and the role of technology and health care companies in California’s covid response.

Private-sector companies from Silicon Valley and the health care industry have participated in California’s public health response to covid-19 in a variety of ways, big and small. Some have received multimillion-dollar contracts from the state of California to perform testing, vaccination and other activities. Others have donated money and resources to the effort, such as free public health advertising time.

KHN identified the companies that received pandemic-related contracts or work from the state by filing Public Records Act requests with state agencies; searching other sources, including California’s “Released COVID-19 Response Contracts” page; and contacting state agencies and companies directly.

We then searched the California Fair Political Practices Commission website for tech and health care companies that didn’t receive contracts but played a role in the state’s pandemic response by donating money and resources. Through what are known as “behested payments,” these companies donated to charitable causes or Gov. Gavin Newsom’s policy initiatives on his behalf. These contributions included money to help fund and design state public health initiatives such as quarantine hotel rooms.

Based on those searches, we found at least 30 health or technology companies that have participated in the state’s pandemic response: Google and its sister company Verily Life Sciences; Salesforce; Facebook; Apple; McKinsey & Co.; OptumServe and OptumInsight — subsidiaries of national health care company UnitedHealth Group; Netflix; Pandora; Spotify; Zoom Video Communications Inc.; electric car manufacturer BYD; Bloom Energy; Color Health Inc.; DoorDash; Twitter; Amazon; Accenture; Skedulo; Primary.Health; Pfizer; HP Inc.; Microsoft; Snapchat; Blue Shield of California; Kaiser Permanente; Lenovo Inc.; YouTube; and TikTok. The Chan Zuckerberg Initiative, the philanthropic organization started by Facebook founder Mark Zuckerberg and his wife, Priscilla Chan, also participated.

We then searched the California secretary of state’s website to determine which of those companies, and their executives, gave direct political contributions to Newsom’s personal campaign accounts and a ballot measure account run by the governor called “Newsom’s Ballot Measure Committee” during his five campaigns for statewide office since 2010, plus the ongoing recall effort against him.

We found that at least 24 of the tech or health companies that participated in the state’s pandemic response, or their executives, gave direct political contributions to Newsom, made behested payments in his name or both.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Telemedicine Is a Tool — Not a Replacement for Your Doctor’s Touch

Kaiser Health News - 1 hour 37 min ago

Earlier in the pandemic it was vital to see doctors over platforms like Zoom or FaceTime when in-person appointments posed risks of coronavirus exposure. Insurers were forced — often for the first time — to reimburse for all sorts of virtual medical visits and generally at the same price as in-person consultations.

This story also ran on The New York Times. It can be republished for free.

By April 2020, one national study found, telemedicine visits already accounted for 13% of all medical claims compared with 0.15% a year earlier. And covid hadn’t seriously hit much of the country yet. By May, Johns Hopkins’ neurology department was conducting 95% of patient visits virtually compared with just 10 such visits weekly the year before, for example.

Covid-19 let virtual medicine out of the bottle. Now it’s time to tame it. If we don’t, there is a danger that it will stealthily become a mainstay of our medical care. Deploying it too widely or too quickly risks poorer care, inequities and even more outrageous charges in a system already infamous for big bills.

The pandemic has demonstrated that virtual medicine is great for many simple visits. But many of the new types of telemedicine being promoted by start-ups more clearly benefit providers’ and investors’ pockets, rather than yielding more convenient, high-quality and cost-effective medicine for patients.

“Right now there’s a lot of focus on shiny objects — ideas that sound cool — rather than solving problems,” said Dr. Peter Pronovost, a national expert in medical innovation at University Hospitals Cleveland Medical Center, who has written about finding the value of virtual medicine. “We know preciously little about its impact on quality.”

Even so, the financial world is abuzz with investment opportunities. In the first six months of 2020, telehealth companies raised record amounts of funding, with five start-ups each raising more than $100 million.

There are now telehealth apps that target niche markets like the mental health of pregnant women. Others provide medicines, like HIV prevention pills, after a virtual consultation with their doctors. You can even do a digital eye appointment, meet with your dentist virtually to monitor your oral health and orthodontic progress, and send a dermatologist a photo of a suspicious mole.

With telemedicine generously reimbursed, many practices are offering — even encouraging — patients to visit virtually. But, intentionally or not, that choice becomes a revenue multiplier, adding to patient expense.

When he noticed a curious rash, a relative was first directed to a practice’s telemedicine portal and billed $235 for a five-minute video appointment. Since rashes are often hard to evaluate in two dimensions, he was told he needed to see a doctor in person for the diagnosis and then was charged $460 more for that visit. I worry that pandemic-era reimbursement practices have taken traditionally free screening calls and rebranded them as billed visits, with no value added.

Going forward, some types of virtual visits will deserve insurance coverage. Think of follow-up appointments to check blood pressure or an arrhythmia, in which measurements can now be collected at a pharmacy or at home and transmitted to the physician digitally.

For most patients, in-person visits were required in large part because it was the only way a doctor could bill. But they are colossal time sucks, and for people with disabilities they created hardship. After a head injury last April — when I couldn’t yet drive — I was grateful for some insurance-reimbursed virtual visits with doctors and physical therapists.

But there are things that virtual medicine can miss, studies suggest.

One study showed that commercial telemedicine services were much more likely to prescribe antibiotics for children’s respiratory infections than a primary care doctor would be at an in-person visit. That’s in part because if you can’t see into the ear to observe a bulging drum, for example, the safer course is to overtreat — even though that’s contrary to prescribing guidelines intended to prevent antibiotic resistance.

An internist depresses the tongue and looks for pus on the tonsils to detect possible strep throat. A surgeon suspects appendicitis by pushing on the belly to see if there’s pain with rapid release.

Can psychiatrists develop a therapeutic relationship with a new patient equally well over Zoom? In some cases, sure. But better diagnosing of my own post-injury gait problems required office visits with hands-on maneuvers, like checking my reflexes and feeling my joints move.

“There is still real value in being in the same room, in touch, in the laying on of hands,” Dr. Pronovost said. Studies show that such interactions build trust, increasing the likelihood that patients will comply with treatment.

Telemedicine also raises new questions of equity. Even though it promises improved access for people in rural and underserved areas, video visits require high-speed internet, which is less common among the same groups. Alternatively, will the poor get mostly telemedicine clinics (cheaper, since no front-desk staff is needed), while those with good insurance have easy access to doctors’ offices?

Insurers are already rolling back their willingness from earlier in the pandemic to pay for telehealth visits. And providers and insurers are battling over reimbursement levels. Is a video call worth the same as an in-person doctor’s visit? If a commercial telemedicine-only doctor determines a patient requires an in-person assessment, is the fee discounted or waived? And how is a smart referral done if that telemedicine provider is thousands of miles away?

There is much to be resolved and fast, with scientific evidence and doctors, hopefully, driving the decisions. If we allow the market to make the choice, we risk preserving those telemedicine services that make money for business and providers — or save it for insurers — and lose those that most benefit patients.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Study: Massachusetts Leads In Stimulant Prescriptions 

CommonHealth (WBUR) - Wed, 05/05/2021 - 5:29pm

Massachusetts has the highest rate of prescriptions for stimulants among 26 representative states reviewed by a federal agency. The numbers, pulled from prescription drug monitoring programs, include medications to treat ADHD such as Adderall, Ritalin and Concerta.

Categories: Health Care

New Acquisition: Justinian’s Institutes in Emblemata, Johannes Buno’s Memoriale Institutionum Juris

In Custodia Legis - Wed, 05/05/2021 - 3:16pm

This post was created with the assistance of Elizabeth Korres, Library Technician in the Law Library’s Global Legal Collection Directorate.

Memorization is an inevitable part of studying law, and it has been for a very long time. To grapple with this, authors have tried to offer students strategies for memorization that will make learning the law a little more manageable. Take, for example, an item that the Law Library recently acquired for its rare books collection: the memorable legal study aid, Memoriale Insitutionum Juris (Ratzeburg, 1672), written by the seventeenth-century German minister and secondary school instructor Johannes Buno.

Title page of Johannes Buno’s Memoriale Institutionum Juris. Ratzeburg: Typis Exscripsit Nicolaus Nissen, 1672. Photo by Nathan Dorn.

The book is an example of what Buno called his Emblematische Lehrmethode, or emblematic teaching method, which was a way of using emblemata to help students memorize their lessons. Originally introduced by the French humanist jurist Andrea Alciato in his 1531 publication Emblematum Liber, emblemata were exceedingly popular in renaissance Europe. Essentially, emblemata are formed by the combination of a picture with a short motto and an epigram. They usually incorporated vignettes from fables and mythology. Part of their novelty was that by combining images and words, an author could allow the interplay of these components to communicate ideas by implication and suggestion.

Buno first published on the use of emblemata for teaching in 1649, in a book that taught world history and the history of the Christian church through fables and pictures. The way he used emblemata was to create an image that captured, often in an unexpected or comical way, some part of the meaning of a passage in the text he is teaching. This was based on a well-known strategy for memorization. The idea was that by associating the ideas that you are trying to memorize with strange or shocking images you will be more likely to remember them. It is a strategy that goes back to antiquity but is often traced through the works of the renaissance philosopher and magician Giordano Bruno, whose work helped to popularize the ars memorativa  – or the art of memory. Buno’s innovation was to apply this strategy to memorizing canonical textbooks passage by passage. Over the course of his life, Buno created a number of works that related to the law. In three books in particular (see below), he covered the contents of the major works of Roman law. This book, Memoriale institutionum juris, covers the contents of Justinian’s Institutes, which was used as an introduction to Roman law.

Foldout with illustrations for Books I-IV of Justinian’s Institutes. Photo by Ellie Korres.

In the following example, taken more or less at random from the work, you can see how Buno’s system works. The item appears in the lower left-hand quadrant of the foldout depicted above. It is in the section dedicated to book III of the Institutes. A close-up of that section can be seen in the image below. The item is labeled with a number 8 and it has the word “Habit” printed next to it. Typographically, it appears as “HAbit”.

Detail of the foldout containing Buno’s illustrations for Book III of Justinian’s Institutes. Of special interest is the item numbered 8 in which a child holds out a hat while a man wearing a hat looks on. Photo by Ellie Korres.

For each illustration on the foldout, Buno gives an explanation on a nearby page in a column under the heading “imaginum explicatio,” or “explanation of the images.” For this image, Buno explains that the word “Habit” should make us think of the hats that you see in the image. He writes, “Habitus libertorum olim erat pileus,” which means, “The manner of dress of freedmen was once the hat called a pileus.” Roman law recognized slavery. This particular image relates to the chapter in the Institutes which lays out the laws of inheritance as they relate to freedmen [formerly enslaved people]. In the Roman Empire, a pileus was a hat that was a sign of a freedman’s freedom. It showed that a freedman had achieved the status of a Roman citizen. Still, freedmen were not entirely independent. They were counted as part of their enslaver’s household. The enslaver could even, under some circumstances, inherit the freedman’s property.

A close-up image of a boy, the son of the freedman, and a man, the former enslaver, standing together on a hat. Photo by Ellie Korres.

The image shows a boy, reaching out toward or holding a hat. It also shows a man standing near him who is similarly wearing a hat. The two in turn are standing on a hat. Buno explains that the boy is the son of a freedman, and that the man is the enslaver (who, he says, you can identify by the luxurious quality of his clothes). The fact that they both have a hat is meant to remind us that they share something under rules of inheritance as they relate to freedmen. The son of a freedman inherits not only his father’s status as a free man, but also his father’s wealth. The enslaver too, however, can inherit the freedman’s wealth where the freedman has no other heir. The image depicts both the enslaver, and the freedman’s son on a single hat because “ambo stant in pileo tanquam in hereditate,” or “as both stand on [lit. “in”] the pileus, likewise they stand in inheritance.”

A foldout engraving from Buno’s Memoriale Institutionum Juris. Photo by Nathan Dorn.

The book is in two parts and it contains five foldout plates of illustrations. The work, along with the others in  the series (listed below), is an artistic treasure that stands out in the literature of its day for its playful approach to the law.

Buno, Johannes [1617-1697]. Memoriale Institutionum Juris… Ratzeburg: Typis Exscripsit Nicolaus Nissen, 1672.

Buno, Johannes [1617-1697].  Memoriale Juris Civilis Romani… Hamburg: Typis exscripsit G. Rebenlin, prostat Guelferbyti apud C. Bunonis heredes, 1673-1674.

Buno, Johannes [1617-1697]; [Justinian I (483-565 CE), Emperor of the East].  Memoriale Codicis justinianei, Authenticarum seu novellarum et consuetudinum feudorum…  Hamburg: Typis exscripsit G. Rebenlin, prostat Guelferbyti apud C. Bunonis heredes, 1673-1674.


“Buno, Johannes,” in Allgemeine Deutsche Biographie, v. 3 (1876), p. 540–541.




Categories: Research & Litigation

Walk-Ins Welcomed At Mass Vax Sites Starting Monday

CommonHealth (WBUR) - Wed, 05/05/2021 - 1:56pm

Six of the state's mass vaccination sites will begin offering shots on a walk-up basis next Monday, Gov. Charlie Baker said Wednesday.

Categories: Health Care

Worcester Field Hospital Demobilizing

CommonHealth (WBUR) - Wed, 05/05/2021 - 11:26am

The 220-bed field hospital was first set up last spring, then reopened in December to treat patients during a second surge of coronavirus cases. It stopped taking new patients in March but remained in place and ready to reopen in the event of another surge.

Categories: Health Care

Covid Shot in the Arm Not Enough to Keep Pharmacies in Business

Kaiser Health News - Wed, 05/05/2021 - 5:00am

Tobin’s pharmacy and department store had already stocked its shelves with Easter and Mother’s Day items last spring, and the staff had just placed the Christmas orders. The shop in Oconomowoc, Wisconsin, had been operating on a razor’s edge as retail sales moved online and mail-order pharmacies siphoned off its patients. It was losing money on 1 out of 4 pill bottles filled, so the front of the store, where it sold clothing, cosmetics and jewelry, had been compensating for pharmacy losses for years.

This story also ran on Fortune. It can be republished for free.

“And then covid hit,” said Dave Schultz, who co-owned the store with his brother. “And that was the final straw.”

The covid-19 pandemic sank many businesses in 2020, particularly those relying on in-person sales to stay afloat. For pharmacies — especially independent pharmacies — the pandemic lockdowns exacerbated long-standing economic pressures. Many small owner-operated pharmacies adapted quickly, delivering their traditional amenities in safer ways or capitalizing on new services created by the pandemic, such as covid testing and vaccinations. But others, like Tobin’s, became casualties of the pandemic, closing their doors for good.

It’s too early to quantify just how many pharmacies succumbed to covid and assess how patients will be affected. The total number of pharmacies has declined less than 1% over the past five years, as pharmacy chains get larger while independent community pharmacies — often the last place left to fill a prescription in some small towns — go under. The Rural Policy Research Institute found that 1,231 independently owned rural pharmacies, about 16%, closed for good from 2003 to 2018, well before the pandemic pinch. And according to the Drug Channels Institute, after five years of declines, the number of urban and rural independent pharmacies dipped below 20,000 for the first time in 2020.

Revenue from covid testing and vaccinations may help keep some independents afloat, but that comes with added costs and logistical challenges.

“Pharmacies are struggling,” said Harry Lattanzio, president of PRS Pharmacy Services, a consulting firm in Latrobe, Pennsylvania. “We’re getting calls from a lot more pharmacy owners that want to sell their stores. They’ve had enough.”

Most pharmacies, he said, saw a decline in prescriptions last year as customers hesitated to visit their doctors for anything but emergencies. That drop in business also meant fewer sales of over-the-counter medicines and ancillary items sold by the stores. Meanwhile, pharmacies had to buy protective equipment to keep staffers and customers safe and beef up their technology to address the new reality.

Lattanzio said some independent pharmacies, which had always preferred the personal touch of having staff members answer the phones, have had to invest in new systems to handle thousands of calls a day from people seeking vaccines. Costs rose even as revenues dropped.

“For the most part, they lost money,” Lattanzio said. “If you didn’t lose money, you did something really right.”

When Lattanzio opened his first pharmacy 20 years ago, he saw gross profit margins of 36%. Now independent pharmacies are fortunate to see margins of 3% to 5%, if they survive the pandemic at all. Much of that decline comes from the impact of pharmacy benefit managers, which manage commercial and public health plans’ prescription drug reimbursements to pharmacies. Those PBMs, often aligned with large drugstore chains, systematically squeezed the profits out of independent pharmacies. That left many smaller chains or unaffiliated pharmacies unable to bear the added hit from the pandemic.

“I’m afraid to see the outcome,” said Joe Moose, co-owner of Moose Pharmacy, a chain of seven drugstores on the outskirts of Charlotte, North Carolina. “The delay in payments, the increased cost to keep operating in the early days of this, combined with the fact that reimbursement is so poor already — covid may be the final nail in the coffin for some of us.”

Moose Pharmacy is trying to adapt. When it had to stop in-store purchases during the pandemic, the chain expanded curbside services and hired additional drivers. Home deliveries tripled. Workers ferried food, toilet paper, paper towels and shampoo to customers.

“We had to build out our website. We put in technology so that people could text us from the parking lot. It had to be HIPAA-compliant,” said Moose, who owns the chain with his brother. “And keep in mind that all of that is happening at no change in reimbursement.”

Covid also interrupted the medication supply chain. In normal times, the pharmacy’s supply of drugs is automated, so when it dispenses medicines, replacements show up in the next day’s delivery. But Moose and his staff had to resort to the old way of calling up five or six wholesalers to see who had the drugs in stock.

When covid testing was scarce, the pharmacies taught their employees to perform rapid tests. Once vaccines arrived, Moose sought out patients who couldn’t make an appointment on a smartphone, who couldn’t drive to mass vaccination clinics, or who were just afraid to leave their home.

Staffers delivered vaccines to one elderly man with cancer, whose wife had died a year earlier. He and his disabled adult son didn’t want to risk going out and contracting the virus.

“But he trusts us, and so we deliver medication to him probably every other week,” Moose said. “So it made sense that we bring the vaccine to him.”

Tripp Logan, a pharmacist in Charleston, Missouri, said one of his three pharmacies is in rural Mississippi County, which has no hospital or chain pharmacy for the 14,000 residents. There, four independent pharmacies and the county health department formed a consortium to help distribute covid vaccines.

“It started with a group text, and the next thing you know, we’re vaccinating hundreds of people a week collectively,” Logan said.

Because pharmacies can make up to $70 per covid test and $40 for each vaccination,  many pharmacies are earning new revenue to offset some of the retail losses, said Owen BonDurant, president of Independent Rx Consulting in Centerville, Ohio.

“So that has brought a significant increase in profit margins for the short term,” BonDurant said. “Covid has probably saved a lot of pharmacies. Because PBM pressure has been so hard, especially on some of these rural and inner-city pharmacies, a lot of them still are on the verge of going out of business.”

The cash infusion from the federal Paycheck Protection Program also kept many pharmacies afloat, and allowed some to make investments that better position them for the future.

“We would have had to shut down or sell because the PBMs were brutal last year, and they killed off a lot of our friends in Wisconsin,” said Dan Strause, president and chief executive officer of Hometown Pharmacy in Madison, Wisconsin. “Without the PPP, there would have been far more facing the same fate.”

Some of the changes born of necessity could stick. In a recent survey by the National Community Pharmacists Association, 3 in 5 community pharmacists said they expect more pharmacies to offer point-of-care testing after the pandemic, and more than half said additional pharmacies will give immunizations.

Hashim Zaibak, CEO of Hayat Pharmacy in Milwaukee, said his pharmacy is considering testing for the flu, strep and hemoglobin A1C levels for those with diabetes, and it will continue providing vaccinations.

“Those changes are here to stay,” Zaibak said.

Tobin’s owners considered selling their pharmacy, but finding no buyers, they shut down for good in September. Schultz said it’s unclear whether they could have survived had covid not happened — or if the vaccine revenue might have helped. He knows of two other independent pharmacies in Wisconsin that closed in the past 18 months.

“The real crux of the matter is you’re getting paid, in some cases, $60 under the cost that we end up paying for the medication,” he said. “How do you justify that portion of your business?”

Oconomowoc has one independent drugstore, two grocery store pharmacies and a Walgreens to serve its 17,000 residents. But Schultz worries about many of the older, sicker customers who relied on the personalized care his pharmacy provided. One of his former pharmacists now works at a drugstore outside of town but delivers medications to some of Tobin’s most vulnerable former customers on her way home.

“She just didn’t think they would survive going someplace else,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Hit by Higher Prices for Gear, Doctors and Dentists Want Insurers to Pay

Kaiser Health News - Wed, 05/05/2021 - 5:00am

SACRAMENTO — Treating patients has become more expensive during the pandemic, and doctors and dentists don’t want to be on the hook for all the new costs.

This story also ran on Los Angeles Times. It can be republished for free.

For instance, the box of 100 gloves that cost $2.39 in February 2020 costs $30 now, said Dr. Judee Tippett-Whyte, president of the California Dental Association, who has a private dental practice in Stockton.

Her practice used to rely on surgical masks that cost 20 cents each but has upgraded to N95 masks at $2.50 a pop. On top of that, her office is scheduling two or three fewer patients each day to accommodate physical distancing and give staff members time to disinfect between patients, she said.

“We’ve sustained a lot of financial costs,” Tippett-Whyte said. “We shouldn’t have to bear the cost of this for ourselves.”

Her argument raises a fundamental covid question: Who should pay for pandemic expenses? Should it be health care providers contending with new pandemic-era protocols or insurance companies, which may pass on their additional costs to customers in the form of higher premiums?

California’s dentist and doctor lobbies say insurance companies are flush with cash after collecting premiums during the pandemic but paying fewer claims than usual — and should foot the bill. The California Medical Association, which represents doctors, has sponsored legislation that would require insurers to reimburse medical and dental practices for pandemic-related expenses like personal protective equipment, disinfectant and the staff time required to screen patients for symptoms before an appointment.

A request by doctors to bill Medicaid and Medicare for supplies and other pandemic-related costs recently failed at the federal level. But in Washington state, a new law sponsored by the state doctors’ lobby requires private health insurers to reimburse a portion of those costs.

Insurance trade groups have opposed both state measures.

Reimbursing the cost of nonmedical supplies isn’t typically the responsibility of insurers, said Mary Ellen Grant, spokesperson for the California Association of Health Plans.

“Here we are with treatment and office levels back at pre-pandemic levels. Now they want additional payment from plans to pay for nonmedical expenses,” Grant said.

The insurance industry also points out that doctors and dentists haven’t had to fend for themselves when it comes to PPE and other pandemic-related expenses. Since April 2020, the U.S. Department of Health and Human Services has distributed $9.9 billion to more than 50,000 California medical providers through the Provider Relief Fund, out of $178 billion available nationally.

And more than 900,000 businesses in the “health care and social assistance” category — including some medical practices and dentists — have gotten Paycheck Protection Program loans from the Small Business Administration since March 2020.

A letter from insurance groups opposing California’s bill points to other assistance, such as advance payments on insurance claims from the federal government and insurance plans, state-based grants and loans, and programs that distributed free PPE to some practices.

“They’ve gotten plenty of help from the feds to cover these costs,” Grant said.

Health insurance companies saw their margins and profits skyrocket at the beginning of the pandemic when they were collecting premiums while patients put off non-urgent medical care. Those tapered off when people started returning to the doctor. Still, the nation’s largest medical insurer, UnitedHealth Group, recently announced its net income for the first quarter of 2021 was 44% higher than in the same quarter last year.

Allison Hoffman, a professor who researches health policy at the University of Pennsylvania’s law school, said she has little sympathy for health insurance companies that “made a fortune over the past year” by collecting premiums without paying for the typical number of treatments and doctors’ visits.

“We’re starting to see a kind of broader definition of what health insurance might pay for in order to keep people healthy,” Hoffman said. “There’s nothing like a public health emergency to shine a light on the fact that sometimes it’s not a prescription drug or surgical procedure that’s going to improve health.”

Late last year, the American Medical Association lobbied the federal Centers for Medicare & Medicaid Services to approve a procedure code doctors could use to bill those public insurance programs for PPE, disinfecting materials, office modifications to keep people apart, and staff time spent instructing patients before their visits and checking their symptoms. Often, when federal regulators approve a new billing code for Medicare and Medicaid, private insurers start reimbursing for the corresponding costs as well.

Allowing doctors to bill for that code would help them follow infection control protocols without further cutting into revenues, the association wrote to the federal agency.

But CMS denied the request, saying it considers payment for those costs part of the payment for the rest of the appointment, according to an agency spokesperson.

In the wake of that decision, two state medical associations took up the cause themselves.

The Washington State Medical Association backed a law, which took effect April 16, that allows health care providers to bill state-regulated private insurance companies $6.57 when they see a patient in person — on top of billing for whatever services they provide — to cover the cost of extra PPE, staff time, and materials to conduct and transport covid tests. The new rules last through the rest of the federally declared public health emergency.

For a law that put the state’s medical association and insurance association on opposite sides of the bargaining table, it was remarkably uncontentious, said state Sen. David Frockt (D-Seattle), who introduced the bill.

California’s legislation, which is still being debated, is more open-ended than Washington’s.

SB 242 doesn’t specify a dollar amount but would require private health plans regulated by the state to reimburse dental and medical practices for the “medically necessary” business expenses associated with a public health emergency.

The California Medical Association said physician practice revenues fell by one-third while PPE costs rose by 14% in the first six months of the pandemic, according to an October 2020 survey of its members. Of the survey respondents, 87% said they were worried about their financial viability.

“When you look at the record profits on some of these publicly traded companies and what they’re showing their shareholders, this would be a drop in the bucket,” association spokesperson Anthony York said of health insurers. “We’re not surprised plans don’t want to pay more, but ultimately this is a fight we’ll have in the legislature.”

The bill is intended to keep small and medium-sized practices from closing their doors in the face of rising costs, said its author, state Sen. Josh Newman (D-Fullerton). The state medical and dental associations warn that anything that adds costs and cuts into revenues could force smaller practices to close or consolidate, exacerbating physician and dentist shortages around the state.

“What I’m doing, as a legislator, is to deliberately offset some of these burdensome costs so we don’t lose physicians and practices,” Newman said. “It would be a shame if those communities lost access to health care.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Trouble Managing Money May Be an Early Sign of Dementia

Kaiser Health News - Wed, 05/05/2021 - 5:00am

After Maria Turner’s minivan was totaled in an accident a dozen years ago, she grew impatient waiting for the insurance company to process the claim. One night, she saw a red pickup truck on eBay for $20,000. She thought it was just what she needed. She clicked “buy it now” and went to bed. The next morning, she got an email about arranging delivery. Only then did she remember what she’d done.

This story also ran on The New York Times. It can be republished for free.

Making such a big purchase with no forethought and then forgetting about it was completely out of character for Turner, then a critical care nurse in Greenville, South Carolina. Although she was able to back out of the deal without financial consequences, the experience scared her.

“I made a joke out of it, but it really disturbed me,” Turner said.

It didn’t stop her, though. She shopped impulsively online with her credit card, buying dozens of pairs of shoes, hospital scrubs and garden gnomes. When boxes arrived, she didn’t remember ordering them.

Six years passed before Turner, now 53, got a medical explanation for her spending binges, headaches and memory lapses: Doctors told her that imaging of her brain showed all the hallmarks of chronic traumatic encephalopathy. CTE is a degenerative brain disease that in Turner’s case may be linked to the many concussions she suffered as a competitive horseback rider in her youth. Her doctors now also see evidence of Alzheimer’s disease and frontotemporal dementia, which affects the frontal and temporal lobes of the brain. These may have roots in her CTE.

Turner’s money troubles aren’t unusual among people who are beginning to experience cognitive declines. Long before they receive a dementia diagnosis, many people start losing their ability to manage their finances and make sound decisions as their memory, organizational skills and self-control falter, studies show. As people fall behind on their bills or make unwise purchases and investments, their bank balances and credit rating may take a hit.

Mental health experts say the covid pandemic may have masked such early lapses during the past year. Many older people have remained isolated from loved ones who might be the first to notice unpaid bills or unopened bank notices.

“That financial decision-making safety net may have been weakened,” said Carole Roan Gresenz, interim dean at Georgetown University’s School of Nursing and Health Studies, who co-authored a study examining the effect of early-stage Alzheimer’s disease on household finances. “We haven’t been able to visit, and while technology can provide some help, it’s not the same … as sitting next to people and reviewing their checking account with them.”

Even during times that aren’t complicated by a global health crisis, families may miss the signs that someone is struggling with finances, experts say.

“It’s not uncommon at all for us to hear that one of the first signs that families become aware of is around a person’s financial dealings,” said Beth Kallmyer, vice president for care and support at the Alzheimer’s Association.

Early in the disease, Kallmyer said, dementia robs people of the abilities they need to manage money: “executive functioning” skills like planning and problem-solving, as well as judgment, memory and the ability to understand context.

People who live alone may be the most likely to slip through the cracks, their lapses unnoticed, Kallmyer said. And many adult children may be reluctant to discuss personal finances with their parents, who often guard their independence.

About 6 million Americans are living with Alzheimer’s disease, the most common cause of dementia. Dementia is an umbrella term for a range of conditions associated with declines in mental abilities that are severe enough to interfere with daily life. There is no cure. Alzheimer’s, which killed more than 133,000 Americans in 2020, is the seventh-leading cause of death in the U.S.

Many people have mild symptoms for years before they are diagnosed. During this stage, before obvious impairment, they may make substantial errors managing their finances.

In Gresenz’s study, researchers linked data from Medicare claims between 1992 and 2014 with results from the federally funded Health and Retirement Study, which regularly surveys older adults about their finances, among other things. Her study, published in the journal Health Economics in 2019, found that during early-stage Alzheimer’s, people were up to 27% more likely than cognitively healthy people to experience a large decline in their liquid assets, such as savings and checking accounts, stocks and bonds.

Another study, published in JAMA Internal Medicine in November, linked Medicare claims data to the Federal Reserve Bank of New York/Equifax Consumer Credit Panel to track people’s credit card payments and credit scores. The study found that people with Alzheimer’s and related dementias were more likely to miss bill payments up to six years before they were diagnosed than were people who were never diagnosed. The researchers also noted that the people later diagnosed with dementia started to show subprime credit scores 2.5 years before the others.

“We went into the study thinking we might be able to see these financial indicators,” said Lauren Hersch Nicholas, an associate professor of public health at the University of Colorado, who co-authored the study. “But we were sort of surprised and dismayed to find that you really could. That means it’s sufficiently common because we’re picking it up in a sample of 80,000 people.”

For decades, Pam McElreath kept the books for the insurance agency that she and her husband, Jimmy, owned in Aberdeen, North Carolina. In the early 2000s, she started having trouble with routine tasks. She assigned the wrong billing codes to expenditures, filled in checks with the wrong year, forgot to pay the premium on her husband’s life insurance policy.

Everyone makes mistakes, right? It’s just part of aging, her friends would say.

“But it’s not like my friend that made that one mistake, one time,” said McElreath, 67. “Every month I was having to correct more mistakes. And I knew something was wrong.”

She was diagnosed with mild cognitive impairment in 2011, at age 56, and with early-onset Alzheimer’s two years later. In 2017, doctors changed her diagnosis to frontotemporal dementia.

Receiving a devastating diagnosis is hard enough, but learning to cope with it is also hard. Eventually both McElreath and Maria Turner put mechanisms in place to keep their finances on an even keel.

Turner, who has two adult children, lives alone. After her diagnosis, she hired a financial manager, and together they set up a system that provides Turner with a set amount of spending money every month and doesn’t allow her to make large withdrawals on impulse. She ditched her credit cards and removed eBay and Amazon from her phone.

Though not a micromanager, Turner’s financial adviser keeps an eye on her spending and questions her when something seems off.

“Did you realize you spent X?” she’ll ask, Turner said.

“And I’ll be like, ‘No, I didn’t.’ And that’s the thing. I’m aware but I’m not aware,” she added.

In 2017, Pam and Jimmy McElreath sold their insurance agency to spend more time together and moved west to Sugar Grove, in the Blue Ridge Mountains. They worked with a therapist to figure out how to ensure Pam is able to continue to do as much as possible.

These days, Pam still signs their personal checks, but now Jimmy looks them over before sending them out. The system is working so far.

“At first I was mad, and I went through this dark time,” Pam said, adding: “But the more that you come to accept your problem, the easier it is to say, ‘I need help.’”

Jimmy’s gentle approach helped. “He was so good about telling me when I did something wrong but doing it in such a kind way, not blaming me for making mistakes. We’ve been able to work it out.”

Tips for Helping a Loved One

It’s not easy to broach financial management issues with an elderly parent or other relative experiencing cognitive trouble. Ideally, you and they will have these conversations before problems develop.

As an adult child, you might mention you’ve been talking with a financial adviser about managing your own finances to ease into a conversation about what your elder is doing, said Beth Kallmyer of the Alzheimer’s Association.

Or suggest that allowing a shared financial management arrangement would eliminate the hassle of tracking and paying bills.

“Often people are open to the idea of making their lives easier,” Kallmyer said.

Whatever the approach, it’s important to plan and take steps to protect assets.

“Part and parcel of any legal or estate planning is protecting oneself in the event of incapacity,” said Jeffrey Bloom, an elder law attorney at Margolis & Bloom in the Boston area.

Specific steps depend on the family and their financial situation, but here are some to consider:

Encourage the parent in need of help to sign a financial power of attorney.

These legal documents authorize you or another person to act on a parent’s behalf in financial matters. The terms may be narrow or broad, allowing you to make all financial decisions or to perform specific duties like paying bills, making account transfers or filing taxes.

A “durable” power of attorney allows you to make decisions even if your parent becomes incapacitated. In some states, power of attorney documents are automatically considered durable.

Put assets in a trust.

A trust is a legal vehicle that can hold a range of assets and property. It can spell out how those assets are managed and distributed while people are alive or after they die.

“We do believe in the power of attorney, but we believe in the trust as an even better tool in the event of incapacity,” Bloom said.

Trusts can be tailored to a client’s concerns and provide more guidance than a power of attorney document about what money can be spent on and who has access under what circumstances, among other things.

You might be a co-trustee on major distributions, for example, or there may be rules that provide for you or others to review and be notified of any changes, Bloom said.

The Alzheimer’s Association recommends working with an attorney who specializes in trusts to ensure all laws and regulations are followed, Kallmyer said.

Have your name added as another user on a parent’s bank accounts, credit cards or other financial accounts.

This may be a convenient way to make payments or monitor activity. But a shared account can be problematic if children are sued, for example, or wish to withdraw the money for their own use.

The funds typically belong to all parties whose names are on the account. Unlike a power of attorney, the child isn’t obligated to act in a parent’s best interest.

Each of these setups may help protect a parent’s assets. But parents may not welcome what they see as interference, no matter how well meaning family members are. Typically, they can refuse to permit children’s access to their financial information or revoke permission previously granted.

Finding a balance between protecting someone and usurping their rights is hard, said Bloom. The only way to ensure financial control is to go to court to establish guardianship or conservatorship. But that is a serious step not to be taken lightly.

“You only want to do that if there’s a major risk.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Covered California dice que el seguro de salud se ha vuelto demasiado barato como para ignorarlo

Kaiser Health News - Tue, 05/04/2021 - 11:41am

Una nueva ley federal podría hacer que sea mucho más barato comprar tu propio seguro si no tienes cobertura a través de un empleador o un programa del gobierno como Medicare o Medicaid.

La ley proporciona miles de millones de dólares federales para reducir las primas de las personas que compran cobertura a través de los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Esta ayuda amplía un crédito fiscal federal creado por ACA que se puede recibir por adelantado como un descuento en tu prima, o como un reclamo en tus impuestos del año siguiente. Estos subsidios está disponible para quienes compran pólizas individuales o familiares en el mercado privado por fuera de los intercambios de ACA. Por lo tanto, si tienes un plan de salud por fuera de estos mercados, podrías ahorrar mucho dinero si cambias a uno que ofrezcan los mercados de ACA.

Si ya estás inscrito en un plan del mercado de seguros, podrías ver una cuenta más baja, en muchos casos mucho más baja, comenzando tan pronto como con tu prima de mayo.

Covered California, el mercado de seguros de salud de ACA del estado, abrió un período de inscripción especial el 12 de abril para las personas que quieran aprovechar la nueva ayuda al inscribirse o cambiar de cobertura. El período se extiende hasta diciembre. Los subsidios recientemente mejorados entran en vigencia con la cobertura que comienza el 1 de mayo. Para obtener cobertura el primer día de cualquier mes, solo necesitas inscribirte el día anterior.

Casi el 90% de los beneficiarios de Covered California ya reciben ayuda financiera, y muchos ahora recibirán más. Algunos afiliados que antes no calificaban para créditos fiscales ahora pueden ser elegibles.

Darci Gutiérrez, una agente de seguros en Dublin, California, dijo que un cliente con una familia numerosa ahorró $425 al mes en una PPO de Blue Shield en el nivel Plata, el segundo nivel más bajo de cobertura.

“Me sorprendió la cantidad de reducción de costos. Yo estaba como, ‘Santo cielo’”, dijo Gutiérrez.

Está previsto que la ayuda federal adicional se detenga después de 2022, lo que significa que tu seguro podría costarte más después.

La nueva ley también asigna dinero para brindar una cobertura prácticamente sin prima, solo en 2021, para cualquier persona que reciba beneficios por desempleo en cualquier momento durante el año.

Si ya estás inscrito en Covered California, puedes mantener tu plan y aprovechar los ahorros, o puedes comparar precios y ahorrar aún más, o cambiar a un nivel más alto de cobertura sin aumentar tu gasto mensual.

Si no cambias, Covered California calculará automáticamente tu prima más baja y verás un crédito de mayo en tu factura de junio. También obtendrás ese ahorro de manera retroactiva durante los primeros cuatro meses de 2021 en forma de una reducción adicional de la prima, en cuotas mensuales iguales, durante el resto del año.

Sin embargo, si no tienes seguro o tienes un plan de salud por fuera de los mercados de seguros de ACA, debes tomar medidas. Investiga tus opciones e inscríbete, o cambia de plan.

Para saber si reúnes los requisitos para recibir asistencia federal, inicia una sesión en el sitio

Haz clic en el botón “busca y compara” para encontrar los planes de salud disponibles para tí en tu área, junto con la prima mensual que pagarás después que se descuento tu subsidio.

También puedes hacer clic en un botón para recibir una llamada de un agente de seguros de salud certificado que puede ayudarte a resolver todo, sin cobrarte. Si no tienes una computadora, llama a línea de Covered California en español, al 800-300-0213.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

A Primary Care Physician for Every American, Science Panel Urges

Kaiser Health News - Tue, 05/04/2021 - 11:01am

The federal government must aggressively bolster primary care and connect more Americans with a dedicated source of care, the National Academies of Sciences, Engineering and Medicine warn in a major report that sounds the alarm about an endangered foundation of the U.S. health system.

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It can be republished for free.

The urgently worded report, which comes as internists, family doctors and pediatricians nationwide struggle with the economic fallout of the coronavirus pandemic, calls for a broad recognition that primary care is a “common good” akin to public education.

The authors recommend that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation’s fragmented medical system.

And the report calls on major government health plans such as Medicare and Medicaid to shift money to primary care and away from the medical specialties that have long commanded the biggest fees in the U.S. system.

“High-quality primary care is the foundation of a robust health care system, and perhaps more importantly, it is the essential element for improving the health of the U.S. population,” the report concludes. “Yet, in large part because of chronic underinvestment, primary care in the United States is slowly dying.”

The report, which is advisory, does not guarantee federal action. But reports from the national academies have helped support major health initiatives over the years, such as curbing tobacco use among children and protecting patients from medical errors.

Strengthening primary care has long been seen as a critical public health need. And research dating back more than half a century shows that robust primary care systems save money, improve people’s health and even save lives.

“We know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care,” said Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world.

Recognizing the value of this kind of care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care.

And many have reaped significant rewards. Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found.

For decades, experts here have called for this country to make a similar commitment.

But only about 5% of U.S. health care spending goes to primary care, versus an average of 14% in other wealthy nations, according to data collected by the Organization for Economic Co-operation and Development.

Other research shows that primary spending has declined in many U.S. states in recent years.

The situation grew even more dire as the pandemic forced thousands of primary care physicians — who didn’t receive the government largesse showered on major medical systems — to lay off staff members or even close their doors.

Reversing this slide will require new investment, the authors of the new report conclude. But, they argue, that should yield big dividends.

“If we increase the supply of primary care, more people and more communities will be healthier, and no other part of health care can make this claim,” said Dr. Robert Phillips, a family physician who co-chaired the committee that produced the report. Phillips also directs the Center for Professionalism and Value in Health Care at the American Board of Family Medicine.

The report urges new initiatives to build more health centers, especially in underserved areas that are frequently home to minority communities, and to expand primary care teams, including nurse practitioners, pharmacists and mental health specialists.

And it advocates new efforts to shift away from paying physicians for every patient visit, a system that critics have long argued doesn’t incentivize doctors to keep patients healthy.

Potentially most controversial, however, is the report’s recommendation that Medicare and Medicaid, as well as commercial insurers and employers that provide their workers with health benefits, ask their members to declare a primary care provider. Anyone who does not, the report notes, should be assigned a provider.

“Successfully implementing high-quality primary care means everyone should have access to the ‘sustained relationships’ primary care offers,” the report notes.

This idea of formally linking patients with a primary care office — often called empanelment — isn’t new. Kaiser Permanente, consistently among the nation’s best-performing health systems, has long made primary care central. (KHN is not affiliated with Kaiser Permanente.)

But the model, which was at the heart of managed-care health plans, suffered in the backlash against HMOs in the 1990s, when some health plans forced primary care providers to act as “gatekeepers” to keep patients away from costlier specialty care.

More recently, however, a growing number of experts and primary care advocates have shown that linking patients with a primary care provider need not limit access to care.

Indeed, a new generation of medical systems that rely on primary care to look after elderly Americans on Medicare with chronic medical conditions has demonstrated great success in keeping patients healthier and costs down. These “advanced primary care” systems include ChenMed, Iora Health and Oak Street Health.

“If you don’t have empanelment, you don’t really have continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the Center for Excellence in Primary Care at the University of California-San Francisco and has called for stronger primary care systems for decades.

Bodenheimer added: “We know that continuity of care is linked to everything good: better preventive care, higher patient satisfaction, better chronic care and lower costs. It is really fundamental.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Mississippi Raises TANF Benefits But More Improvements Needed, Especially in South

Center on Budget and Policy Priorities - Tue, 05/04/2021 - 10:11am
Mississippi, which for over 50 years provided the nation’s lowest cash assistance benefits to families with children, has increased the maximum Temporary Assistance for Needy Families (TANF) grant by $90, so a family of three with no other income will now receive $260 per month. The increase will help all children receiving TANF but especially Black children, who make up over three-fourths of Mississippi children receiving TANF. Though Mississippi has the nation’s highest child poverty rate, its TANF program does a particularly poor job of assisting families experiencing poverty. Prior to the
Categories: Benefits, Poverty

Celebrating AAPI History through the Cherry Blossoms – Pic of the Week

In Custodia Legis - Tue, 05/04/2021 - 8:30am

Washington, D.C.’s cherry blossom trees reached peak bloom at the end of March of this year, bringing springtime to the region. This week’s Pic of the Week is a close-up of one of these beautiful trees.

Close-up photo of a cluster of cherry blossom flowers at sunrise. The DC Wharf is in the background. Photo by Bailey DeSimone.

On May 1, 2012, President Barack Obama’s proclamation for Asian American and Pacific Islander Heritage Month recognized two major anniversaries. The first was the 70th anniversary of Executive Order No. 9066 (published in 7 Fed. Reg. 1407), which was later enforced through the passage of the law at ch.191, 56 Stat. 173, “An act to provide a penalty for violation of restriction or orders with respect to persons entering, remaining in, leaving, or committing any act in military areas or zones.” These actions authorized the forced relocation and internment of Japanese immigrants and Japanese-Americans living in the United States during World War II. President Obama also posthumously awarded civil rights activist Gordon Hirabayashi, who fought against this law in the Supreme Court case Hirabayashi v. United States, the Presidential Medal of Freedom.

The second anniversary commemorated was the centennial of the planting of the first cherry blossom trees in Washington, D.C. Cherry blossom trees serve as an “enduring symbol of the friendship shared between the United States and Japan.”

The Law Library of Congress’s collections contain many interesting references to the cherry blossoms and their significance. Kelly wrote about the first arrival of cherry blossom trees and the resulting Plant and Quarantine Act of 1912. Using the Guide to Law Online, I learned a bit more about D.C.’s connections to the cherry blossoms, including cherries being the official fruit of the city. The Law Library also has a guide to researching executive documents, including presidential proclamations and executive orders.

Close-up of a blooming branch of cherry blossoms. Photo by Bailey DeSimone.

I took these photographs in East Potomac Park, an extension of the National Mall, right after sunrise. A photographer across the street from me asked if I had been asked for a photography permit upon entering the park. I said no, as all the equipment I had was my phone camera.

I was curious, and checked the National Park Service’s website for more information. A decision from the U.S. District Court for the District of Columbia in Price v. Barr on January 22, 2021 determined that “the permit and fee requirements applying to commercial filming under 54 U.S.C. 100905, 43 C.F.R. Part 5, and 36 C.F.R. Part 5.5 are unconstitutional.” Currently, the National Park Service is applying interim regulations while the policy undergoes revision.

Luckily, since my photos were not for commercial use, I am able to share some of my favorite cherry blossom trees today.

Categories: Research & Litigation

Covid no discrimina por edad: dramático aumento de casos en adultos jóvenes

Kaiser Health News - Tue, 05/04/2021 - 5:43am

Después de pasar gran parte del año pasado atendiendo a pacientes de edad avanzada, los médicos están viendo un cambio demográfico claro: los adultos jóvenes y de mediana edad constituyen una parte cada vez mayor de los pacientes en las salas de covid-19 de los hospitales.

Es tanto una señal del éxito del país en la protección de los adultos mayores con la vacunación como un recordatorio urgente de que las generaciones más jóvenes pagarán un alto precio si se permite que siga habiendo brotes en todo el país.

“Ahora vemos personas de 30, 40 y 50 años, jóvenes que están realmente enfermos”, dijo el doctor Vishnu Chundi, especialista en enfermedades infecciosas y presidente del grupo de trabajo de covid de la Sociedad Médica de Chicago. “La mayoría de ellos lo superan, pero algunos no… acabo de perder a un hombre de 32 años con dos hijos, es desgarrador”.

A nivel nacional, los adultos menores de 50 años representan ahora los pacientes con covid más hospitalizados en el país, alrededor del 36% de todas las admisiones. Las personas de 50 a 64 años representan el segundo grupo con más internaciones, alrededor del 31%. Las hospitalizaciones entre los adultos mayores de 65 años se han reducido significativamente.

Aproximadamente el 32% de la población de los Estados Unidos ya está completamente vacunada, pero la gran mayoría son personas mayores de 65 años, un grupo al que se le dio prioridad en la fase inicial de inmunización.

Aunque las nuevas infecciones están disminuyendo gradualmente en todo el país, algunas regiones han enfrentado un resurgimiento del coronavirus en los últimos meses, lo que algunos han llamado una “cuarta ola”, impulsado por la variante B.1.1.7, identificada por primera vez en el Reino Unido, que se estima que es entre un 40% y un 70% más contagiosa.

Como muchos estados abandonan las precauciones por la pandemia, esta cepa más virulenta todavía tiene un amplio margen para propagarse entre la población más joven, que sigue siendo ampliamente susceptible a la enfermedad.

La aparición de cepas más peligrosas del virus en el país, Incluidas las variantes descubiertas por primera vez en Sudáfrica y Brasil, ha hecho que el esfuerzo de vacunación sea aún más urgente.

“Estamos en un juego completamente diferente”, dijo Judith Malmgren, epidemióloga de la Universidad de Washington.

El aumento de las infecciones entre los adultos jóvenes crea un “reservorio de enfermedad” que eventualmente “se extiende al resto de la sociedad”, sociedad que aún no ha alcanzado la inmunidad colectiva, y presagia un aumento más amplio de casos, dijo.

Afortunadamente, la posibilidad de morir por covid sigue siendo muy pequeña para las personas menores de 50 años, pero este grupo de edad puede enfermarse gravemente o experimentar síntomas a largo plazo después de la infección inicial. Las personas con afecciones subyacentes, como obesidad y enfermedades cardíacas, también tienen más probabilidades de enfermarse gravemente.

“B.1.1.7 no discrimina por edad, y cuando se trata de jóvenes, nuestro mensaje al respecto sigue siendo demasiado suave”, dijo Malmgren.

En todo el país, la afluencia de pacientes más jóvenes con covid ha sorprendido a los médicos que describen salas de hospital llenas de pacientes, muchos de los cuales parecen estar más enfermos de lo que se vio durante las oleadas anteriores de la pandemia.

“Muchos de ellos requieren atención en terapia intensiva”, dijo la doctora Michelle Barron, jefa de prevención y control de infecciones en UCHealth, uno de los grandes sistemas hospitalarios de Colorado.

La edad promedio de los pacientes con covid en los hospitales de UCHealth ha disminuido en más de 10 años en las últimas semanas, de 59 a 48 años, agregó Barron.

“Creo que seguiremos viendo eso, especialmente si no hay mucha aceptación de la vacuna en estos grupos”, dijo.

Si bien la mayoría de los hospitales están lejos de la avalancha de casos durante el invierno, la explosión de casos en Michigan subraya las posibles consecuencias de flexibilizar las restricciones cuando una gran parte de los adultos aún no están vacunados.

Existe una fuerte evidencia de que las tres vacunas que se están utilizando en el país rindan una buena protección contra la variante del Reino Unido.

Un estudio sugiere que la variante B.1.1.7 no causa complicaciones graves, como se pensaba anteriormente. Sin embargo, los pacientes infectados con esta variante parecen tener más probabilidades de tener más virus en sus cuerpos que aquellos con la cepa que dominaba antes, lo que puede ayudar a explicar por qué se propaga más fácilmente.

“Creemos que esto puede estar causando más de estas hospitalizaciones en personas más jóvenes”, dijo la doctora Rachael Lee en el hospital de la Universidad de Alabama-Birmingham.

El hospital de Lee también ha observado un aumento en los pacientes más jóvenes. Al igual que en otros estados del sur, Alabama tiene una tasa baja de absorción de vacunas.

Pero incluso en el estado de Washington, donde gran parte de la población está optando por vacunarse, las hospitalizaciones han aumentado constantemente desde principios de marzo, especialmente entre los jóvenes. En el área de Seattle, actualmente se interna a más personas de 20 años por covid que personas de 70, según el doctor Jeff Duchin, director de salud pública de Seattle y el condado de King.

“Todavía no tenemos suficientes adultos jóvenes vacunados para contrarrestar la mayor facilidad con la que se propagan las variantes”, dijo Duchin en una conferencia de prensa reciente.

A nivel nacional, alrededor del 32% de las personas de 40 años están completamente vacunadas, en comparación con el 27% de las personas de 30 años. Esa proporción se reduce a aproximadamente el 18% para los jóvenes de 18 a 29 años.

“Tengo la esperanza de que la curva de muerte no aumente tan rápido, pero está ejerciendo presión sobre el sistema de salud”, dijo el doctor Nathaniel Schlicher, médico de emergencias y presidente de la Asociación Médica del Estado de Washington.

Schlicher, también de unos 30 años, recuerda con horror a dos de sus pacientes recientes, cercanos a su edad y previamente sanos, que ingresaron con insuficiencia cardíaca causada por covid.

“Lo he visto de cerca y eso es lo que más me asusta”, dijo.

“Entiendo que los jóvenes se sientan invencibles, pero lo que les diría es que no tengan miedo de morir, tengan miedo de la insuficiencia cardíaca, el daño pulmonar y no poder hacer las cosas que amas hacer”.

Los médicos y los expertos en salud pública esperan que el preocupante aumento de las hospitalizaciones entre la población más joven sea temporal, algo que las vacunas contrarrestarán pronto. Solo desde el 19 de abril todos los adultos se volvieron elegibles para la vacuna.

Pero algunas encuestas nacionales preocupantes indican que una parte considerable de los adolescentes y adultos de entre 20 y 30 años no necesariamente tienen planes de vacunarse.

“Solo tenemos que hacer que sea muy fácil, sin inconvenientes”, apuntó Malmgren, el epidemiólogo de Washington. “Tenemos que pensar un poco diferente”.

Esta historia es parte de una asociación que incluye a NPR y KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Covered California Says Health Insurance Just Got Too Cheap to Ignore

Kaiser Health News - Tue, 05/04/2021 - 5:00am

If you are uninsured because health coverage seemed too expensive the last time you looked, it’s time to look again.

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A new federal law could make it a whole lot cheaper to buy your own insurance if you don’t get coverage through an employer or a government insurance program such as Medicare or Medicaid.

The law, the American Rescue Plan, provides billions of federal dollars to reduce premiums for people who buy their coverage through the insurance exchanges established by the Affordable Care Act.

The aid expands a federal tax credit created by the ACA that you can take upfront as a discount on your premium or claim when you file your taxes the following year. It is not available for those who buy individual or family policies in the open market outside an ACA exchange. So, if you are in an off-exchange health plan, you might save a lot of money by switching to one inside the exchange.

Covered California, the state’s ACA exchange, opened a special enrollment period on April 12 for people who want to take advantage of the new aid by enrolling or switching coverage. The period runs through December — 4½ months later than the Aug. 15 special enrollment end date on the federally run exchanges.

Covered California estimates the new money will reduce its customers’ monthly premium bills by an average of $180 per household. Nearly 90% of Covered California enrollees already get financial aid, and many will now get more. Some enrollees who didn’t previously qualify for tax credits may now be eligible.

Darci Gutierrez, an insurance agent in Dublin, California, says a client with a large family saved $425 a month on a Blue Shield PPO at the silver tier — the second-lowest level in the ACA’s four-tier system of coverage.

“I was shocked at the amount of reduction in cost. I was like, ‘Holy cow,’” Gutierrez says.

The additional federal aid is slated to stop after 2022, which means your insurance could cost you more after that. But there is talk in Congress about extending the enhanced tax credits for longer.

The new law follows the lead of California, which provided groundbreaking state-funded tax credits starting last year to augment the ACA credits and push eligibility for aid well into the middle class. The new federal dollars will provide assistance even further up the income scale.

Covered California estimates 100,000 consumers with incomes too high to qualify for federal or state credits under prior law will now be eligible for subsidies averaging $500 a month per household.

The share of the new money going to California could be about four times as much as those state-funded subsidies and will completely replace them, saving the state about $761 million this fiscal year and next.

The newly enhanced federal tax credits take effect with coverage that starts May 1. To get coverage for the first of any month, you need only sign up by the day before.

If you are currently enrolled in Covered California, you can keep your plan and take the savings, or you could shop around and save even more — or switch to a higher level of coverage without increasing your monthly bill.

“It’s critical that anybody who buys coverage as an individual take a look, because they may be leaving hundreds if not thousands of dollars on the table,” says Anthony Wright, executive director of Health Access, a Sacramento-based consumer advocacy group.

The new law, signed by President Joe Biden in March, also allocates money to provide virtually premium-free coverage — in 2021 only — for anyone, regardless of income, who receives unemployment benefits at any point during the year.

California is projected to get about $3 billion of the new federal money. Officials at Covered California think the state can get even more, and the exchange is spending more than $20 million on a television, radio and social media advertising blitz to drum up business. It is targeting in particular the approximately 810,000 uninsured Californians who are eligible for federal support under the new law.

“We need to rattle uninsured people to look again and realize this is new and different,” says Peter Lee, Covered California’s executive director. “If they think it’s just the same old same old, they ain’t going to check.”

Covered California is also marketing itself to an additional 270,000 people who are enrolled in health plans outside the exchange and would qualify for subsidized coverage if they switched to Covered California.

In an example used by Covered California in its promotional campaign, an Oakland couple making $77,580 a year, both 45 years old, pay the full monthly premium of $1,271 for a silver plan outside the exchange. By switching to the same plan in Covered California, they would pay only $550 — a monthly saving of $721.

If you are a current enrollee, Covered California — unlike the federally run exchanges — will automatically calculate your lower premium, and you will see a credit for May on your June bill. You will also reap that saving retroactively for the first four months of 2021 in the form of an additional premium reduction, in equal monthly installments, over the rest of the year.

If you are uninsured or in an off-exchange health plan, however, you need to take action. The money won’t just come to you. Research your options and enroll.

To find out if you qualify for federal assistance, log on to

Click the “shop and compare” button to find the health plans available to you in your area, along with the monthly premium you will pay after your tax credit.

You can also click a button to get a call from a licensed health insurance agent who can help you figure it all out — without charging you. If you don’t have a computer, call Covered California at 800-300-1506.

In contrast to the federally operated exchanges, Covered California requires that people switching from off-exchange health plans into exchange-based ones be allowed to apply any deductible paid so far this year against the new policy, as long as they don’t change insurance companies. That flexibility also applies if you are exchanging one Covered California plan for another, but with more restrictions, so ask your health plan before you make any changes.

If you are coming to Covered California from the open market, it should be easy to keep doctors you like, since most off-exchange plans mirror ones in Covered California and have the same networks. But there are cases in which you would not be able to keep your doctors, so be sure to ask your insurer about it before making a final decision.

Another notable feature of the new federal tax credits is that they no longer carry upper-income limits for eligibility. Instead, the amount people pay in premiums is limited to a fixed percentage of their income, ranging from zero for low-income consumers to 8.5% for the most affluent.

For the 2020 tax year, the new law overrides a requirement that consumers whose incomes exceeded their original estimate pay back any subsidy amounts to which they are not entitled.

Tom Freker, an insurance agent in Huntington Beach, California, says one of his clients made a big profit on a property sale last year, which raised his income to a level that would have required paying back the $10,000 subsidy he received in 2020.

“But the new American Rescue Plan waived that repayment,” Freker says. “That’s a big deal.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Covid ‘Doesn’t Discriminate by Age’: Serious Cases on the Rise in Younger Adults

Kaiser Health News - Tue, 05/04/2021 - 5:00am

After spending much of the past year tending to elderly patients, doctors are seeing a clear demographic shift: young and middle-aged adults make up a growing share of the patients in covid-19 hospital wards.

This story also ran on NPR. It can be republished for free.

It’s both a sign of the country’s success in protecting the elderly through vaccination and an urgent reminder that younger generations will pay a heavy price if the outbreak is allowed to simmer in communities across the country.

“We’re now seeing people in their 30s, 40s and 50s — young people who are really sick,” said Dr. Vishnu Chundi, a specialist in infectious diseases and chair of the Chicago Medical Society’s covid-19 task force. “Most of them make it, but some do not. … I just lost a 32-year-old with two children, so it’s heartbreaking.”

Nationally, adults under 50 now account for the most hospitalized covid patients in the country — about 36% of all hospital admissions. Those ages 50 to 64 account for the second-highest number of hospitalizations, or about 31%. Meanwhile, hospitalizations among adults 65 and older have fallen significantly.

About 32% of the U.S. population is now fully vaccinated, but the vast majority are people older than 65 — a group that was prioritized in the initial phase of the vaccine rollout.

Although new infections are gradually declining nationwide, some regions have contended with a resurgence of the coronavirus in recent months — what some have called a “fourth wave” — propelled by the B.1.1.7 variant, first identified in the United Kingdom, which is estimated to be somewhere between 40% and 70% more contagious.

As many states ditch pandemic precautions, this more virulent strain still has ample room to spread among the younger population, which remains broadly susceptible to the disease.

The emergence of more dangerous strains of the virus in the U.S. — including variants first discovered in South Africa and Brazil — has made the vaccination effort all the more urgent.

“We are in a whole different ballgame,” said Judith Malmgren, an epidemiologist at the University of Washington.

Rising infections among young adults create a “reservoir of disease” that eventually “spills over into the rest of society” — one that has yet to reach herd immunity — and portends a broader surge in cases, she said.

Fortunately, the chance of dying of covid remains very small for people under 50, but this age group can become seriously ill or experience long-term symptoms after the initial infection. People with underlying conditions such as obesity and heart disease are also more likely to become seriously ill.

“B.1.1.7 doesn’t discriminate by age, and when it comes to young people, our messaging on this is still too soft,” Malmgren said.

Hospitals Filled With Younger, Sicker People

Across the country, the influx of younger patients with covid has startled clinicians who describe hospital beds filled with patients, many of whom appear sicker than what was seen during previous waves of the pandemic.

“A lot of them are requiring ICU care,” said Dr. Michelle Barron, head of infection prevention and control at UCHealth, one of Colorado’s large hospital systems, as compared with earlier in the pandemic.

The median age of covid patients at UCHealth hospitals has dropped by more than 10 years in the past few weeks, from 59 down to about 48 years old, Barron said.

“I think we will continue to see that, especially if there’s not a lot of vaccine uptake in these groups,” she said.

While most hospitals are far from the onslaught of illness seen during the winter, the explosion of cases in Michigan underscores the potential fallout of loosening restrictions when a large share of adults are not yet vaccinated.

There’s strong evidence that all three vaccines being used in the U.S. provide good protection against the U.K. variant.

One study suggests that the B.1.1.7 variant doesn’t lead to more severe illness, as was previously thought. However, patients infected with the variant appear more likely to have more of the virus in their bodies than those with the previously dominant strain, which may help explain why it spreads more easily.

“We think that this may be causing more of these hospitalizations in younger people,” said Dr. Rachael Lee at the University of Alabama-Birmingham hospital.

Lee’s hospital also has observed an uptick in younger patients. As in other Southern states, Alabama has a low rate of vaccine uptake.

But even in Washington state, where much of the population is opting to get the vaccine, hospitalizations have been rising steadily since early March, especially among young people. In the Seattle area, more people in their 20s are now being hospitalized for covid than people in their 70s, according to Dr. Jeff Duchin, public health chief officer for Seattle and King County.

“We don’t yet have enough younger adults vaccinated to counteract the increased ease with which the variants spread,” said Duchin at a recent press briefing.

Nationwide, about 32% of people in their 40s are fully vaccinated, compared with 27% of people in their 30s. That share drops to about 18% for 18- to 29-year-olds.

“I’m hopeful that the death curve is not going to rise as fast, but it is putting a strain on the health system,” said Dr. Nathaniel Schlicher, an emergency physician and president of the Washington State Medical Association.

Schlicher, also in his late 30s, recalls with horror two of his recent patients — close to his age and previously healthy — who were admitted with new-onset heart failure caused by covid.

“I’ve seen that up close and that’s what scares the hell out of me,” he said.

“I understand young people feeling invincible, but what I would just tell them is — don’t be afraid of dying, be afraid of heart failure, lung damage and not being able to do the things that you love to do.”

Will Younger Adults Get Vaccinated?

Doctors and public health experts hope that the troubling spike in hospitalizations among the younger demographic will be temporary — one that vaccines will soon counteract. It was only on April 19 that all adults became eligible for a covid vaccine, although they were available in some states much sooner.

But some concerning national polls indicate a sizable portion of teens and adults in their 20s and 30s don’t necessarily have plans to get vaccinated.

“We just need to make it super easy — not inconvenient in any way,” said Malmgren, the Washington epidemiologist. “We have to put our minds to it and think a little differently.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

Democrats Disagree About How to Spend Potential Prescription Drug Windfall

Kaiser Health News - Tue, 05/04/2021 - 5:00am

One of the few surprises in President Joe Biden’s social safety-net proposal, the American Families Plan, was something that didn’t make it into the final version: any mention of reining in the price of prescription drugs.

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The American Families Plan, the second part of Biden’s expansive “infrastructure” agenda, includes sweeping programs aimed at boosting access to child care, higher education and paid family leave. But despite White House signals in March that health also would be a major part of the package, the only health proposal was one that would make permanent the temporary subsidy increases, passed as part of the covid relief bill earlier this spring, on insurance purchased through the Affordable Care Act’s health exchanges.

Initial reports suggest that Biden and his aides did not want to pick a fight now with the powerful prescription drug industry, which is riding high in public opinion after producing covid vaccines in record time. They worry that the industry’s impressive lobbying clout could endanger the rest of the program.

But there is likely another big reason Democrats are loath to address drug prices, despite broad bipartisan support. After nearly a year of uncharacteristically being on the same page when it comes to health care, Democratic lawmakers are reverting to a more familiar position: They are at loggerheads about what to do next.

Most Democrats agree the time is ripe to tackle high drug prices. In 2019 the Democratic-led House passed a broad drug price bill that was reintroduced just days ago with the backing of Speaker Nancy Pelosi. Senate Democrats have also been working on drug price legislation. There is some difference between liberals and moderates on how far to push the drug industry for savings, but the consensus is that drugs cost too much and the government needs to step in.

The real problem is what to do with the considerable budget savings that would be produced by policies like allowing Medicare to negotiate drug prices. That’s something that pits the more liberal Democratic backers of a “Medicare for All” insurance system against moderates who would instead put the savings into expanding the benefits of the Affordable Care Act.

Biden is, for the moment at least, taking both sides. Savings from drug price reforms “can go to strengthen the Affordable Care Act and expand Medicare coverage and benefits — without costing taxpayers one additional penny,” he said in his speech to a joint session of Congress on Wednesday night.

But the factions are taking shape in Congress.

On hearing reports that Biden’s families plan would leave major health items on the cutting-room floor, Medicare for All sponsor Sen. Bernie Sanders (I-Vt.) and 16 Senate Democratic colleagues urged Biden not just to include Medicare drug price negotiation authority in his package, but also to use the proceeds to lower the Medicare eligibility age (a Biden campaign promise) and add hearing, vision and dental benefits to Medicare. House Democrats in their 2019 bill opted to use the savings to provide those added health benefits to current Medicare beneficiaries. “We have an historic opportunity to make the most significant expansion of Medicare since it was signed into law,” wrote the senators. A similar letter went to the president signed by 80 House members, led by Medicare for All backer Rep. Pramila Jayapal (D-Wash.).

But at the same time, more than 50 members of the “New Democrat Coalition,” a more moderate group of House Democrats, also wrote to Biden, urging him to use the package to enhance the ACA. “Over a decade after the passage of the Obama-Biden administration’s landmark health care legislation, we are eager to work with the Biden-Harris administration to fortify and build on the ACA to achieve universal coverage with access to affordable, quality care,” they wrote.

This particular disagreement harks back to the 1980s and ’90s, when generations were pitted against each other in a sometimes ugly way. Younger Americans, worried about rising rates of the uninsured, accused Medicare beneficiaries who wanted better benefits of being “greedy geezers.” A law Congress passed in 1988 that would have boosted Medicare benefits and added a cap on catastrophic expenses caused a backlash when Congress decided wealthier seniors should pay for it themselves via added taxes. Seniors angry that younger people would not help foot the bill rebelled, and the entire program was repealed in 1989 before it ever took effect.

“It’s a very American debate,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill who has written extensively about Medicare. “It’s a function of the fact that we have a fragmented health insurance system and it’s fragmented by age. You don’t have this conversation in Canada or France or anywhere else.”

Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, said the obvious next step is to make the new ACA subsidies permanent. “It’s simple, it’s all winners, and certainly affordable in the context,” he said. In other words, there are no deep-pocketed stakeholders, like health insurers or drug companies, who would step in to fight the plan.

But neither plan, she said, gets to the biggest need, which is to help those caught in the “Medicaid gap” — at least 2.2 million people in states that didn’t expand Medicaid who are still uninsured. They don’t qualify for ACA marketplace coverage, because they earn too little, or for Medicaid, because they earn too much. “My general preference is to create a public program for those folks to enroll,” Adler said.

Oberlander and Adler said it’s likely this fight will be settled the old-fashioned way: Rather than pick one pathway, lawmakers will do both, expanding the ACA and Medicare. “If you try to do these policies in a somewhat frugal manner, there are some opportunities here,” said Adler.

But Oberlander warned that Congress shouldn’t spend the drug price bounty before it’s passed. In the 1990s the fight was over whether to expand health insurance for younger Americans or provide more long-term care options for seniors. Said Oberlander, “In the end, they did neither.”

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

En los Apalaches y el delta del Mississippi, millones deben viajar lejos para recibir atención por accidentes cerebrovasculares

Kaiser Health News - Tue, 05/04/2021 - 5:00am

Una mañana de verano en 2019, Debbie Cook estaba todavía en pijamas cuando recibió una llamada de su hijo: “Algo malo le pasa a la abuela”.

This story also ran on Investigate TV. It can be republished for free.

Por el miedo en la voz de su hijo supo que se trataba de algo serio. Marcó el 911 de inmediato, sabiendo que una ambulancia podría tardar un buen tiempo en recorrer las carreteras rurales del condado de Fentress, en Tennessee.

Se vistió y condujo a través de la granja familiar, dos puentes y un riachuelo, hasta la casa de su madre. Cook rezó para que una de las tres ambulancias que cubrían su condado de aproximadamente 500 millas cuadradas estuviera cerca.

Cuando llegó, encontró a su madre, Lottie Crouch, en el baño, incapaz de pararse o caminar. Cook, quien es enfermera licenciada, reconoció rápidamente los signos: cara torcida, un lado de la boca caído.

Su mamá estaba sufriendo un accidente cerebrovascular (ACV, también llamado ataque cerebral).

“Me quedé petrificada”, recordó Cook, quien comenzó su carrera trabajando con pacientes en rehabilitación tras accidentes cerebrovasculares, y sabía que obtener la atención adecuada rápidamente podría hacer la diferencia entre la vida o la muerte. O una gran diferencia en la calidad de vida de su madre. Crouch tenía 75 años, todavía estaba enérgica y le encantaba hacer cosas como prepararse sopa. Para seguir viviendo la vida que Crouch conocía, cada paso hacia la atención adecuada, en un área rural, tenía que salir bien.

Cuando llegaron los paramédicos, la pregunta crucial fue: ¿A dónde llevarían a Crouch para que recibiera atención?

En todo el país, cerca de 800,000 personas sufren accidentes cerebrovasculares cada año. El problema es particularmente grave en las regiones de los Apalaches y el delta del Mississippi, donde más del 80% de los condados tienen tasas de muerte por ACV superiores al promedio nacional. Muchos de estos condados también enfrentan altos índices de pobreza y albergan a poblaciones de adultos mayores vulnerables. Tienen escasez de proveedores médicos o han visto cerrar hospitales locales.

En Tennessee, 2 millones de personas, casi un tercio del estado, están en la situación de Crouch: viven a más de 45 minutos de un hospital certificado para el tratamiento de accidentes cerebrovasculares y capaz de brindar la atención más avanzada, según un nuevo análisis de KHN e InvestigateTV.

Y las tasas son aún más altas en los estados del delta como Arkansas y Mississippi, donde más de la mitad de los residentes deben conducir más de 45 minutos hasta estos centros especializados.

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El análisis es parte de un proyecto de un año llamado Bridging the Great Health Divide, durante el cual KHN y el equipo de investigación nacional de Gray Television, InvestigateTV, investigan los problemas de salud que históricamente han plagado a estas regiones. Y los accidentes cerebrovasculares son los principales. A pesar de los avances médicos en la atención de estos ataques, enviar a los pacientes de las zonas rurales de los Apalaches y el delta del Mississippi a las instalaciones adecuadas es un intrincado rompecabezas.

"No existe una única respuesta correcta para todos los pacientes", dijo el doctor Raul Nogueira, neurólogo intervencionista del Grady Memorial Hospital en Atlanta, Georgia. El lugar donde se debe cuidar a un paciente "realmente depende del tiempo de viaje", dijo. "Todo es cuestión de tiempo".

Durante años, el consejo para los pacientes con ACV ha sido llegar al hospital más cercano lo antes posible. Esta emergencia interrumpe el flujo sanguíneo a una parte del cerebro y, cuanto antes se lo pueda restaurar, mejor. Entonces, la idea ha sido llevar a los pacientes a un médico, cualquier médico, rápidamente.

Pero ahora, ese consejo está evolucionando. Investigaciones muestran que algunos pacientes con ACV se benefician más de los procedimientos avanzados que suelen realizar especialistas en grandes centros médicos. Por eso, el nuevo objetivo es llevar a los pacientes al médico adecuado en el hospital adecuado lo antes posible.

En algunos casos, eso no significa la instalación más cercana. Para los pacientes con accidentes cerebrovasculares graves, en los que un coágulo está bloqueando a una de las arterias principales del cerebro, las asociaciones médicas recomiendan viajar hasta 30 minutos adicionales en áreas urbanas y 60 minutos en áreas rurales para llegar a un hospital con capacidad de tratar un ataque cerebral con técnicas avanzadas.

Si bien eso es bastante fácil en una ciudad donde hay muchos hospitales, en áreas rurales como el condado de Fentress, la cuestión de dónde llevar a un paciente se ha vuelto cada vez más complicada.

Grandes decisiones, poco tiempo

Cuando Lottie Crouch tuvo su accidente cerebrovascular, el que habría sido el hospital más cercano, a menos de 20 minutos, había cerrado dos meses antes. Es uno de los 136 hospitales rurales en todo el país que han cerrado desde 2010, incluidos casi tres docenas en Appalachia y el delta.

Eso significaba que, para Crouch, el hospital estatal más cercano estaba a casi 45 minutos en auto, y los centros médicos con la atención más avanzada estaban a más de una hora. Eso hizo que los servicios de emergencias médicas se esforzaran por transportar a los pacientes más lejos.

Cada paso en el proceso para conseguir que alguien que había sufrido un derrame cerebral recibiera la atención adecuada en el tiempo adecuado se había vuelto más complejo.

Las decisiones del momento rara vez son claras, dijo Nogueira. Si un paciente tiene un accidente cerebrovascular severo, podría beneficiarse de ir a un centro médico grande donde pueda someterse a una cirugía de inmediato, agregó. Detenerse en un hospital más pequeño que no puede realizar ese procedimiento podría retrasar innecesariamente la atención.

Pero si el ataque es menos grave, podría ser mejor ir primero a un centro más cercano en donde el paciente podría recibir medicamentos para disolver el coágulo antes, dijo Nogueira. Así, evitaría facturas médicas innecesarias por un viaje largo, desde $500 por un viaje en la parte trasera de una ambulancia regular hasta $50,000 por un helicóptero. Y la familia podría ahorrar el tiempo y el dinero que implica visitar al paciente en un hospital lejano.

El problema es que los socorristas no necesariamente pueden saber qué tan grave es un derrame cerebral con solo mirar a alguien. Por lo tanto, se basan en una evaluación de los síntomas del paciente para tomar la mejor decisión.

A Jamey Beaty, un paramédico en el condado de Fentress que respondió a la casa de Lottie Crouch, le pesan la gravedad de estas decisiones.

"Cuando estás solo en la parte trasera de una ambulancia y tienes un paciente que se está muriendo, lo único en lo que puedes pensar es: ¿Cómo puedo mantener vivo a este paciente hasta que pueda llevarlo a alguna parte?", dijo Beaty. "Eso es todo lo que se te pasa por la cabeza".

Cada vez que Beaty recibe una llamada por un ataque cerebral, su primera respuesta es mirar al cielo.

Desde que cerró el hospital local, una ambulancia aérea es la forma más rápida para que el paciente llegue al lugar del tratamiento. Afortunadamente, el día que Lottie Crouch tuvo su ataque, el cielo de Tennessee estaba azul claro. Crouch fue trasladada casi 100 millas a un hospital en Knoxville con servicios avanzados para accidentes cerebrovasculares.

Viajes largos hacia la atención avanzada

Durante las últimas dos décadas, dos tratamientos principales han hecho que avanzara la atención de los accidentes cerebrovasculares causados ​​por un bloqueo, el tipo de ataque más común en Estados Unidos.

El primero es un medicamento administrado por vía intravenosa para disolver los coágulos en los vasos sanguíneos de los pacientes. El medicamento debe administrarse dentro de las 4½ horas posteriores al inicio de los síntomas. El segundo es un procedimiento que utiliza un catéter para remover físicamente el coágulo de los vasos de un paciente. Este tratamiento se puede realizar hasta 24 horas después del comienzo de los síntomas, pero generalmente se usa solo para accidentes cerebrovasculares graves.

En todo el país, los hospitales están certificados por niveles, en gran parte en función de su capacidad para proporcionar estos tratamientos con regularidad. Algunos hospitales no tienen certificación. Entre los hospitales certificados para accidentes cerebrovasculares, el primer nivel son los que están preparados para accidentes cerebrovasculares agudos, que pueden evaluar a los pacientes con accidente cerebrovascular, mantenerlos estables y proporcionar medicamentos anticoagulantes.

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En el otro extremo del espectro están los centros integrales de accidentes cerebrovasculares, que cuentan con equipos especializados de neurólogos y neurocirujanos. Además de administrar los medicamentos anticoagulantes, estos centros pueden remover los coágulos con cirugía.

La gran pregunta es ¿a qué centro se puede y se debe llevar primero a los pacientes con ACV para que reciban la atención adecuada en un tiempo adecuado?

En Appalachia, aproximadamente el 11% de los residentes deben conducir más de 45 minutos para llegar a cualquier tipo de centro de accidentes cerebrovasculares, según el análisis de KHN e InvestigateTV. Esa proporción es aún mayor en el delta, donde casi un tercio de los residentes tienen que conducir más de 45 minutos para llegar a uno de estos centros. Otro tercio solo tiene centros de atención básica para accidentes cerebrovasculares dentro de esa distancia y necesitaría conducir más lejos para cirugías avanzadas.

Y en las partes rurales más remotas de estas dos regiones, es menos probable que las personas estén cerca de un centro de atención avanzada para accidentes cerebrovasculares.

Rural y mayoritariamente afroamericano

Si bien para muchos estadounidenses rurales como Crouch, que es blanca no hispana, es difícil llegar a tiempo al lugar adecuado para recibir la atención, las preocupaciones se agravan en los lugares con una gran población de raza negra.

Los afroamericanos tienen accidentes cerebrovasculares con más frecuencia y a edades más tempranas que sus contrapartes caucásicas. También es menos probable que reciban medicamentos anticoagulantes porque generalmente llegan al hospital fuera de la ventana del tratamiento.

En el condado de Sumter, Alabama, varias personas entrevistadas, desde el dueño de un negocio local hasta un profesor universitario y el juez de distrito, pudieron nombrar a alguien que había tenido un ataque cerebral. Más del 70% de la población del condado es de raza negra, y es una de las áreas más pobres del estado.

El único hospital dentro de las fronteras del condado no tiene certificación para ACV. Loretta Wilson, directora ejecutiva del Hospital Hill del condado de Sumter, quisiera que su centro pudiera hacer más por los pacientes con ACV. Pero los medicamentos anticoagulantes pueden costar $8,000 por dosis y el hospital no siempre puede permitirse el lujo de tenerlos a mano, dijo.

A la mayoría de los pacientes con accidente cerebrovascular se los traslada a hospitales más grandes, al menos a 30 o 40 minutos de distancia. Ese puede ser un viaje largo y costoso para muchos residentes, agregó Wilson.

Por eso, Wilson se centra principalmente en los esfuerzos de prevención. Dirige una organización sin fines de lucro que aborda problemas como la presión arterial alta, la obesidad y la diabetes, que aumentan el riesgo de una persona de sufrir un ACV. Su organización tiene alianzas con iglesias para educar a las personas sobre alimentación saludable y ejercicio, y distribuye monitores de presión arterial para que los feligreses puedan tomarse la presión ellos mismos.

"Tenemos una alta población afroamericana", dijo Wilson, quien también es afroamericana, "y esos son los que realmente necesitan los servicios".

Otras organizaciones en el condado también trabajan para educar a las personas sobre la salud cardíaca y cuándo llamar al 911. El programa de enfermería de la universidad local tiene una beca destinada a atraer a más proveedores médicos al área.

Usando telestroke para impulsar la atención rural

En los hospitales rurales, incluso si los médicos tienen acceso a medicamentos anticoagulantes, pueden dudar en administrarlos por temor a dañar al paciente. En raras ocasiones, alrededor del 2% al 7% de los casos, los medicamentos pueden causar sangrado cerebral.

Pero no usar las drogas también puede tener consecuencias. Un estudio nacional publicado en 2020 encontró que los pacientes con accidente cerebrovascular tenían menos probabilidades de recibir esos medicamentos en hospitales rurales que en los urbanos, y los pacientes con estos ataques tenían más probabilidades de morir en hospitales rurales.

Los programas de telestroke pueden ayudar a cerrar esa brecha, explicó la doctora Amelia Adcock, neuróloga de WVU Medicine en West Virginia y jefa de la red de telestroke del sistema.

Al conectar a médicos de hospitales más pequeños, a menudo rurales, con un especialista de guardia en un gran centro médico, los programas permiten que las personas “compartan la carga de la toma de decisiones”, dijo Adcock. Y la responsabilidad.

El doctor Michael Gould es médico de medicina de emergencia en el Hospital Potomac Valley de 25 camas en la zona rural del norte de West Virginia. Su hospital no está certificado para accidentes cerebrovasculares y no cuenta con un neurólogo de planta. Dijo que administrar medicamentos anticoagulantes es "una de las decisiones de la medicina que me pone más nervioso".

Pero consultar con neurólogos en el centro de Medicina de WVU a unas 80 millas de distancia en Morgantown le ha dado más confianza, dijo. Gould estimó que ahora administra los medicamentos una o dos veces al mes.

Un estudio de la red de telestroke de WVU Medicine halló que el número de pacientes con accidente cerebrovascular que recibieron medicamentos anticoagulantes casi se duplicó durante los primeros tres años del programa.

El otoño pasado, Christopher Green estaba haciendo las compras cuando de repente sintió un fuerte dolor de cabeza y perdió la visión periférica. Green, un veterano paramédico, reconoció de inmediato lo que estaba sucediendo. "Oh, Dios mío, estoy sufriendo un ataque cerebral", recuerda haber pensado. Lo llevaron al hospital de Gould y el personal de emergencias inmediatamente puso en marcha el programa de telestroke.

En 30 minutos, Green consiguió medicamentos para disolver el coágulo en sus vasos. "Un resultado de libro de texto", dijo Green, quien ha respondido a muchas llamadas al 911 por accidentes cerebrovasculares.

Rememorando, Green dijo que probablemente habría llevado a un paciente en su situación a un hospital más lejano que estuviera certificado para accidentes cerebrovasculares. Pero experimentar el programa de telestroke en carne propia cambió su perspectiva.

"Ahora veo que retrasar el tratamiento de 20 a 30 minutos marca la diferencia entre tener una solución completa o algún tipo de efecto residual", dijo.

“¿Qué pudo haber sido?”

De vuelta en Tennessee, Debbie Cook estaba agradecida de que a su madre la hubieran llevado al centro de atención avanzada para accidentes cerebrovasculares en Knoxville. Le permitió a Lottie Crouch recibir el tratamiento que necesitaba para poder llevar una vida mayormente independiente.

Pero la distancia le pasó factura a la familia. Cook, su hermana y su hija se turnaron para conducir casi dos horas de ida y dos de vuelta para pasar la noche con Crouch en el hospital.

Después de 10 días, cuando Crouch fue trasladada a un centro de rehabilitación más cercano a su casa, la familia sintió una sensación de alivio. Podrían llevarle pastel de carne y dumplings de moras silvestres para la cena. Y "un montón de caramelos de menta", recuerda Crouch, su favorito.

Aunque Crouch ahora está sana, y en casa, su nieta de 27 años, Haelee Stockton, todavía está obsesionada de solo pensar lo que podría haber sucedido ese día. Si los paramédicos no hubieran llegado a tiempo o si el mal tiempo hubiera impedido que el helicóptero volara, es posible que su abuela no estuviera viva.

"¿Qué pudo haber sido?", se preguntó Stockton. “¿Qué tanta suerte tuvo? ¿Y cuántas personas van a tener esa suerte en el futuro?".

Aneri Pattani lideró las entrevistas y la redacción de esta historia. Hannah Recht lideró el análisis de datos y los gráficos. Daniela Molina de InvestigateTV colaboraron con la historia.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care

In Appalachia and the Mississippi Delta, Millions Face Long Drives to Stroke Care

Kaiser Health News - Tue, 05/04/2021 - 5:00am

Debbie Cook was in her pajamas on a summer morning in 2019 when she got a call from her son: “Something bad is wrong with Granny.”

This story also ran on Investigate TV. It can be republished for free.

The fear in his voice told Cook it was serious. She dialed 911 immediately, knowing it could take time for an ambulance to navigate the country roads in Fentress County, Tennessee.

She got dressed and made the short drive across the family farm, over two bridges and a creek, to her mother’s house. Cook prayed that one of the three ambulances covering their roughly 500-square mile county was near.

When Cook arrived, she found her mother, Lottie Crouch, in the bathroom, unable to stand or walk. Cook, a licensed practical nurse, quickly recognized the signs: lopsided face, one side of the mouth drooping.

Her mama was having a stroke.

“I was petrified,” Cook recalled. She started her career working with stroke rehab patients and knew that getting the right care fast could mean life or death. Or a big difference in her mother’s quality of life. Crouch was 75 and still energetic and loved doing things like firing up a kettle of soup for herself. To continue living the life Crouch knew, each step toward getting care in a rural area had to go right.

But when the paramedics arrived, one of the biggest questions was: Where would they take Crouch for care?

Across the nation, nearly 800,000 people suffer strokes each year. The issue is particularly acute across the regions of Appalachia and the Mississippi Delta, where more than 80% of counties have stroke death rates above the national average. Many of these counties also face high rates of poverty and are home to vulnerable elderly populations. They have a shortage of medical providers or have seen local hospitals shutter.

In Tennessee, 2 million people — nearly one-third of the state — are people like Crouch who live more than 45 minutes from a hospital that is stroke-certified and able to provide the most advanced care, according to a new analysis by KHN and InvestigateTV. And rates are even higher in Delta states such as Arkansas and Mississippi, where more than half of residents must drive longer than 45 minutes to those specialized stroke centers.

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The analysis is part of a yearlong project called Bridging the Great Health Divide, in which KHN and Gray Television’s national investigative team, InvestigateTV, are digging into health issues that have historically plagued these regions. Strokes are chief among them. Despite medical advancements in stroke care, routing patients from rural parts of Appalachia and the Delta to the appropriate facility is an intricate jigsaw puzzle.

“There’s not the same one correct answer for all patients,” said Dr. Raul Nogueira, an interventional neurologist at Grady Memorial Hospital in Atlanta. Where a patient should be taken for care “really depends on travel time,” he said. “It’s all about time.”

For years, the advice for stroke patients has been to get to the nearest hospital as soon as possible. A stroke cuts off blood flow to part of the brain, and the sooner that blood flow can be restored the better. So, the idea has been to get patients to a doctor — any doctor — quickly.

But that advice is now evolving. Research shows some stroke patients benefit more from advanced procedures typically done by specialists at large medical centers. The new goal is to get patients to the right doctor at the right hospital as soon as possible.

In some cases, that means skipping the closest facility. For patients with severe strokes, in which a clot is blocking one of the brain’s major arteries, the American Heart and Stroke associations recommend traveling up to an additional 30 minutes in urban areas and 60 minutes in rural areas to reach a hospital with more advanced stroke capabilities.

While that’s easy enough in a city where multiple hospitals are clustered together, in rural areas like Fentress County the question of where to take a patient has become increasingly fraught.

Big Decisions, Little Time

When Lottie Crouch had her stroke, what would have been the nearest hospital, less than 20 minutes away, had closed two months earlier. It’s one of 136 rural hospitals nationwide that have shuttered since 2010, including nearly three dozen across Appalachia and the Delta. That meant the closest in-state hospital for Crouch was nearly 45 minutes away by car, and medical centers with the most advanced care were more than an hour’s drive. That left EMS services stretched thin trying to transport patients farther away.

Each step in the process to get someone who’d had a stroke to the right care within the right amount of time had become more complex.

The decisions along the way are rarely clear-cut, Nogueira said. If a patient has a severe stroke, they might benefit from getting to a large medical center where they can undergo surgery right away, he said. Stopping at a smaller hospital that can’t perform that procedure might unnecessarily delay care.

But if the stroke is less severe, the person might benefit more from first going to a closer facility that can offer medications to break up the clot sooner, Nogueira said. Then the patient could avoid unnecessary medical bills from a long trip, anything from $500 for a ride in the back of a regular ambulance to $50,000 for a helicopter. And their family could save the time and money needed to visit them in a faraway hospital.

The problem is that first responders can’t necessarily tell how severe a stroke is just by looking at someone. So, they rely on an evaluation of the patient’s symptoms to make the best choice.

The gravity of these decisions weighs on Jamey Beaty, a paramedic in Fentress County, who responded to Lottie Crouch’s home.

“When you’re in the back of a truck and all alone and you have a patient actively dying on you, the only thing you can think about is: How can I keep this patient alive until I can get them somewhere?” Beaty said. “That’s all that crosses your mind.”

Anytime Beaty gets a call about a stroke, his first response is to look at the sky.

Since the local hospital closed, an air ambulance is how he quickly gets people to treatment. The day Lottie Crouch had her stroke, luckily the Tennessee sky was clear blue. Crouch was taken nearly 100 miles to a hospital in Knoxville with advanced stroke services.

Long Journeys to Advanced Care

Over the past two decades, two main treatments have advanced care for strokes caused by a blockage — the most common type of stroke in America. The first is a medication delivered through an IV to break up clots in patients’ blood vessels. The medicine has to be given within 4½ hours of when symptoms start. The second is a procedure using a catheter to physically remove the clot from a patient’s vessels. This treatment can be done up to 24 hours after symptoms start but is generally used only for severe strokes.

Across the country, hospitals are certified by tiers, largely based on their ability to regularly provide these treatments. Some hospitals have no certification. Among stroke-certified hospitals, the first level is acute stroke-ready hospitals, which can assess stroke patients, keep them stable and provide clot-busting medications. At the other end of the spectrum are comprehensive stroke centers, which have specialized teams of neurologists and neurosurgeons. In addition to giving the clot-busting drugs, these centers can physically remove clots.

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The big question is: Which facility can and should stroke patients be taken to first to get the right care within the right time span?

In Appalachia, about 11% of residents must drive more than 45 minutes to reach any kind of stroke center, according to the KHN and InvestigateTV analysis. That proportion is even higher in the Delta, where nearly a third of residents have to drive more than 45 minutes to a stroke center. Another third of Delta residents have only basic-care stroke centers within that distance and would need to drive farther for advanced stroke surgeries.

And in the most rural parts of both these regions, people are less likely to be near an advanced-care stroke facility.

Rural and Largely African American

While reaching appropriate stroke care in time is difficult for many rural Americans, such as Crouch, who is white, the concerns are compounded for places with a large Black population.

Black Americans have strokes more often and at younger ages than their white counterparts. They’re also less likely to receive clot-busting medications because they often arrive at the hospital outside the window of treatment.

In Sumter County, Alabama, several people interviewed — from a business owner to a college professor to the district judge — were able to name someone off the top of their heads who has had a stroke. The county is more than 70% Black, and it is one of the poorest areas of the state.

The only hospital within county lines has no stroke certification. Loretta Wilson, the CEO of Hill Hospital of Sumter County, wishes her facility could do more for stroke patients. But clot-busting medications can cost $8,000 per dose, and the hospital can’t always afford to keep them on hand, she said.

Most stroke patients are taken to larger hospitals at least 30 or 40 minutes away. That can be a long and expensive journey for many residents, Wilson said.

Understanding that, Wilson focuses largely on prevention efforts. She runs a nonprofit that tackles issues like high blood pressure, obesity and diabetes, all of which increase a person’s risk of stroke. Her organization partners with churches to teach people about healthy eating and exercise, and passes around blood pressure monitors so congregants can screen themselves after services.

“We have a high African American population,” said Wilson, who is African American too, “and those are the ones who really need the services.”

Other organizations in the county also work to educate people about heart health and when to call 911. The local college’s nursing program has a scholarship aimed at bringing more medical providers to the area.

Using Telestroke to Boost Rural Care

In rural hospitals, even if doctors have access to clot-busting drugs, they may hesitate to administer them for fear of harming the patient. In rare instances — about 2% to 7% of cases — the drugs can cause bleeding in the brain.

But not using the drugs can also have consequences. A national study published in 2020 found stroke patients were less likely to receive those medications in rural hospitals than urban ones, and stroke patients were more likely to die in rural hospitals.

Telestroke programs can help bridge that gap, said Dr. Amelia Adcock, a neurologist at WVU Medicine in West Virginia and head of the system’s telestroke network.

By connecting doctors from smaller, often rural, hospitals with an on-call specialist at a large medical center, the programs allow people “to share the burden of decision-making,” Adcock said. And the liability.

Dr. Michael Gould is an emergency medicine doctor at the 25-bed Potomac Valley Hospital in rural northern West Virginia. His hospital is not stroke-certified and does not have a neurologist on staff. He said giving clot-busting drugs is “one of the decisions in medicine that makes me the most nervous.”

But consulting with neurologists at WVU Medicine’s hub about 80 miles away in Morgantown has given him more confidence, he said. Gould estimated he now administers the drugs once or twice a month.

A study of WVU Medicine’s telestroke network found the number of stroke patients receiving clot-busting medications nearly doubled over the first three years of the program.

Last fall, Christopher Green was picking up groceries when he suddenly developed a severe headache and lost his peripheral vision. Green, a longtime paramedic, immediately recognized what was happening. “Oh, my God, I’m having a stroke,” he remembers thinking. He was brought to Gould’s hospital, and the ER staff immediately fired up the telestroke program.

Within 30 minutes, Green got drugs to break up the blockage in his vessels. "A textbook outcome," said Green, who has responded to many 911 calls for stroke.

Looking back, Green said he probably would have taken a patient in his situation to a farther hospital that was stroke-certified. But experiencing the telestroke program firsthand changed his outlook.

”Now I see that delaying that treatment 20 to 30 minutes makes a difference on whether you have a full resolution or some kind of residual effects,” he said.

‘What Could It Have Been?’

Back in Tennessee, Debbie Cook was grateful her mother was taken to the advanced-care stroke center in Knoxville. It allowed Lottie Crouch to get the treatment she needed so she can still lead a mostly independent life.

But there were trade-offs. The distance took a toll on the family. Cook, her sister and her daughter took turns driving nearly two hours each way to watch over Crouch in the hospital each night.

After 10 days, when Crouch was transferred to a rehab facility closer to home, the family felt a sense of relief. They could bring her meatloaf and wild blackberry dumplings for dinner. And “a lot of peppermint candy,” Crouch recalled — her favorite.

Although Crouch is now healthy and at home, her 27-year-old granddaughter, Haelee Stockton, is still haunted by the possibility of what could have happened that day. If the paramedics hadn’t made it in time or if bad weather had prevented the helicopter from flying, her granny might not be alive.

“What could it have been?” Stockton said. “How lucky was she? And how many people are going to get that lucky in the future?”

Aneri Pattani led the reporting and writing for this story. Hannah Recht led the data analysis and graphics. InvestigateTV’s Daniela Molina contributed to this report.

Read the methodology to learn how we did this analysis and visit the Github repository to see the code.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Categories: Health Care
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