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KHN’s ‘What the Health?’: Biden Social-Spending ‘Framework’ Pulls Back on Key Health Pledges

Kaiser Health News - 2 hours 49 min ago

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President Joe Biden unveiled a purported compromise on his social-spending plan shortly before taking off for a series of meetings in Europe. But it remains unclear whether the proposal — which jettisons some of the president’s health priorities — will win the support of enough Democrats to push it over the finish line.

Meanwhile, the Supreme Court on Monday will hear oral arguments in a case brought by the Biden administration trying to strike down the Texas law that has stopped most abortions in the state since it took effect in September.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico and Johns Hopkins, Sarah Karlin-Smith of the Pink Sheet and Rachana Pradhan of KHN.

Among the takeaways from this week’s episode:

  • The framework announced by the White House provides few details about health care provisions. But the White House may have pushed this forward because the president wanted to show progress on climate provisions as he heads to an international climate meeting next week and figured that the health issues could be resolved later.
  • Despite Democrats’ longtime push for bringing down Medicare drug prices, the framework announced by the White House includes only one fairly small provision that would affect that spending. It would overturn a Trump administration effort to make sure discounts offered by drugmakers to insurers be passed on to consumers. In the byzantine world of federal budgeting, that measure was going to cost the government money and jettisoning the policy will provide savings that lawmakers can use for other benefits they want to put into the overall spending bill.
  • Progressives in the Democratic Party have been pushing hard for an expansion of Medicare benefits to cover hearing, vision and dental services. But the framework includes only some hearing coverage.
  • The framework also dramatically reduces a proposal to improve home health services.
  • The Supreme Court arguments next week are in a suit seeking to overturn a Texas abortion law that bans the procedure after fetal cardiac activity can be detected — usually at about six weeks of pregnancy. Although conservatives are hoping the justices will use the case to overturn Roe v. Wade, much of the case could revolve around other issues, including the law’s unusual enforcement mechanism that allows individuals — not the state — to bring civil cases against people who help women get an abortion.
  • If the high court were to overturn Roe, it’s possible abortion could become a voting issue for progressives. But it’s not likely to mobilize enough people in deeply red states to change the conservative culture or leadership.
  • The Food and Drug Administration was expected to announce this week that one of the covid-19 vaccines can be used safely in children ages 5 to 11. After that, the Centers for Disease Control and Prevention will offer its assessment. Health experts will be watching to see whether the CDC says all children in that age group need the vaccine or the agency sets up different criteria among groups of kids.
  • The FDA last week said Cyltezo, a biosimilar drug that treats some inflammatory diseases, can be used interchangeably with the expensive biologic drug Humira. That means pharmacies can substitute the drug without a doctor’s approval. But it doesn’t mean prices will fall immediately; it often takes several drug alternatives to bring down costs.

Also this week, Rovner interviews Amy Howe of SCOTUSblog about the upcoming Supreme Court arguments over Texas’ controversial abortion law.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Rewire News Group’s “When a Miscarriage Becomes a Jail Sentence,” by Caroline Reilly.

Joanne Kenen: Nature’s “COVID Vaccine Makers Brace for a Variant Worse Than Delta,” by Emily Waltz.

Rachana Pradhan: KHN’s “3 States Limit Nursing Home Profits in Bid to Improve Care,” by Susan Jaffe.

Sarah Karlin-Smith: KHN’s “‘Down to My Last Diaper’: The Anxiety of Parenting in Poverty,” by Jenny Gold.

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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.

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Categories: Health Care

Democrats’ Plans to Expand Medicare Benefits Put Pinch on Advantage Plans’ Funding

Kaiser Health News - 12 hours 4 min ago

“Did you think we wouldn’t notice?” an older woman says, speaking into the camera. “You thought you could sneak this through?” an older man later adds. Others warn that Washington is “messing with” their Medicare Advantage health coverage and trying to raise their premiums.

But the television ad, paid for by Better Medicare Alliance, a research and advocacy group for Medicare Advantage plans, doesn’t spell out what cuts congressional lawmakers might be trying to slip past unsuspecting seniors.

Concerned that viewers could be confused and alarmed about coverage changes, we asked the Better Medicare Alliance for specifics about the sneaky moves the organization aims to alert people to. It’s not just one ad. The organization has launched a $3 million TV, radio and online advertising campaign, according to advertising tracker AdImpact.

In response, the group offered this emailed comment from its president and CEO, Mary Beth Donahue.

“Better Medicare Alliance is airing messages encouraging Congress to guard against cuts to seniors’ Medicare Advantage coverage, whether through benchmark policies in the reconciliation bill or other avenues.”

While still light on specifics, Donahue’s comment offered an important detail not mentioned in the ad. The group is concerned about coverage cutbacks through “benchmark policies in the reconciliation bill.”

Now we were getting somewhere. In the Democrats’ climate and social-spending bill being hammered out in Congress, one key health care proposal would add dental, hearing and vision coverage to the traditional Medicare program.

The provision, championed by Sen. Bernie Sanders (I-Vt.), is estimated to cost $350 billion over 10 years. As Democrats have labored to winnow their $3.5 trillion social-spending bill to make it palatable to moderates in the party, it’s unclear whether the Medicare benefits expansion will make it into the final version.

Assuming it does, here’s where benchmark calculations, and presumably the Better Medicare Alliance’s concerns, come into play.

Traditional Medicare vs. Medicare Advantage

First, some background. Most Medicare beneficiaries are in the so-called traditional Medicare program, in which members generally pay 20% of the cost of medical services after meeting a deductible. A separate plan covers prescription drugs. Enrollees can visit any doctor, hospital or other medical provider participating in the program, the vast majority of whom do nationwide. Many beneficiaries buy supplemental Medigap policies that cover their cost-sharing obligations and fill in other financial gaps.

However, a growing number of Medicare beneficiaries — more than 26 million, or 42% of Medicare enrollees — are in Medicare Advantage plans. Cost sharing is generally lower in these private-sector managed-care plans than in traditional Medicare, but the networks of doctors and hospitals are smaller, too. Many Medicare Advantage plans offer supplemental benefits such as dental, vision and hearing coverage, although the level of coverage varies widely.

“Traditional Medicare is a lousy program, and that’s why Medicare Advantage has really taken off over the last five or 10 years,” said Joseph Antos, a senior fellow at the American Enterprise Institute. “Medicare Advantage looks like the coverage you used to have [before joining Medicare] and there [isn’t] confusing cost sharing that most people don’t understand. Whereas with traditional Medicare, there are different deductibles and holes in coverage.”

The Benchmark

The federal Medicare program pays Medicare Advantage plans a set amount per member. Medicare Advantage health plans submit bids annually to federal officials that reflect how much they estimate it will cost to provide a package of benefits covering hospitalization (Medicare Part A) and outpatient services (Medicare Part B) to enrollees. Those bids are compared against a “benchmark,” which is based on the average spending per beneficiary in the traditional Medicare program, with geographic adjustments.

Plans that bid below the benchmark, as most do, receive a rebate they can use to reduce beneficiary cost sharing, subsidize premiums or pay for supplemental benefits like dental, vision and hearing.

The Benchmark Controversy

Groups like the Better Medicare Alliance say they support providing dental, hearing and vision coverage to all Medicare beneficiaries. But they’re worried that congressional leaders won’t factor the cost of new traditional Medicare benefits into the benchmark, resulting in lower rebates from the program, which could threaten other supplemental benefits that Medicare Advantage members enjoy, such as meals and transportation services, gym memberships and in-home care.

It’s not evident that lawmakers are considering excluding the benefit from the benchmark, however.

“I feel like this is the industry flexing its muscles and sending loud signals, but it’s not clear that Congress has any intention to modify payments as part of this legislation,” said Tricia Neuman, executive director of the program on Medicare policy at KFF.

Still, excluding the new benefits from the Medicare benchmark has generated interest as one way to pay for the pricey new benefits. According to one analysis, excluding the cost of the new benefits from the benchmark would reduce the fiscal cost by an estimated 41%, compared with a scenario that included the cost in the benchmark.

“This is because federal payments to [Medicare Advantage] plans would rise only modestly if the benchmarks excluded the new benefits, whereas they would rise substantially if the benchmarks included them,” according to the analysis by Matthew Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy.

Since rebates would fall, Medicare Advantage plans would have less to spend on supplemental benefits. But dental, vision and hearing would no longer be considered supplemental and would need to be incorporated into plans’ estimate of regular Medicare coverage costs, Fiedler noted.

That shift would mean that the rebate dollars that plans currently devote to dental, vision and hearing could be used for other supplemental benefits, which could shield those other benefits from substantial reductions, Fiedler said.

An analysis commissioned by AHIP, an industry group, estimated that incorporating a dental, vision and hearing benefit without adjusting the benchmark would have a substantial impact, resulting in a 48% decline in the national average rebate amount, or $58 per member per month.

No Sympathy

Critics of the Medicare Advantage program have long argued that the government is too generous in paying the private plans. When the Medicare program began incorporating private plans in the 1970s, part of the rationale was that the private plans could provide care more efficiently and save the program money. That hasn’t happened. In a June report to Congress, the Medicare Payment Advisory Commission estimated that the government pays 4% more for beneficiaries enrolled in Medicare Advantage than for those in traditional Medicare.

MedPAC recommended a 2% reduction in capitated payments to Medicare Advantage plans.

In addition, in a September report, the Office of Inspector General for the Department of Health and Human Services found that 20 of 162 Medicare Advantage companies used patient chart reviews and health risk assessments to boost their payments disproportionately compared with their enrollment size.

Losing Their Competitive Advantage

A big selling point for Medicare Advantage plans has been that they provide coverage for valuable benefits that the traditional Medicare program does not. In 2021, 94% of Medicare Advantage enrollees in individual plans are in plans with some level of dental coverage, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

But “some” coverage doesn’t necessarily mean comprehensive coverage. In a separate analysis, KFF found that Medicare beneficiaries faced high out-of-pocket costs for dental and hearing services, no matter what type of plan they had. In 2018, average out-of-pocket spending on dental care for traditional Medicare enrollees was $992. Medicare Advantage members spent modestly less out-of-pocket: $766.

In 2010, when the Affordable Care Act reduced Medicare Advantage plan payments to bring them in line with traditional Medicare, some in the industry predicted plans would pull out and benefits would be cut. That didn’t happen.

“The truth is Medicare Advantage has grown rapidly since then and extra benefits have proliferated,” Neuman said. So, if the payment methodology changes because of the addition of dental, hearing and vision benefits, “it’s hard to say what would really happen.”

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.

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Categories: Health Care

Medicare Punishes 2,499 Hospitals for High Readmissions

Kaiser Health News - 12 hours 4 min ago

The federal government’s effort to penalize hospitals for excessive patient readmissions is ending its first decade with Medicare cutting payments to nearly half the nation’s hospitals.

In its 10th annual round of penalties, Medicare is reducing its payments to 2,499 hospitals, or 47% of all facilities. The average penalty is a 0.64% reduction in payment for each Medicare patient stay from the start of this month through September 2022. The fines can be heavy, averaging $217,000 for a hospital in 2018, according to Congress’ Medicare Payment Advisory Commission, or MedPAC. Medicare estimates the penalties over the next fiscal year will save the government $521 million. Thirty-nine hospitals received the maximum 3% reduction, and 547 hospitals had so few returning patients that they escaped any penalty.

An additional 2,216 hospitals are exempt from the program because they specialize in children, psychiatric patients or veterans. Rehabilitation and long-term care hospitals are also excluded from the program, as are critical access hospitals, which are treated differently because they are the only inpatient facility in an area. Of the 3,046 hospitals for which Medicare evaluated readmission rates, 82% received some penalty, nearly the same share as were punished last year.

The Hospital Readmissions Reduction Program (HRRP) was created by the 2010 Affordable Care Act and began in October 2012 as an effort to make hospitals pay more attention to patients after they leave. Readmissions occurred with regularity — for instance, nearly a quarter of Medicare heart failure patients ended up back in the hospital within 30 days in 2008 — and policymakers wanted to counteract the financial incentives hospitals had in getting more business from these boomerang visits.

MedPAC has found readmission rates declined from 2008 to 2017 after the overall health conditions of patients were taken into account. Heart failure patient readmission rates dropped from 24.8% to 20.5%, heart attack patient rates dropped from 19.7% to 15.5%, and pneumonia patient rates decreased from 20% to 15.8%, according to the most recent MedPAC analysis. Readmission rates for chronic obstructive pulmonary disease, hip and knee replacements, and conditions that are not tracked and penalized in the penalty program also decreased.

“The HRRP has been successful in reducing readmissions, without causing an adverse effect on beneficiary mortality,” MedPAC wrote. The commission added that untangling the exact causes of the readmission rates was complicated by changes in how hospitals recorded patient characteristics in billing Medicare and an increase in patients being treated in outpatient settings. Those factors made it difficult to determine the magnitude of the readmission rate drop due to the penalty program, MedPAC said.

The current penalties are calculated by tracking Medicare patients who were discharged between July 1, 2017, and Dec. 1, 2019. Typically, the penalties are based on three years of patients, but the Centers for Medicare & Medicaid Services excluded the final six months in the period because of the chaos caused by the pandemic as hospitals scrambled to handle an influx of covid-19 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.

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Categories: Health Care

Look Up Your Hospital: Is It Being Penalized By Medicare?

Kaiser Health News - Wed, 10/27/2021 - 5:00am

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.

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.

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Categories: Health Care

How Billing Turns a Routine Birth Into a High-Cost Emergency

Kaiser Health News - Wed, 10/27/2021 - 5:00am

Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn’t prepare her for the resources the conservation biologist would owe after the birth of her second son.

Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only entrance open.

Despite the weird covid vibe — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse offering to wheel her to the labor and delivery department. She even took a selfie, smiling, as she entered the delivery room.

“I was just thrilled that he was here and it was on his due date, so we didn’t have to have an induction,” she said. “I was doing great.”

Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.

Wells Salerno expected the bill for Gus’ birth to be heftier than that for her first child, Hank, which had cost the family a mere $30. She was a postdoctoral fellow in California with top-notch insurance when Hank was born, about four years earlier. They were braced to pay more for Gus, but how much more?

Then the bill came.

The Patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

Medical Service: A routine vaginal delivery of a full-term infant.

Total Bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.

Service Provider: Poudre Valley Hospital in Fort Collins, Colorado, operated by UCHealth, a nonprofit health system.

What Gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.

The total bill was huge, but what really made Wells Salerno’s eyes pop was a line for the highest level of emergency services. It didn’t make any sense. Was it for checking in at the ER desk, as she’d been instructed to? She recalls going through security there on her way to labor and delivery, yet there was a $2,755 charge for “Level 5” emergency department services — as if she had received care there like a patient with a heart attack or fresh from a car wreck. It is the biggest item on the bill other than the delivery itself.

Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California-San Francisco and a practicing ER doctor, said Level 5 charges are supposed to be reserved for serious cases — “a severe threat to life, or very complicated, resource-intense cases” — not for patients who can walk through a hospital on their own. Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required.

But over the past 20 years, hospitals and doctors have learned there’s great profit in upcoding visits. After all, the insurer isn’t in the exam room to know what transpired. An investigation by the Center for Public Integrity found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 steadily grew from 23% to 34% for patients with commercial insurance.

After repeated calls questioning the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with KHN, explaining that “the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room.” 

A customer service representative later explained it was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.

Some hospitals provide that package of services via an “obstetrical emergency department.” OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren’t physically located anywhere near the ER.

Health care staffing company TeamHealth — owned by the investment company Blackstone, and known for marking up ER bills to boost profit — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a white paper, the company said an OB-ED is an “entrepreneurial approach to strengthening hospital finances” because with “little to no structural investment” it allows hospitals to “collect facility charges that are otherwise lost in the obstetrical triage setting.”

The OB Hospitalist Group, which is owned by a private equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals “leave a lot of money on the table” by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.

An Arizona facility said its revenue increased $365,000 per quarter after turning their obstetric triage area into an OB-ED. Poudre Valley Hospital’s website doesn’t list “OB-ED” as part of the facility’s offerings, though UCHealth documents do reference OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other area moms after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.

In Wells Salerno’s case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. “Being seen there in OB-ED did not impact this bill whatsoever,” said Dan Weaver, a spokesperson with UCHealth.

But in one of the other moms’ cases, it did: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.

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Ge Bai, a professor of accounting and health policy at Johns Hopkins University, said it’s a “questionable” billing practice, and one that can matter to those who don’t have the same kind of insurance as Wells Salerno, or have none at all.

Dr. Mark Simon, chief medical officer with OB Hospitalist Group, said OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.

UCHealth’s Weaver said they can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7, often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine “OB-ED” treatment, without their knowledge.

Weaver said the only time someone in labor would not go through the OB-ED — and therefore the only time they would not receive the emergency charge — is if they have a scheduled induction or cesarean section or are directly admitted from a provider’s office.

Hsia, the UCSF researcher and ER doctor, is unconvinced: “If they’re actually going to charge a special fee that you didn’t get directly admitted from your physician, that’s absolutely ridiculous.”

Wells Salerno’s “OB-ED” exam was performed by her clinician, but the OB-ED charge still showed up on her bill.

Resolution: After trying to determine that the charge wasn’t a mistake, Wells Salerno eventually threw in the towel and paid the bill.

“I was at a very vulnerable time during pregnancy and immediately postpartum,” she said. “I just felt like I had kind of been taken advantage of financially at a time when I couldn’t muster the energy to fight back.”

The fact that two healthy brothers could come with such different price tags isn’t surprising to Dr. Michelle Moniz. “There is no clinical reason that we have this level of variation,” said Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her research shows that people with private insurance pay anywhere from nothing to $10,000 for childbirth.

“You don’t get what you pay for,” said Wells Salerno, who maintains that — despite their price difference — both of her children are equally “awesome.”

Data from the Colorado Division of Insurance shows that Poudre Valley typically received about $12,000 for similar births in 2020, about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.

The Takeaway: Anything in our health system labeled as an emergency room service likely comes with a big additional charge.

Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.

If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 — and protest if your visit was misrepresented. Ask, “Has this bill been upcoded?” You are the only one who knows how much time you spent with a medical provider and how much care was given. Here’s a chart that will help with the proper definition of each level.

Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. It took hours on the phone with UCHealth, a lot of confidence and countless repetitions of the birth story — and how an emergency charge for a routine delivery just didn’t, and doesn’t, make sense.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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.

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Categories: Health Care

Medicare Plans’ ‘Free’ Dental, Vision, Hearing Benefits Come at a Cost

Kaiser Health News - Wed, 10/27/2021 - 5:00am

When Teresa Nolan Barensfeld turned 65 last year, she quickly decided on a private Medicare Advantage plan to cover her health expenses.

Barensfeld, a freelance editor from Chatham, New York, liked that it covered her medications, while her local hospitals and her primary care doctor were in the plan’s network. It also had a modest $31 monthly premium.

She said it was a bonus that the plan included dental, hearing and vision benefits, which traditional Medicare does not.

But Barensfeld, who works as a copy editor, missed some of the important fine print about her plan. It covers a maximum of $500 annually for care from out-of-network dentists, including her longtime provider. That means getting one crown or tending to a couple of cavities could leave her footing most of the bill. She was circumspect about the cap on dental coverage, saying, “I don’t expect that much for a $31 plan.”

Through television, social media, newspapers and mailings, tens of millions of Medicare beneficiaries are being inundated this month — as they are each autumn during the open enrollment period — by marketing from Medicare Advantage plans touting low costs and benefits not found with traditional Medicare. Dental, vision and hearing coverage are among the most advertised benefits.

Those services are also at the center of heated negotiations on Capitol Hill among Democrats as they seek to expand a number of social programs. Progressives, led by Sen. Bernie Sanders (I-Vt.), are pressing to add dental, vision and hearing benefits to traditional Medicare.

Despite the high-powered advertising of the Medicare Advantage plans pitched by the likes of celebrities Joe Namath and Jimmie Walker, beneficiaries still generally end up with significant out-of-pocket costs for many of these services, a recent study by KFF found. That’s partly because the private plans limit benefits. While people in traditional Medicare paid on average about $992 for dental care in 2018, those in Medicare Advantage plans paid $766, according to the study. For vision, people with traditional Medicare paid $242, compared with $194 for those covered by a Medicare Advantage plan.

“It stands to reason there would be lower out-of-pocket spending in Medicare Advantage than in traditional Medicare, but the differences are not as large as one might expect,” said Tricia Neuman, a senior vice president at KFF and executive director of its Medicare policy program.

More than 26 million people were enrolled in Medicare Advantage plans for this year — 42% of all Medicare beneficiaries. Enrollment in the private plans has doubled since 2012 and tripled since 2007. Unlike traditional Medicare, these private plans generally allow coverage through a limited network of doctors, hospitals and pharmacies.

Open enrollment for 2022 plans runs from Oct. 15 to Dec. 7, and some Advantage plans offer enticements such as hundreds of dollars’ worth of groceries, home-delivered meals or $1,000 in over-the-counter items such as adhesive bandages and aspirin.

But many seniors don’t realize there are restrictions on these benefits. They may cover extras only for enrollees with certain health conditions or have a narrow network of providers or annual dollar limits, often around $100 for vision or $1,300 for dental.

“All these extra benefits encourage people to sign up, but people don’t know what they have until they try to use it,” said Bonnie Burns, a training and policy specialist for California Health Advocates who helps Medicare beneficiaries evaluate their health plan options.

Seniors typically can choose from more than 30 Medicare Advantage plans sold by several insurers. The choice is so daunting that fewer than a third of seniors bother to shop and compare during the open enrollment window — even though costs and benefits change every year.

And for those who want to shop around, comparisons are not easy. The Medicare.gov website provides an overview of health plan costs and benefits and lets seniors compare plans’ premiums based on what medications the beneficiary uses. But it doesn’t offer a comparison of which doctors, dentists or hospitals are in the Medicare Advantage network or provide details about limits on dental, hearing and vision care. For that information, consumers must go to each insurer’s website and read through a summary of benefits that can be dozens of pages long.

Mary Beth Donahue, CEO of the Better Medicare Alliance, a research and trade group representing Medicare Advantage plans, sees things differently. “Medicare Advantage’s flexible benefit design means that beneficiaries can choose a plan tailored to their needs — whether that means more robust coverage, or more basic coverage, potentially for a lower cost,” she said.

Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center in New York, an advocacy group for seniors, said the extra benefits offered by plans have increased confusion among beneficiaries. Those benefits come at a price.

“There is almost always a trade-off such as narrower provider networks, tighter drug formulary or restrictions in other areas,” she said.

Jenny Chumbley Hogue, an insurance broker near Dallas and an analyst at medicareresources.org, which helps seniors navigate the program, said marketing misleads some of her clients. “They see a TV ad that says they can get everything for free when they may not qualify for those benefits,” she said. “It’s hard to know if they are misinformed or not reading the fine print.”

She added that consumers should choose a plan based on whether their doctor is in that network or their drugs are covered at the lowest cost. For example, while most plans offer a hearing aid benefit, it’s usually only for a certain type of aid from a single company, Chumbley Hogue said.

“The devil is in the details, particularly when it comes to dental,” she said. “The coverage is not typically what they are used to coming from an employer plan.”

Medicare Advantage dental benefits are becoming more robust, though. Nearly 90% of the private plans offer dental benefits at no extra cost and most offer coverage for treatment as well as cleanings and checkups, according to a report by the consulting firm Milliman. The percentage of plans offering preventive and comprehensive dental has jumped to 71% this year from 48% in 2019.

Plans also are increasing benefits so they meet Medicare’s requirement to spend at least 85% of enrollees’ premium dollars on health services, Neuman said. Plans that don’t reach that threshold can face sanctions, including not being allowed to enroll new members.

While some consumers may find the dental benefit alluring, not everyone uses the coverage. The Medicare plan may not cover their existing dentist, so they continue to pay out-of-pocket, she said.

Medicare Advantage beneficiaries use their dental benefits less frequently than people with dental coverage through their employer, said Joanne Fontana, a principal with Milliman. “Not everyone buys a plan because it covers dental,” she said, “and it’s not top of mind or they [don’t] think to go the dentist every year.”

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.

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Pharma Campaign Cash Delivered to Key Lawmakers With Surgical Precision

Kaiser Health News - Wed, 10/27/2021 - 5:00am

The Biden administration and Congress are embroiled in high-stakes haggling over what urgent priorities will make it into the ever-shrinking social spending bill. But for the pharmaceutical industry there is one agenda: Heading off Medicare drug price negotiation, which it considers an existential threat to its business model.

The siren call to contain rising drug costs helped catapult Democrats to power, and the idea is popular among voters regardless of their politics. Yet granting Medicare broad authority to intervene in setting prices has nonetheless divided the party.

And so, as it normally does, the drug industry gave generously to members of Congress, according to new data from KHN’s Pharma Cash to Congress database. Contributions covering the first half of this year show that some of its biggest donations were delivered with surgical-strike precision to sympathetic or moderate Democratic lawmakers the industry needs to remain in its corner.

Campaign donations to members of Congress — which must be reported to the Federal Election Commission — are the tip of the iceberg, signaling far greater activity in influence peddling that includes spending millions on lobbying activities and advertising campaigns.

Unusually, in the first half of this year Republicans and Democrats in Congress were virtually neck and neck in pulling in drug industry money, according to a KHN analysis of campaign contributions. In prior years, Republicans dominated giving from that sector, often by huge margins.

Pharmaceutical companies and their lobbying groups gave roughly $1.6 million to lawmakers during the first six months of 2021, with Republicans accepting $785,000 and Democrats $776,200, the Pharma Cash to Congress database shows. Since the 2008 cycle, the industry has generally favored Republicans. The exception was 2009-10, the last time Democrats controlled both chambers of Congress and the White House.

Democrats again narrowly hold both the House and Senate, and political scientists and other money-in-politics experts said the contributions likely reflect who is in power, which lawmakers face tougher reelection bids next year, and who has outsize sway over legislation affecting the industry’s bottom line.

Several pharmaceutical companies paused contributions to Republican lawmakers who voted against certifying the results of the 2020 election, blunting the GOP’s total fundraising haul and overall industry giving compared with other years.

The drug industry’s campaign contributions are markedly strategic, said Steven Billet, an associate professor at the Graduate School of Political Management at George Washington University.

“This is a really well-organized commercial sector,” Billet said. “If I’m one of these PACs, I’ve surveyed the landscape at the front end of the process, decided on our agenda and budget, and figured out who I may be able to get to and who I wouldn’t be able to get to.”

Of the top 10 recipients of funding, Republican lawmakers accounted for six; Democrats, four. Rep. Scott Peters (D-Calif.) received the most money of any member of Congress, with $63,900 in contributions in the first half of the year. Peters, whose San Diego-area district includes multiple drug companies, has consistently accepted money from drugmakers since he took office in 2013, according to KHN’s database. Right behind Peters was Rep. Cathy McMorris Rodgers (R-Wash.), who received $50,000 from the industry in the first six months of 2021. McMorris Rodgers was chosen this year to be the most senior Republican on the House Energy and Commerce Committee, which has significant influence on pharmaceutical issues. Peters sits on the same committee.

“They’re typically going to saturate the committees that are relevant to their industry,” said Nick Penniman, CEO of Issue One, a nonprofit that advocates reforming money’s influence in politics.

Next in line was Sen. Robert Menendez (D-N.J.), who accepted $49,300, the most of any senator this year despite not facing reelection until 2024. The vote of Menendez, a longtime ally of the industry, would be crucial for Democrats to pass any proposal giving the government greater control over drug prices. The pharmaceutical industry is a major employer in New Jersey, home to headquarters of behemoths like Johnson & Johnson, Merck, Novo Nordisk and Sanofi.

Menendez said he’s waiting to see the proposal, “which I expect will include language to allow Medicare to negotiate drug prices.”

“The focus of any proposal must be lowering patient costs,” he said, “and that will drive my analysis.”

Among other moderate Democrats is Sen. Kyrsten Sinema (D-Ariz.), whose vote also is critical to passage. She received $108,500 in pharma contributions in 2019-20, according to the KHN database. However, in the first half of this year, she received only $8,000. She has not said publicly where she stands on the current pricing proposal.

As Billet sees it, the pharmaceutical industry knew allowing Medicare to negotiate drug prices would likely be on the table, and drug companies shored up members, such as Peters and Menendez, who have sided with them in the past. Plus, “right now, the Democrats are driving the train, and because of that they’re going to get a few more contributions,” Billet added.

Peters received funds from nearly two dozen companies or industry groups, including Eli Lilly, Takeda Pharmaceutical, Pfizer, Merck, GlaxoSmithKline, EMD Serono and Amgen. Menendez’s donors included Boehringer Ingelheim, Sanofi, Pfizer, Merck, Gilead Sciences, Eli Lilly, Teva and Novo Nordisk. A spokesperson for Peters did not respond to request for comment.

Controlling drug prices has broad support among adults regardless of political party, according to polling from KFF (KHN is an editorially independent program of KFF). But facing industry opposition, Democrats have yet to agree on a plan as lawmakers weigh which policies make it into a massive domestic spending bill to expand the social safety net and address climate change. Central to the industry’s argument is that greater government intervention in setting prices would harm new drug development; however, drug pricing experts generally say this argument is overblown. Republicans remain unanimously opposed, which means Senate Democrats can’t afford any defections to advance legislation.

Fourth in industry contributions was Sen. Catherine Cortez Masto (D-Nev.), a freshman lawmaker on the powerful Senate Finance Committee, which oversees legislation pertaining to federal health programs like Medicare. Cortez Masto received $46,000, with cash flowing in from companies like Eli Lilly, Merck, Pfizer, Johnson & Johnson and Mallinckrodt Pharmaceuticals, the latter of which filed for bankruptcy in 2020 after being swamped with litigation over its alleged role in the opioid crisis. One of her recent aides, Eben DuRoss, was hired as a lobbyist this year by the Pharmaceutical Research and Manufacturers of America, or PhRMA, federal disclosures show.

Cortez Masto is up for reelection next year in a battleground state that’s been competitive between Republicans and Democrats in recent elections. She was narrowly elected in 2016, and recent polling showed she held a small lead against her expected Republican challenger in 2022, former Nevada attorney general Adam Laxalt.

But her contributions dwarf those of other Senate Democrats in close races. For example, in the first half of this year, Sen. Maggie Hassan (D-N.H.), who also sits on the Senate Finance Committee, reported having accepted $6,000.

Two other lawmakers in competitive seats, Sen. Raphael Warnock (D-Ga.) and Sen. Mark Kelly (D-Ariz.), didn’t receive funding from the pharmaceutical sector.

Sarah Bryner, research director of OpenSecrets, a nonprofit that tracks money in politics, noted several reasons Cortez Masto would pull in more money. In addition to her committee seat and competitive race, politically she’s more moderate than progressive lawmakers who have been bigger agitators against the drug industry.

“She’s not seen as an extremist, which is the kind of person who would typically take in more money” from political action committees, Bryner said.

Cortez Masto was also a recent past chair of the Democratic Senatorial Campaign Committee and therefore heavily involved in the party’s national fundraising efforts to preserve Democrats’ Senate majority. Those relationships with corporate and other donors could be leveraged for her own race, Bryner said. “Once you’ve made all the relationships, it’s not like they just disappear,” she said.

Still, the freshman Democrat has openly supported allowing Medicare to negotiate prescription drug prices, in contrast to Menendez, who voted against the idea in 2019. The Nevada senator recently told KHN that she “absolutely” backs the policy and that the pharma cash flowing into her campaign coffers doesn’t influence her decisions.

“I’ve already supported it in Finance and actually voted to pass legislation to do just that,” Cortez Masto said. “We need to reduce the health care costs for so many in this country, and that’s what I’m focused on doing, including reducing prescription drug costs.”

Peters — who unseated a Republican in 2012 — was one of four moderate House Democrats who in September voted against a plan to give Medicare broad authority to negotiate prescription drug prices. They backed a narrower alternative that includes caps on out-of-pocket spending and limits the scope of Medicare’s negotiating authority to a smaller set of medications.

The money Peters and McMorris Rodgers got from drugmakers ($63,900 and $50,000, respectively) significantly jumped from the same periods in past cycles. In the first half of 2019, Peters received $19,500, and during those same quarters in 2017 he got $36,000. McMorris Rodgers’ haul for the first six months of 2019 was $2,500, and two years earlier it was $3,000. However, Menendez received more funding in the first half of 2019 ($52,000) than this year.

That some drugmakers — including Pfizer, Johnson & Johnson, Gilead and Eli Lilly — as well as PhRMA and the Biotechnology Innovation Organization, another lobbying group for the industry, paused contributions to Republicans after the events of Jan. 6 seems at least in part to account for overall pharma contributions dropping in comparison with other years. In the first half of 2019 drugmakers gave $3.7 million, and in the first half of 2017 they gave about $4.4 million, versus 2021’s $1.6 million.

However, other drug company PACs and their industry groups kept up contributions or failed to void checks they’d issued to those who refused to certify the election results, according to a KHN analysis of the FEC data.

They include Merck, Novo Nordisk, GlaxoSmithKline, AstraZeneca, Genentech, Boehringer Ingelheim, Amgen, Teva, EMD Serono and the Association for Accessible Medicines, which all gave $1,000 or more to at least one of the 147 Republicans who voted to overturn the election results.

Direct contributions to lawmakers’ political accounts are only one way for the industry to channel cash to Congress. Companies also give money to trade associations and 501(C)(4)s, which are nonprofits that often function as “dark money” groups because they are not required to disclose their donors.

“We know that they’re giving; they didn’t stop giving. Their giving went underground,” said Carlos Holguin, research director for the Center for Political Accountability, a nonprofit that tracks money in politics.

Groups also funnel money into advertising — in September, PhRMA announced a seven-figure ad campaign opposing Democrats’ drug pricing plan — or into advocacy groups from which it may eventually trickle down to political candidates.

Another factor? Hail Mary covid-19 vaccines, developed and distributed in record time, that may have shored up goodwill with lawmakers. Or that, despite everything lawmakers have said about lowering drug costs, the industry suspects drug pricing legislation will stall once again and don’t want to spend their political capital on the issue.

“I think, frankly, drugmakers know they’ve won the match when it comes to drug pricing. This whole question of the cost of pharmaceuticals, it has come up for literally decades now and they have successfully shut it down, year after year,” Penniman said. “At a certain point, they know they have driven the nail far enough in the wood and they don’t need to do much more.”

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.

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Pharma Cash to Congress

Kaiser Health News - Tue, 10/26/2021 - 5:00pm

Every year, pharmaceutical companies contribute millions of dollars to U.S. senators and representatives as part of a multipronged effort to influence health care lawmaking and spending priorities. Use this tool to explore the sizable role drugmakers play in the campaign finance system, where many industries seek to influence Congress. Discover which lawmakers rake in the most money (or the least) and which pharma companies are the biggest contributors. Or use our search tool to look up members of Congress by name or home state, as well as dozens of drugmakers that KHN tracks.

Methodology

 

UPDATE: KHN has removed contributions from Abbott Laboratories after 2013, when the company spun off its pharmaceutical business as Abbvie Inc. Abbott Laboratories is a medical device and health care company.

Kaiser Health News uses campaign finance reports from the Federal Election Commission (FEC) to track donations from political action committees (PACs) registered with the FEC by pharmaceutical companies. Totals include donations to the principal campaign committees and leadership PACs for current members of Congress. We include only donations to members for election cycles in which they hold office (even if they weren’t in office for the full cycle, in the case of special elections). Donations are assigned to the quarter in which they were given, regardless of when they are reported by the receiving committee or PAC. Exact amounts can change as amendments and refunds are reported; KHN will update the analysis quarterly. Occasionally, refunds are reported in a different cycle from the original contribution, resulting in a negative total for the cycle.

There is a legal limit to how much each PAC can give to a member of the Senate or House of Representatives: $5,000 per election (including primaries and general elections) and per committee, or $10,000 per cycle. Each cycle is two calendar years, e.g. Jan. 1, 2017-Dec. 31, 2018.

When calculating changes in contributions from one cycle to another, we compare the latest quarter in the current cycle to the same point in the previous cycle for all drugmakers and for members of the House, who run for re-election every two years. For senators, who run for re-election every six years, we compare the current cycle to the cycle six years prior. We use the ProPublica Congress API to gather some information about past and present members. We use both Open Secrets and CQ Political Moneyline to collect additional information about PACs and verify our work.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold 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.

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Analysis: A Procedure That Cost $1,775 in New York Was $350 in Maryland. Here’s Why.

Kaiser Health News - Tue, 10/26/2021 - 5:00am

For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: “Now you’ll be able to write about your own bills.” After all, I’d spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.

But my bills were, in fact, mostly totally reasonable.

That’s largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, the one state in the nation that controls what hospitals can charge for services and has a cap on spending growth.

Players in the health care world — from hospitals to pharmaceutical manufacturers to doctors’ groups — act as if the sky would fall if health care prices were regulated or spending capped. Instead, health care prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.

But for decades, an independent state commission of health care experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called “all-payer rate setting.” In 2014, Maryland also instituted a global cap and budget for each hospital in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost could rise only a small amount annually, forcing price increases to be circumspect.

If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland’s financial guardrails for hospitals effectively protected my wallet.

During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.

Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as “surgery,” for a price of $6,244.38. The physician charge was $3,782.

I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America’s sky-high health care costs and our rising insurance premiums to cover them.

It wasn’t easy for Maryland to enact its unique health care system. The state imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.

The rate was more generous than Medicare’s usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.

In subsequent decades, however, hospitals did end runs around price controls by simply ordering more hospital visits and tests. Spending was growing. Maryland risked losing the federal waiver that had long underpinned its system. Also, under the waiver’s terms, Maryland’s hospitals were at risk for paying a hefty penalty to the federal government for the excessive growth in cost per patient.

That’s why in 2014 the state worked with the federal Centers for Medicare & Medicaid Services to institute the global cap and budget system in place today. Dr. Joshua Sharfstein, who was the state’s health and mental hygiene secretary, met skeptical hospital administrators to “sell the concept,” as he described it, assuring them the hospitals would still get reasonable revenue while gaining new opportunities to improve the health of their communities with money to invest in preventive services.

Studies show the program, which was further revised in 2019, generally worked at keeping costs down and generated savings of $365 million for Medicare in 2019 and over $1 billion in the prior four years. What’s more, working with a fixed budget has provided incentives for hospitals to keep patients out, resulting in programs like better outpatient efforts to manage chronic illnesses and putting doctors in senior housing to keep residents out of hospitals through on-site care.

Instituting this type of plan may be politically unacceptable statewide in other places today, given the much greater power now of hospital trade groups and large consolidated hospital networks. “Where hospitals are making money hand over fist, it’s a hard sell to switch,” Sharfstein said. “But where hospitals are facing economic pressure, there is much more openness to financial stability and the opportunity to promote community health.”

Sharfstein thinks the Maryland approach can be especially attractive for financially strapped rural and urban hospitals that treat mostly people on Medicaid and the uninsured.

Though Maryland is an oddity in the United States (the few other states that tried price controls in the 1970s abandoned the experiment long ago), many countries successfully use price guidelines and budget limits to control medical spending. Notable among them is Germany, whose health system is otherwise similar to the United States’, with multiple insurers. A landmark 1994 study comparing efforts here and abroad did find that the German system, for example, can be stingier at providing care that is expensive or elective.

But, referring in part to that issue, the study’s author concluded that costs are so high in the United States that the country “could probably lower our expenditures and see none of the problems that we found in our study for a number of years.”

Data also shows that operating margins, a measure of profit, are generally slimmer in Maryland than those of big health systems in the rest of the country. Johns Hopkins’ margin was 1.2% in fiscal year 2019, compared with 6.9% at the Mayo Clinic in Minnesota and 5.8% at the University of Pennsylvania Health System; Stanford Health Care’s was 7.1%.

But those margins can also reflect how much of its income a hospital chooses to spend on things like amenities and executive pay. Living with financial constraints may be at least partly why Johns Hopkins Hospital’s main entrance is pleasant but functional, lacking the elegant art-filled marble lobbies I often encounter at its peer hospitals.

My experience demonstrates that excellent care can be delivered to patients by a system that works within financial limits. And that’s something America needs.

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.

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Direct Primary Care, With a Touch of Robin Hood

Kaiser Health News - Tue, 10/26/2021 - 5:00am

MODESTO, Calif. — Britta Foster and Minerva Tiznado are in different leagues as far as health care is concerned.

Foster, who married into the family that owns the $2.5 billion Foster Farms chicken company, has Blue Shield coverage as well as a high-octane primary care plan that gives her 24/7 digital access to her doctor for a $5,900 annual fee that also covers her husband and two of their children.

Tiznado is from Nayarit, Mexico, and has no insurance. She gets free primary care visits and steep discounts on prescription drugs, lab tests and imaging.

But Tiznado, 32, and Foster, 48, go to the same place for their care: St. Luke’s Family Practice, in this Central Valley city of about 217,000. St. Luke’s, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

The annual fees that St. Luke’s collects from Foster’s family and some 550 other paying patients help cover free care for a somewhat larger number of uninsured patients, many of them, like Tiznado, Spanish-speaking immigrants who can’t get Medicaid because they lack documents.

The clinic does not accept insurance of any kind but requires its paying patients to have coverage for major medical expenses outside its scope of care.

The paying patients, whom St. Luke’s calls “benefactors,” say they are happy to participate in this “Robin Hood” model. It gives them highly personalized care with great access to their doctors and the emotional satisfaction of supporting those less privileged, the “recipients.”

Foster said it’s been a “huge, huge benefit” for her family to be able to text or call their doctor at any time and be seen on short notice: “Knowing that their group is here also to serve our community makes it all feel even more important.”

Tiznado, who visited the clinic one September morning for a scheduled monitoring of ovarian cysts, said St Luke’s “has helped us a lot — economically and in every way. I think if we moved somewhere else, I would continue coming here.”

But Tiznado and the other uninsured patients don’t get the same 24/7 access that benefactors do. The two groups used separate waiting rooms until the pandemic hit.

St. Luke’s is a local response to systemic U.S. health care problems including physician burnout, patient dissatisfaction and the fact that millions still lack care. Nearly 3.2 million Californians, including 1.3 million undocumented people, will be uninsured in 2022, although the state is gradually expanding Medicaid coverage to many immigrants. St. Luke’s is part of the movement for direct primary care, an alternative for doctors fleeing insurance-dominated medical groups.

Roughly 200 direct primary care practices start up each year in the United States, and there are currently 1,581 of them employing an estimated 3,000 doctors, according to Dr. Philip Eskew, founder of DPC Frontier, which provides resources for doctors who want to make the switch. That’s a tiny fraction of the nearly 209,000 primary care doctors in the U.S.

“We are indeed a small movement at this time,” Eskew said.

Their biggest challenges are regulatory. If the clinics take fees from people enrolled in Medicare, for example, their doctors must forgo Medicare reimbursement anywhere they practice. And some state regulators may consider direct primary care practices to be health plans and impose terms or restrictions that make it difficult or impossible for them to operate.

Doctors in direct primary care typically charge patients a monthly or annual fee in exchange for enhanced access via phone, text or video, shorter wait times and longer face-to-face visits. And they generally don’t accept insurance, thus eliminating the need to chase bills and treatment authorizations.

“In my old practice, we spent almost half our time collecting payments. I thought if we could just get rid of all that overhead, we could spend more time with patients — and it proved true,” said Dr. Bob Forester, the conceptual father and co-founder of St. Luke’s, who retired earlier this year.

Many direct primary care docs scoff at the high-tech investor-owned firms such as One Medical and Forward Health. They are widely viewed as direct primary care companies, but critics say they are more focused on expanding volume than on offering personalized service.

“Direct primary care is where a physician has a relationship with a patient. We do not have to be accountable to an investor, because our investors are our patients,” said Dr. Maryal Concepcion, a family doctor in the remote mountain town of Arnold, California, who recently left a commercial practice to launch her own one-woman direct primary care practice.

St. Luke’s paid patients must have insurance to cover hospitalization, surgeries, specialty care, imaging and prescription drugs.

The clinic is often able to find steep discounts for its uninsured patients. For example, Quest Diagnostics charges them only 10% to 15% of its regular price for lab work, said Dr. R.J. Heck, one of the two family physicians at St. Luke’s and co-founder of the clinic. It often refers uninsured patients who need operations to Cirugía sin Fronteras, a reduced-rate surgery center in Bakersfield.

St. Luke’s recently got a $75,000 grant for imaging, lab tests, X-rays and some prescription drugs from the Legacy Health Endowment, a local foundation. And it works with several radiology groups that provide discounts, Heck said.

Tiznado, who needs periodic ultrasounds for her ovarian cysts, said she pays around $150 for them. “If I did it in another place, it would cost between $900 and $1,200,” she said.

St. Luke’s nonprofit tax-exempt status encourages donations, including from local corporate benefactors such as Foster Farms and winemaker E. & J. Gallo. Some workers at donor companies are among St. Luke’s uninsured patients.

Tax-exempt status also confers a benefit on paying patients: They can take a tax deduction on the portion of their annual fees they don’t use for medical care. Every year, St. Luke’s sends them a statement that puts a dollar value, based on Medicare prices, on the services they received.

Forester said St. Luke’s arose from his concern for the uninsured and his disdain for bureaucratic systems. But “the bottom line,” he said, “is that the idea for St. Luke’s came in an inspired moment of prayer.” He and Heck launched it over 17 years ago as a Catholic-inspired medical office.

However, while Catholic symbols adorn the walls of St. Luke’s, many of its patients are not Christian, and Catholic medical doctrine is not central to its practice.

“There’s nobody coming in here and looking or telling us what we should or shouldn’t do,” said Dr. Erin Kiesel, the clinic’s other family doctor.

Kiesel said she wouldn’t prescribe an abortion, but she would tell somebody where to go if they asked — which nobody has.

Heck and Kiesel took big pay cuts to come to St. Luke’s. Kiesel makes about $60,000 less a year than in her previous practice. Having more time with patients, less paperwork and better work-life balance more than offsets the lower pay, she said.

Patients cited the personal relationships they’ve built with their St. Luke’s providers.

Paul Neumann, a patient of Heck’s for 25 years who followed him to St. Luke’s, said that relationship has been a godsend.

He told of returning from a trip to Rome in 2009 with a case of walking pneumonia. When his wife called Heck the next morning, he came to the house immediately.

Neumann, 84, pays St. Luke’s well north of $10,000 a year for himself, his wife and his son’s family.

“I’d be happy to write a check twice as large,” he said.

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.

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Understaffed State Psychiatric Facilities Leave Mental Health Patients in Limbo

Kaiser Health News - Tue, 10/26/2021 - 5:00am

Many patients dealing with mental health crises are having to wait several days in an ER until a bed becomes available at one of Georgia’s five state psychiatric hospitals, as public facilities nationwide feel the pinch of the pandemic.

“We’re in crisis mode,’’ said Dr. John Sy, an emergency medicine physician in Savannah. “Two weeks ago, we were probably holding eight to 10 patients. Some of them had been there for days.”

The shortage of beds in Georgia’s state psychiatric facilities reflects a national trend linked to staffing deficits that are cramping services in the public mental health system. The bed capacity problem, which has existed for years, has worsened during the covid-19 pandemic, creating backlogs of poor or uninsured patients as well as people in jails who are awaiting placement in state facilities.

Many state workers, such as nurses, are leaving those psychiatric units for much higher pay — with temp agencies or other employers — and less stressful conditions. The departures have limited the capacity of state-run psychiatric units for patients, who often are poor or uninsured, forcing some people with serious mental illness to languish in hospital emergency rooms or jails until beds open up in the state systems, according to local leaders of the National Alliance on Mental Illness.

“Such patients are sometimes strapped down or held in isolation, and often receive little or no mental health services,” said Roland Behm, a board member of the Georgia chapter of the American Foundation for Suicide Prevention.

Nationally, the shortage of beds and mental health workers has collided with an increasing, pandemic-driven demand for mental health treatment.

“ERs have been flooded with patients needing psychiatric care,” said Dr. Robert Trestman, chairperson of the American Psychiatric Association’s Council on Healthcare Systems and Financing. “The current crisis is unprecedented in the extent, severity and sweep of its national impact.”

Virginia has severely curtailed admissions to state mental hospitals because of staffing shortages amid increased demand for services. “I have never seen an entire system bottleneck this bad,” said Kathy Harkey, executive director of the National Alliance on Mental Illness’ Virginia chapter. The strain is spilling over into the private system, she added.

A Texas advisory committee reported in July that a near-record number of people were on the waitlist for state hospital beds for forensic patients, meaning those involved in the court system who have mental illness.

Last month, National Guard soldiers returned to Oregon’s largest public psychiatric facility to shore up the workforce there.

In Maine, a committee of criminal justice and mental health officials has been working on adding state psychiatric beds and finding placements for people who need treatment for mental illness but are being held in jails.

The well-insured normally can choose private facilities or general hospital psychiatric wards, Trestman said. But in many cases, those beds are now filled, too.

Like the medical system overall, the behavioral health system is “under a great deal of strain,” said Dr. Brian Hepburn, head of the National Association of State Mental Health Program Directors. The workforce shortage is especially acute at inpatient or residential behavioral health facilities, he said, and that pressure extends to private providers.

States are now focused on suicide prevention and crisis services to reduce pressure on emergency rooms and inpatient services, Hepburn added.

In Georgia, roughly 100 beds in the state’s five psychiatric hospitals — or about 10% — are empty because there's no one to take care of the patients who would occupy them. Space in short-term crisis units is also squeezed. The turnover rate for hospital workers was 38% over the past fiscal year, according to the state Department of Behavioral Health and Developmental Disabilities.

Beyond hospitals, Melanie Dallas, CEO of Highland Rivers Health, which delivers behavioral health services in northern Georgia, said the challenge of dealing with higher demand amid such a diminished number of staffers is unprecedented in her 33 years in the field. “Everybody is exhausted.”

Nationally, scores of nurses and other mental health workers have left state jobs.

It’s “hard work and it’s grueling,” said Hannah Longley, community program director of the Maine chapter of the National Alliance on Mental Illness. State work doesn’t offer “a significant salary and benefit package.”

A state hospital nurse in the U.S. typically makes $40 to $48 an hour, while the rate for a temp agency nurse runs $120 to $200, Trestman said.

“A lot of people are chasing the covid money,” said Netha Carter, a nurse practitioner who works in an Augusta, Georgia, state facility for developmentally disabled people. She said that temp agencies are offering “triple the pay” given by state facilities, though she's staying put because she likes the kind of work she's doing.

Kim Jones, executive director of NAMI in Georgia, said she has received more calls about people with mental health needs who can’t get long-term hospital services as the bed backlog increases.

Such waits for care can worsen patients’ conditions. Several years ago, Tommie Thompson’s son Cameron waited 11 months to get a state hospital bed in Atlanta while in jail. “By the time he got to the hospital, he was totally psychotic,” Thompson said.

The backlog in public services is playing out in jails across Georgia, with more people being kept behind bars because mental health facilities are swamped.

The Georgia Sheriffs’ Association said its members have relayed their difficulties in placing people in state-run treatment. “A lot of these folks don’t need to be in jail, but they’re stuck in there,” said Bill Hallsworth, the association’s coordinator of jail and court services. “There’s no place to put them.”

Hospital ERs also are feeling the shortage of state beds, said Anna Adams, a senior vice president of the  Georgia Hospital Association. People with mental illness arriving in the ER “tend to be at the end of the line,” said Robin Rau, CEO of Miller County Hospital in rural southwestern Georgia.

Rau said the bed backlog is horrible. “Covid has just exacerbated everything.”

Need Help?

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

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.

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Categories: Health Care

3 States Limit Nursing Home Profits in Bid to Improve Care

Kaiser Health News - Mon, 10/25/2021 - 5:00am

Nursing homes receive billions of taxpayers’ dollars every year to care for chronically ill frail elders, but until now, there was no guarantee that’s how the money would be spent.

Massachusetts, New Jersey and New York are taking unprecedented steps to ensure they get what they pay for, after the devastating impact of covid-19 exposed problems with staffing and infection control in nursing homes. The states have set requirements for how much nursing homes must spend on residents’ direct care and imposed limits on what they can spend elsewhere, including administrative expenses, executive salaries and advertising and even how much they can pocket as profit. Facilities that exceed those limits will have to refund the difference to the state or the state will deduct that amount before paying the bill.

The states’ mandates mark the first time nursing homes have been told how to spend payments from the government programs and residents, according to Cindy Mann, who served as Medicaid chief in the Obama administration.

With this strategy, advocates believe, residents won’t be shortchanged on care, and violations of federal quality standards should decrease because money will be required to be spent on residents’ needs. At least that’s the theory.

“If they’re not able to pull so much money away from care and spend it on staffing and actual services, it should make a big difference,” said Charlene Harrington, professor emeritus at the University of California-San Francisco’s School of Nursing who has spent four decades studying nursing home reimbursement and regulation. “I would expect the quality of care would improve substantially.”

“The actual effect will be just the opposite,” said Andrew Aronson, president and CEO of the Health Care Association of New Jersey. “By trying to force providers to put more money into direct care, you’re creating a disincentive for people to invest in their buildings, which is going to drive the quality down.”

Next year, New York’s nursing facilities will have to spend at least 70% of their total revenue —including payments from Medicaid, Medicare and private insurers — on resident care and at least 40% of that direct-care spending must pay for staff members involved in hands-on care. In Massachusetts, Gov. Charlie Baker issued rules requiring nursing homes have to spend at least 75% of all revenue on residents’ care. New Jersey’s law requires its nursing homes to spend at least 90% of revenue on patient care. But its state regulators have proposed that the requirement apply only to Medicaid funding. No final determination has been made.

All three states promise a boost in Medicaid payments to facilities that comply with the laws.

Harrington and other advocates say the measures are well overdue, but they are watching how regulators in each state define direct care, who qualifies as a direct care worker, what counts as revenue and whether it is reported accurately.

Jim Clyne, president and CEO of LeadingAge New York, which represents nonprofit nursing facilities, questions the legality of some provisions in New York’s law. “I don’t think there’s any doubt that it will end up in court,” he said.

Aronson said the mandate is based on a misconception — that nursing homes could have kept covid-19 out of their facilities if they had only marshaled their resources properly. “As long as covid is in our communities, it will also find its way into our facilities,” he said.

But poor infection control practices resulting from inadequate staffing have been the most common violation cited by nursing home inspectors over the years, according to a study released last year by the federal Government Accountability Office. The pandemic did little to change that trend. In August 2020, a frustrated Seema Verma, then-administrator of the Centers for Medicare & Medicaid Services, warned nursing home operators that “significant deficiencies in infection control practices” were responsible for increases in covid deaths and pleaded with them “to really double down on those practices.”

“Philosophically, if a payer wants to tell the provider how to use their funds within certain parameters, I understand that, but that’s not what the [New York] law does,” said Clyne. “The law goes beyond that. The state is telling the provider how much of other people’s money they have to spend on care also, not just the state’s money.”

Bills paid by Medicare or individuals should be excluded from the state mandate, along with Medicaid funds earmarked for certain purposes such as mortgage expenses, he said.

Medicaid, funded under a state and federal government partnership, provides health insurance to low-income people and typically pays for about 60% of the nursing home care nationwide, usually for long-term residents with chronic health problems. Medicare, funded by federal dollars, insures older or disabled adults, and provides about 16% of facilities’ revenue. The rest comes from private Medicare Advantage and other health insurance companies, and individuals who pay for their own care.

“Nursing homes are primarily funded by public tax dollars, Medicaid or Medicare — and the public has a reason to care about how our dollars are being spent,” said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey, and backed the legislation in both states.

The spending mandates are not a new idea for health care. The Affordable Care Act directs health insurers to spend at least 80 cents of every dollar in premiums to pay for beneficiaries’ health care needs. What remains can be spent on administrative costs, executive salaries, advertising and profits. Companies that exceed the limit must refund the difference to beneficiaries.

Harrington disagrees with industry officials who want to exclude Medicare dollars from the calculation of how much nursing homes must spend on direct care. That would leave a large source of profits untouched, she said, and allow them to use that money “however you want.”

Medicare paid nursing homes $27.8 billion in fiscal year 2019, according to the Medicare Advisory Payment Commission, an independent panel appointed by Congress.

Even if only the Medicaid money is affected, though, there’s still a big problem in the direct care spending mandate, said Aronson. “Ninety percent of facilities are losing money,” he said, because Medicaid payments don’t cover the cost of care. In New Jersey, he added, the shortfall is $40 a day per resident.

But some state lawmakers are not convinced. “Medicaid payments may not fully cover the cost of care, but somehow for-profit nursing homes are making money,” said New York state lawmaker Richard Gottfried, who has chaired the Assembly health committee since 1987. More than two-thirds of the state’s nursing homes operate as for-profit businesses and have been able to hide some of those profits in associated businesses they also own and then hire, he said. They can “use real estate gimmicks and shell contracts to make it look like they’re spending money when what they are really doing is just siphoning income into their own pockets,” he said. The use of such “related parties” payments has occurred across the country for several years.

To uncover the facilities’ true income and expenses, the state mandates require accurate documentation. “If they file false documentation, that will be a felony,” said Gottfried.

The spending mandates come at a challenging time for the industry, which is still recovering from the worst of the pandemic and facing a staffing shortage and low occupancy. But New York Assembly member Ron Kim, whose uncle died in a nursing home from presumed covid, said lawmakers should be able to tell nursing home operators how to spend taxpayers’ money. “If they choose to rely on public dollars to deliver care, they take on a greater responsibility,” he said. “It’s not like running a hotel.”

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.

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Categories: Health Care

Fresh Faces, Fewer Tools: Meet the New Bosses Fighting Covid

Kaiser Health News - Mon, 10/25/2021 - 5:00am

VIRGINIA CITY, Mont. — Emilie Sayler’s roots run deep in southwestern Montana. She serves on a nearby town council and the board of the local Little League. She went to college in a neighboring county and regularly volunteers in the schools of her three kids.

Just a few months into her new job as public health director for Madison County, she had hoped that those local connections might make a difference, that the fewer than 10,000 residents spread out across this agricultural region would see her familiar face and support her efforts to curtail the covid-19 pandemic raging here.

That largely hasn’t happened. School boards have rebuffed even minor measures to prevent outbreaks, vaccination rates languish and the Centers for Disease Control and Prevention categorizes infection levels in the rural county as high. Parents, Sayler said, are sending sick kids to school.

On top of that, a resident phoned her office and told a member of her staff, “I wish that you would get covid and die.”

“People have used the term ‘free-for-all,’ and I really hate to admit that that’s what it kind of feels like,” Sayler said.

Nationally, KHN and The Associated Press have documented that more than 300 public health leaders, weary of abuse and of their expertise being questioned, have resigned or retired as the country struggles to recover from the worst pandemic in a century. They have been replaced by people like Sayler, often inexperienced yet tasked with repairing the trust of a polarized and fatigued public.

At least 26 states have passed laws or regulations limiting the powers of public health officers this year, meaning these replacements have fewer tools and less authority than their predecessors to enforce their orders and recommendations.

Montana passed laws considered some of the most restrictive. This year, the state legislature curbed the powers of health officers to, among other things, quarantine infected citizens or isolate those in close contact with them. Lawmakers also prevented public and private employers from requiring workers to be vaccinated and gave local elected officials the ability to overturn public health orders.

Now Montana is at or near the bottom of many national statistics charting the covid surge — rates of new cases, hospitalizations and deaths — that is happening in counties big and small.

Lori Christenson is the new health officer for Gallatin County, Madison County’s neighbor to the east and home of the city of Bozeman and Montana State University. In June, she replaced Matt Kelley, who before resigning had become a political punching bag as the county mandated masks in public places and restricted business hours and the size of crowds. Protesters on social media demanded his ouster; a few picketed outside his home. Christenson had served in the health department for seven years before her promotion and worked closely with Kelley.

While her office still hears daily from frustrated citizens “on both sides,” she said the vitriol is not quite as malicious as in the past. That’s in large part, she believes, because the new laws that gutted her department’s power shifted criticism to other entities like local school boards that still have the authority to mandate measures such as wearing masks.

“Sometimes it can be pretty frustrating not having the ability to make some immediate changes that previously helped to slow transmission,” Christenson said. “We just don’t have the tools at our disposal in the same way that we did before.”

That reality, she said, has been “morally challenging.”

“I have a duty to protect the community. You want to do what is right, but you also want to do what is lawful. In this situation, it didn’t mesh.”

Joe Russell does not envy health officers new to their positions. He retired as head of the Flathead City-County Health Department in 2017 but returned in December after the interim director resigned over what she called a “toxic environment” inflamed by the “ideological biases” of local politicians.

“Think about going into a brand-new profession, in a leadership role that you’ve never held, in a crisis like covid-19,” Russell said. “It would be miserable.”

He said his experience — 30 years in the Flathead health department, including 20 as its leader — has eased navigating through the pandemic in one of the state’s most populous and conservative counties, although the rate of cases there remains high and its vaccination rate low.

His tenure, he said, has given him the credibility to confront officials who question the seriousness of covid or the safety and effectiveness of vaccines.

“When someone spouts this nonsense, who better to stand up and give them the science-based evidence and tell them that they are full of crap?” Russell said. “I love it when that happens at a public meeting.”

Although Montana laws essentially prevent public health officials from following many CDC guidelines, Christenson said they still have useful tools available to combat the virus: testing, contact tracing, vaccination, communicating with the public.

“That is what I focus on,” she said. “That is what we can do.”

Christenson believes she has the community’s support. She noted that while a few people protested outside of Kelley’s home, crowds countered that criticism by lining Bozeman’s Main Street, offering cheers of support on his drive home.

“Not to say that every day is rosy,” she said. “That would be naive. But you can feel the staff here continue to try to move forward, and that to me is a success.”

In Madison County, Sayler said she is taking an “olive branch” approach to turning things around, advancing recommendations rather than orders, as her staff works to nudge vaccination rates up from the current 48%. She’s doubtful that will quickly reduce covid.

In September, the county saw approximately 200 new cases — roughly 20% of all its infections since the pandemic began — and had more residents hospitalized with the virus than ever before.

While the pandemic has filled Sayler’s first months on the job, she said she looks forward to focusing on other ways the health department can restore the public’s faith and help Madison County, such as offering car seats for babies or nutrition advice for expectant mothers.

“There is a lot of rebuilding to do here, because this whole office has been consumed by covid for so long,” she said. “I can still see long-term goals for us and what we can do for this community. That’s not just a goal. That’s a need.”

Her office has on occasion persuaded those sick with covid, even those who insisted the virus is not serious, to seek medical help. “Tell your story,” Sayler said she advises those covid survivors. “Make sure everybody knows how sick you were.”

But then there are more difficult encounters, such as when a mother cursed her out over the phone about the recommendation that her child be quarantined. A week later, she saw the woman at her daughter’s volleyball game.

“She was sitting there and looked directly at me and then looked away,” Sayler said. “That made me feel better. You truly don’t feel that way. You were just expressing frustration in that moment.”

That experience left her with cautious optimism about the difficult task she has ahead with the pandemic set to enter its second winter.

“It is reassuring that there is potential here. We can still work with these people,” she said. “We just really don’t want to be a punching bag, either.”

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.

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Categories: Health Care

In Maine, Vaccine Mandate for EMTs Stresses Small-Town Ambulance Crews

Kaiser Health News - Mon, 10/25/2021 - 5:00am

On a recent morning, Jerrad Dinsmore and Kevin LeCaptain of Waldoboro EMS in rural Maine drove their ambulance to a secluded house near the ocean, to measure the clotting levels of a woman in her 90s.

They told the woman, bundled under blankets to keep warm, they would contact her doctor with the result.

“Is there anything else we can do?” Dinsmore asked.

“No,” she said. “I’m all set.”

This wellness check, which took about 10 minutes, is one of the duties Dinsmore and LeCaptain perform in addition to the emergency calls they respond to as staffers with Waldoboro Emergency Medical Service.

EMS crews have been busier than ever this year, as people who delayed getting care during the covid-19 pandemic have grown progressively sicker.

But there’s limited workforce to meet the demand. Both nationally and in Maine, staffing issues have plagued the EMS system for years. It’s intense work that takes a lot of training and offers low pay. The requirement in Maine and elsewhere that paramedics and emergency medical technicians be vaccinated against covid is another stress on the workforce.

Dinsmore and LeCaptain spend more than 20 hours a week working for Waldoboro on top of their full-time EMS jobs in other towns. It’s common in Maine for EMS staffers to work for multiple departments, because most EMS crews need the help — and Waldoboro may soon need even more of it.

The department has already lost one EMS worker who quit because of Maine’s covid vaccine mandate for health care workers, and may lose two more.

The stress of filling those vacancies keeps Town Manager Julie Keizer awake at night.

“So, we’re a 24-hour service,” Keizer said. “If I lose three people who were putting in 40 hours or over, that’s 120 hours I can’t cover. In Lincoln County, we already have a stressed system.”

The labor shortage almost forced Waldoboro to shut down ambulance service for a recent weekend. Keizer said she supports vaccination but believes Maine’s decision to mandate it threatens the ability of some EMS departments to function.

Maine is one of 10 states that require health care workers to get vaccinated against covid or risk losing their jobs. Along with Oregon, Washington and Washington, D.C., it also explicitly includes the EMTs and paramedics who respond to 911 calls in that mandate. Some ambulance crews say it’s making an ongoing staffing crisis even worse.

Two hundred miles north of Waldoboro, on the border with Canada, is Fort Fairfield, a town of 3,200. Deputy Fire Chief Cody Fenderson explained that two workers got vaccinated after the mandate was issued in mid-August, but eight quit.

“That was extremely frustrating,” Fenderson said.

Now Fort Fairfield has only five full-time staffers available to fill 10 slots. Its roster of per-diem workers all have full-time jobs elsewhere, many with other EMS departments that are also facing shortages.

“You know, anybody who does ambulances is suffering,” said Fenderson. “It’s tough. I’m not sure what we’re going to do, and I don’t know what the answer is.”

In Maine’s largest city, Portland, the municipal first-responder workforce is around 200 people, and eight are expected to quit because of the vaccine mandate, according to the union president for firefighters, Chris Thomson.

That may not seem like a significant loss, but Thomson said those are full-time positions and those vacancies will have to be covered by other employees who are already exhausted by the pandemic and working overtime.

“You know, the union encourages people to get their vaccine. I personally got the vaccine. And we’re not in denial of how serious the pandemic is,” Thomson said. “But the firefighters and the nurses have been doing this for a year and a half, and I think that we’ve done it safely. And I think the only thing that really threatens the health of the public is short staffing.”

Thomson maintains that unvaccinated staffers should be allowed to stay on the job because they’re experts in infection control and wear personal protective equipment such as masks and gloves.

But Maine’s public safety commissioner, Mike Sauschuck, said EMS departments also risk staff shortages if workers are exposed to covid and have to isolate or quarantine.

“Win-win scenarios are often talked about but seldom realized,” he said. “So sure, you may have a situation where staffing concerns are a reality in communities. But for us, we do believe the broader impact, the safer impact on our system is through vaccination.”

Some EMS departments in Maine have complied fully with the mandate, with no one quitting. Andrew Turcotte, the fire chief and director of EMS for the city of Westbrook, said all 70 members of his staff are now vaccinated. He doesn’t see the new mandate as being any different from the vaccine requirements to attend school or enter the health care field.

“I think that we all have not only a social responsibility but a moral one,” Turcotte said. “We chose to get into the health care field, and with that comes responsibilities and accountabilities. That includes ensuring that you’re vaccinated.”

Statewide numbers released last week show close to 97% of EMS workers in Maine have gotten vaccinated. But that varies by county: Rural Piscataquis and Franklin counties reported that 18% and 10% of EMS employees, respectively, were still unvaccinated as of mid-October.

Not all EMS departments have reported their vaccination rates to the state. Waldoboro is in Lincoln County, where only eight of 12 departments have reported their rates. Among those eight, the rate of noncompliance was just 1.6%.

But in small departments like Waldoboro, the loss of even one staff member can create a huge logistical problem. Over the past few months, Waldoboro’s EMS director, Richard Lash, started working extra long days to help cover the vacancies. He’s 65 and is planning to retire next year.

“I’ve told my town manager that we’ll do the best we can do. But, you know, I can’t continue to work 120 hours a week to fill shifts,” said Lash. “I’m getting old. And I just can’t keep doing that.”

This story is from a reporting partnership that includes Maine Public Radio, 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.

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Categories: Health Care

“Este es el último pañal que me queda”: la ansiedad de ser padres en la pobreza

Kaiser Health News - Fri, 10/22/2021 - 12:30pm

Para los padres que viven en la pobreza, la “matemática del pañal” es un cálculo diario, apremiante y angustiante, con el que están familiarizados.

En los Estados Unidos, los bebés usan de seis a 10 pañales desechables al día, a un costo promedio de $70 a $80 al mes. Los pañales de marca con alta absorción se venden hasta por medio dólar cada uno, un gasto de más de $120 al mes.

Una de cada tres familias estadounidenses no puede pagar por suficientes pañales para mantener a sus bebés y niños pequeños limpios, secos y saludables, según la National Diaper Bank Network. Para muchos padres, eso lleva a elecciones desgarradoras: ¿pañales, comida o renta?

La pandemia de covid-19 ha agravado la situación, engrosando las listas de desempleados y causando interrupciones en la cadena de suministro que han generado precios más altos para una multitud de productos, incluidos los pañales.

Los bancos de pañales, programas financiados por la comunidad que ofrecen pañales gratis a familias de bajos ingresos, distribuyeron un 86% más de pañales en promedio en 2020, comparado con 2019, según la red nacional. En algunos lugares, la distribución aumentó hasta en un 800%.

Sin embargo, ningún programa federal ayuda a los padres a pagar por este producto esencial de la niñez. El programa de asistencia alimentaria del gobierno no cubre pañales, ni la mayoría de los programas de ayuda pública a nivel estatal.

California es el único estado que financia directamente los pañales para las familias, pero el apoyo es limitado. CalWORKS, un programa de asistencia financiera para familias con niños, proporciona $30 al mes para ayudar a las familias a pagar por los pañales para los menores de 3 años.

También se pueden producir cambios en las políticas federales: los legisladores demócratas están presionando para incluir $200 millones para la distribución de pañales en el paquete masivo de reconciliación presupuestaria.

Sin los recursos adecuados, los padres de bajos ingresos luchan por encontrar formas de aprovechar al máximo cada pañal. Esta tarea estresante es el tema de un artículo reciente en American Sociological Review de Jennifer Randles, profesora de sociología en la Universidad Estatal de California en Fresno. En 2018, Randles realizó entrevistas telefónicas con 70 madres en California durante nueve meses. También trató de reclutar padres, pero solo respondieron dos hombres.

Randles habló con Jenny Gold de KHN sobre cómo el costo de los pañales pesa en las mamás de bajos ingresos y la “maternidad creativa” que muchas mujeres adoptan para proteger a sus hijos de los daños de la pobreza.

¿Qué rol juegan los pañales en las ansiedades cotidianas de las madres de bajos ingresos?

En mi muestra, la mitad de las madres me dijeron que se preocupaban más por los pañales que por la comida o la vivienda.

Comencé a preguntarles a las madres: “¿Pueden decirme cuántos pañales tienen a mano en este momento?” Casi todas me dijeron con precisión exacta cuántos tenían: cinco, siete o 12. Y sabían exactamente cuánto duraría esa cantidad, según la frecuencia con la que sus hijos defecaban y orinaban, si su hijo estaba enfermo, o si tenía una dermatitis del pañal en ese momento.

Llevar un registro tan cuidadoso de los suministros de pañales es todo un trabajo emocional y cognitivo.

Estaban preocupadas y pensando: “Está bien, me he quedado casi con mi último pañal. ¿Qué hago ahora? ¿Voy a buscar algunas latas [para vender]? ¿Voy a vender algunas cosas en mi casa? ¿Quién en mi red social podría tener algo de dinero extra en este momento?”. Hablé con mamás que venden plasma sanguíneo solo para comprar pañales a sus bebés.

¿Qué estrategias para afrontar esto le llamaron la atención?

Los que estudiamos los pañales a menudo los llamamos estrategias para estirar los pañales. Una le dejaba puesto un pañal a su niño un poco más de lo habitual, hasta que se llenara por completo. Algunas madres se dieron cuenta de que si compraban un pañal [más caro] que aguantaba más y goteaba menos, podían dejarlo puesto por más tiempo.

También hacían cosas como dejar que el bebé se quedara sin pañal, especialmente cuando estaban en la casa y sentían que no serían juzgadas por esto. Y utilizaban todos los bienes domésticos que puedas imaginar para hacer pañales improvisados: telas, sábanas y fundas de almohada. Están usando cosas que son desechables como toallas de papel con cinta adhesiva. Están haciendo pañales con sus propios suministros para la menstruación o suministros para la incontinencia de adultos cuando pueden obtener una muestra gratis.

Una de las preguntas que me hacen a menudo es: “¿Por qué no usan simplemente tela?” Muchas de las madres con las que hablé habían probado los pañales de tela y descubrieron que eran muy costosos y la mano de obra, prohibitiva. Si pagas por un juego completo de pañales de tela para comenzar, estamos hablando de entre $500 y $1,000. Y estas mamás nunca tuvieron tanto dinero. La mayoría no tenían lavadoras ni secadoras en casa. Algunas ni siquiera tenían casa o acceso consistente a agua, y es ilegal en muchas lavanderías comunitarias y públicas lavar pañales usados. Por lo tanto, las mismas condiciones que evitarían que las mamás puedan pagar fácilmente pañales desechables son las mismas condiciones que les impiden usar telas.

Descubrió que el concepto de muchas mujeres de ser “una buena madre” está relacionado con el cambio de pañales. ¿Por qué es eso?

Los pañales y el manejo de los pañales eran fundamentales para su identidad como buenas mamás. La mayoría de las madres de mi muestra se privaban de su propia comida. No estaban pagando una factura de teléfono celular o comprando sus propios medicamentos o sus propios suministros menstruales, como una forma de ahorrar dinero para pañales.

Hablé con muchas mamás que dijeron que cuando su bebé tiene hambre, eso es horrible. Obviamente, haces todo lo posible para evitarlo. Pero hay algo en un pañal que cubre esta parte vulnerable del cuerpo de un bebé muy pequeño, esta piel tan delicada. Y poder hacer algo para satisfacer esta necesidad humana que todos tenemos, y mantener la dignidad y la limpieza.

Muchas de las mamás habían pasado por el sistema de asistencia social, por lo que viven con este miedo constante [de perder a sus hijos]. Esto es especialmente cierto entre las madres de color, que son mucho más propensas a ser parte del sistema de bienestar infantil. Las personas no necesariamente pueden ver cuándo un bebé tiene hambre. Pero la gente puede ver un pañal en mal estado. Esa será una de las cosas que la etiquetará como mala madre.

¿Su trabajo con los pañales se vio influenciado por su experiencia como madre?

Cuando estaba haciendo estas entrevistas, mi hija tenía alrededor de 2 o 3 años. Así que todavía estaba en pañales. Cuando mi hija orinaba durante un cambio de pañal, pensaba: “Oh, puedo tirar ese. Déjame conseguir otro limpio”. Esa es una elección realmente fácil. Para mi. Pero es una crisis para las madres que entrevisté. Muchas me dijeron que tienen un ataque de ansiedad con cada cambio de pañal.

¿Ve una solución política clara para el estrés relacionado con los pañales?

Lo que resulta un tanto irónico es la cantidad de trabajo físico, emocional y cognitivo que implica la gestión de algo que la sociedad y los legisladores ni siquiera reconocen. Los pañales todavía no se reconocen realmente como una necesidad básica, como lo demuestra el hecho de que todavía están sujetos a impuestos en 35 estados.

Creo que lo que está haciendo California es un excelente comienzo. Y creo que los bancos de pañales son un tipo de organización comunitaria fabulosa, que está satisfaciendo una gran necesidad que no está siendo cubierta por las políticas de la red de seguridad. Entonces, apoyo público a los bancos de pañales.

La ayuda directa en efectivo que forma parte de la red de seguridad social prácticamente se ha desmantelado en los últimos 25 años. California es bastante generosa. Pero hay algunos estados donde solo el costo de los pañales usaría casi la mitad del beneficio estatal promedio de TANF [Asistencia Temporal para Familias Necesitadas] para una familia de tres. Creo que realmente tenemos que abordar el hecho de que el valor de la ayuda en efectivo compra mucho menos de lo que solía hacerlo.

Su trabajo sobre el matrimonio y la familia es fascinante e inusual. ¿Hay una pregunta central detrás de su investigación?

El hilo conductor es: ¿Cómo apoyan nuestras políticas de red de seguridad los objetivos de crianza de los hijos de las familias de bajos ingresos? ¿Son igualitarias las condiciones de la crianza de los hijos? Lo considero un problema de justicia reproductiva. La capacidad de tener un hijo o no tener un hijo, y luego criar a ese hijo en condiciones en las que se satisfagan las necesidades básicas del niño.

Nos gusta decir que somos aptos para tener niños y familias. El tema de los pañales es solo uno de muchos, muchos problemas en los que realmente no ponemos nuestro dinero o nuestras políticas en lo que decimos que haremos, en términos de apoyo a las familias y apoyo a los niños. Creo que mi trabajo está tratando de hacer que la gente piense de manera más colectiva acerca de tener una responsabilidad social con todas las familias y con el otro. Ningún país, pero especialmente el país más rico del planeta, debería tener 1 de cada 3 niños muy pequeños sin satisfacer una de sus necesidades básicas.

Entrevisté a un padre que estaba preso porque escribió un cheque sin fondos. Y como me lo describió, tenía una cierta cantidad de dinero y necesitaban tanto pañales como leche para el bebé. Y nunca lo olvidaré, dijo, “No tomé una buena decisión, pero tomé la correcta”.

Estos no son zapatos elegantes. No se trata de ropa de marca. Este era un padre que necesitaba leche y pañales. No creo que haya nada más básico que eso.

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.

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Confronting Ageism in Health Care: A Conversation for Patients, Caregivers and Clinicians

Kaiser Health News - Fri, 10/22/2021 - 11:14am

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What does ageism in health care look like? It can be a thoughtless quip that makes an older person feel diminished. Or an assumption that patients are unable to follow a conversation or make their own decisions. Maybe it occurs when a concern is voiced, then discounted or dismissed.

Ageism is reflected in care strategies that ignore a patient’s values and ideas about what constitutes a productive life. Too often, attitudes such as “these patients are old and near the end anyway” or “there’s not much we can do to help them” prevail.

Ageism is not new, but the covid pandemic brought it shockingly into view. In its early days, the virus was shrugged off as something of concern mostly to older people, with some arguing they were expendable if the alternative was shutting down the economy. In the grave months that followed, many who died in nursing care were dehumanized in news reports that showed body bags piled outside facilities. To date, about 80% of those who have died of covid-19 have been older adults, including nearly 140,000 nursing home residents — a population beset by understaffing, inadequate infection control and neglect.

KHN and The John A. Hartford Foundation held a web event Thursday. Judith Graham, KHN’s Navigating Aging columnist, hosted the discussion. She was joined by: 

  • Dr. Louise Aronson, a geriatrician, professor of medicine at the University of California-San Francisco and author of “Elderhood.” 
  • Dr. Michael Wasserman, a geriatrician, advocate for vulnerable older adults during the pandemic and leader of the public policy committee of the California Association of Long Term Care Medicine.
  • Dr. Javette Orgain, a family physician and medical director for Longevity Health Plan of Illinois, which serves nursing home residents; former president of the National Medical Association, which represents African American physicians and their patients; and former assistant dean of the University of Illinois-Chicago’s Urban Health Program. 
  • Dr. Rebecca Elon, a geriatrician and caregiver for her mother, who has dementia, and husband, who died earlier this year. 
  • Jess Maurer, a lawyer and executive director of the Maine Council on Aging, which promotes an anti-ageism pledge.

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.

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‘No Mercy’ Bonus Episodes: More From Fort Scott, Kansas

Kaiser Health News - Fri, 10/22/2021 - 5:00am
Searching for the Nuns Who Ghosted Fort Scott

Host Sarah Jane Tribble sets out on a mission to learn more about the Sisters of Mercy, the nuns who founded Fort Scott’s Mercy Hospital and were once prominent leaders of the community. Tribble’s first glimpse into their lives takes her to an old convent. To learn more about the founding of Fort Scott’s hospital, listen to Episode Four.

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Click here to read the episode transcript.

How’s Josh?

Before Fort Scott’s hospital shut down, Josh was a teenager coping with his aging grandparents and the emotional burden of his mother’s opioid death. The family’s troubles worsened after the hospital closed. Tribble gives Josh a call to find out his next steps. If you want to hear more of Josh’s story, we tell it in Episode Six.

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Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on Apple PodcastsStitcherGoogleSpotifyPocket Casts or wherever you listen to podcasts.

To hear all KHN podcasts, click here.

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.

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‘Down to My Last Diaper’: The Anxiety of Parenting in Poverty

Kaiser Health News - Fri, 10/22/2021 - 5:00am

For parents living in poverty, “diaper math” is a familiar and distressingly pressing daily calculation. Babies in the U.S. go through six to 10 disposable diapers a day, at an average cost of $70 to $80 a month. Name-brand diapers with high-end absorption sell for as much as a half a dollar each, and can result in upwards of $120 a month in expenses.

One in every three American families cannot afford enough diapers to keep their infants and toddlers clean, dry and healthy, according to the National Diaper Bank Network. For many parents, that leads to wrenching choices: diapers, food or rent?

The covid-19 pandemic has exacerbated the situation, both by expanding unemployment rolls and by causing supply chain disruptions that have triggered higher prices for a multitude of products, including diapers. Diaper banks — community-funded programs that offer free diapers to low-income families — distributed 86% more diapers on average in 2020 than in 2019, according to the National Diaper Bank Network. In some locations, distribution increased by as much as 800%.

Yet no federal program helps parents pay for this childhood essential. The government’s food assistance program does not cover diapers, nor do most state-level public aid programs.

California is the only state to directly fund diapers for families, but support is limited. CalWORKS, a financial assistance program for families with children, provides $30 a month to help families pay for diapers for kids under age 3. Federal policy shifts also may be in the works: Democratic lawmakers are pushing to include $200 million for diaper distribution in the massive budget reconciliation package.

Without adequate resources, low-income parents are left scrambling for ways to get the most use out of each diaper. This stressful undertaking is the subject of a recent article in American Sociological Review by Jennifer Randles, a professor of sociology at California State University-Fresno. In 2018, Randles conducted phone interviews with 70 mothers in California over nine months. She tried to recruit fathers as well, but only two men responded.

Randles spoke with KHN’s Jenny Gold about how the cost of diapers weighs on low-income moms, and the “inventive mothering” many low-income women adopt to shield their children from the harms of poverty. The conversation has been edited for length and clarity.

Q: How do diapers play into day-to-day anxieties for low-income mothers?

In my sample, half of the mothers told me that they worried more about diapers than they worried about food or housing.

I started to ask mothers, “Can you tell me how many diapers you have on hand right now?” Almost every one told me with exact specificity how many they had — five or seven or 12. And they knew exactly how long that number of diapers would last, based on how often their children defecated and urinated, if their kid was sick, if they had a diaper rash at the time. So just all the emotional and cognitive labor that goes into keeping such careful track of diaper supplies.

They were worrying and figuring out, “OK, I’m down to almost my last diaper. What do I do now? Do I go find some cans [to sell]? Do I go sell some things in my house? Who in my social network might have some extra cash right now?” I talked to moms who sell blood plasma just to get their infants diapers.

Q: What coping strategies stood out to you?

Those of us who study diapers often call them diaper-stretching strategies. One was leaving on a diaper a little bit longer than someone might otherwise leave it on and letting it get completely full. Some mothers figured out if they bought a [more expensive] diaper that held more and leaked less, they could leave the diaper on longer.

They would also do things like letting the baby go diaperless, especially when they were at home and felt like they wouldn’t be judged for letting their baby go without a diaper. And they used every household good you can imagine to make makeshift diapers. Mothers are using cloth, sheets and pillowcases. They’re using things that are disposable like paper towels with duct tape. They’re making diapers out their own period supplies or adult incontinence supplies when they can get a sample.

One of the questions I often get is, “Why don’t they just use cloth?” A lot of the mothers that I spoke with had tried cloth diapers and they found that they were very cost- and labor-prohibitive. If you pay for a full startup set of cloth diapers, you’re looking at anywhere from $500 to $1,000. And these moms never had that much money. Most of them didn’t have in-home washers and dryers. Some of them didn’t even have homes or consistent access to water, and it’s illegal in a lot of laundromats and public laundry facilities to wash your old diapers. So the same conditions that would prevent moms from being able to readily afford disposable diapers are the same conditions that keep them from being able to use cloth.

Q: You found that many women’s concept of being a good mother is wrapped up in diapering. Why is that?

Diapers and managing diapers was so fundamental to their identity as good moms. Most of the mothers in my sample went without their own food. They weren’t paying a cellphone bill or buying their own medicine or their own menstrual supplies, as a way of saving diaper money.

I talked to a lot of moms who said, when your baby is hungry, that’s horrible. Obviously, you do everything to prevent that. But there’s something about a diaper that covers this vulnerable part of a very young baby’s body, this very delicate skin. And being able to do something to meet this human need that we all have, and to maintain dignity and cleanliness.

A lot of the moms had been through the welfare system, and so they’re living in this constant fear [of losing their children]. This is especially true among mothers of color, who are much more likely to get wrapped up in the child welfare system. People can’t necessarily see when your baby’s hungry. But people can see a saggy diaper. That’s going to be one of the things that tags you as a bad mom.

Q: Was your work on diapers influenced by your experience as a parent?

When I was doing these interviews, my daughter was about 2 or 3. So still in diapers. When my daughter peed during a diaper change, I thought, “Oh, I can just toss that one. Here, let me get another clean one.” That’s a really easy choice. For me. That’s a crisis for the mothers I interviewed. Many of them told me they have an anxiety attack with every diaper change.

Q: Do you see a clear policy solution to diaper stress?

What’s kind of ironic is how much physical, emotional and cognitive labor goes into managing something that society and lawmakers don’t even recognize. Diapers are still not really recognized as a basic need, as evidenced by the fact that they’re still taxed in 35 states.

I think what California is doing is an excellent start. And I think diaper banks are a fabulous type of community-based organization that are filling a huge need that is not being filled by safety net policies. So, public support for diaper banks.

The direct cash aid part of the social safety net has been all but dismantled in the last 25 years. California is pretty generous. But there are some states where just the cost of diapers alone would use almost half of the average state TANF [Temporary Assistance for Needy Families] benefit for a family of three. I think we really do have to address the fact that the value of cash aid buys so much less than it used to.

Q: Your body of work on marriage and families is fascinating and unusual. Is there a single animating question behind your research?

The common thread is: How do our safety net policies support low-income families’ parenting goals? And do they equalize the conditions of parenting? I think of it as a reproductive justice issue. The ability to have a child or to not have a child, and then to parent that child in conditions where the child’s basic needs are met.

We like to say that we’re child and family friendly. The diaper issue is just one of many, many issues where we don’t really put our money or our policies where our mouth is, in terms of supporting families and supporting children. I think my work is trying to get people to think more collectively about having a social responsibility to all families and to each other. No country, but especially the richest country on the planet, should have 1 in 3 very young children not having one of their basic needs met.

I interviewed one dad who was incarcerated because he wrote a bad check. And as he described it to me, he had a certain amount of money, and they needed both diapers and milk for the baby. And I’ll never forget, he said, “I didn’t make a good choice, but I made the right one.”

These are not fancy shoes. These are not name-brand clothes. This was a dad needing both milk and diapers. I don’t think it gets much more basic than that.

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.

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Montana Tribes Want to Stop Jailing People for Suicide Attempts but Lack a Safer Alternative

Kaiser Health News - Fri, 10/22/2021 - 5:00am

POPLAR, Mont. — When Maria Vega was a senior in high school in 2015, she found the body of one of her closest friends, who had died by suicide. A few days later, devastated by the loss, Vega tried to take her own life.

After the attempt failed, she was arrested and taken to juvenile detention in Poplar, a remote town on the Missouri River a short drive from the North Dakota oil fields. She was put in a cell and kept under observation for several days until a mental health specialist was available to see her. Her only interaction was with the woman who brought food to her cell.

“I remember asking her if I could have a hug and she told me, ‘I’m sorry, I can’t do that,’” Vega recalled. “That was honestly one of the hardest things I ever went through in my life. I felt like I was being punished for being sad.”

Jailing people because of a mental health issue is illegal in Montana and every other state except New Hampshire. But Vega is a member of the Fort Peck Assiniboine and Sioux Tribes, a sovereign nation with its own laws. An 11-year-old tribal policy allows law enforcement to put members who threaten or attempt suicide in jail or juvenile detention to prevent another attempt.

Fort Peck’s tribal leaders say they approved the policy out of necessity because there were no mental health facilities equipped for short-term housing of people in mental crisis.

The covid pandemic has only exacerbated the crisis. In 2020, the tribes filed a record 62 aggravated disorderly conduct charges, the criminal charge they created in 2010 to allow law enforcement to book people they deemed a risk to themselves or others.

Stacie FourStar, chief judge of the Fort Peck Tribal Court, said this year has been even worse: The tribe is filing two to four charges per week. The policy has swept up people — particularly adolescents — with no criminal records and no experience with the criminal justice system, she said.

The judge fears it creates a perverse incentive not to call 911 or reach out for help when depression sets in. “They don’t want to go to jail,” FourStar said. “They just want somebody to talk to.”

Tribal officials and various mental health advocates have been trying to find an alternative for nearly a decade. But the reservation is still badly lacking in both secure psychiatric facilities and qualified mental health workers. Despite funding available for new positions, recruitment efforts have failed and there is still no viable alternative to keep people safe.

“Their hands are tied,” FourStar said, noting that if “personnel and facilities aren’t available, we’ll be putting people in an unsafe situation.”

Having experienced imprisonment herself as a teen, Vega is now part of a team of tribal members, state educators and policy experts looking for alternative solutions.

The group’s ideas include ensuring that a mental health specialist is the first point of contact for a person in crisis and setting up safe houses, said Harvard University political scientist Daniel Carpenter, the project’s leader.

In May, the group presented a plan to the Fort Peck Tribal Council, which has yet to act on its recommendations. A spokesperson for the Fort Peck Tribes said the tribes are looking into the policy but declined to comment further.

Yet tribal leaders say that unless they can attract mental health workers to remote northeastern Montana, the jailings will likely continue. “We can propose all we want,” said Jestin Dupree, a tribal legislator and chairman of the law and justice committee. “We’re not getting the doctors, the qualified people.”

The Fort Peck reservation, a windswept cluster of small towns surrounded by 2 million acres of rolling farmland, has a suicide rate that in some years has topped six times the national average. Native American adolescents are twice as likely to die by suicide as their white peers.

The 2010 policy that put Vega in jail followed a cluster of more than 150 suicide attempts and the deaths of at least six teenagers. Overwhelmed by the crisis, Fort Peck’s tribal government created the “aggravated disorderly conduct” charge.

“It came from desperation,” said FourStar, who was chief tribal prosecutor at the time. “Families weren’t able to handle the needs of their loved ones and they didn’t want them to hurt themselves.”

People charged with aggravated disorderly conduct are held until they can undergo a mental health evaluation and attend a court hearing, where they may receive a court-ordered treatment plan. If they comply with the plans, the charge is dropped. They usually don’t end up with a public criminal record, but the court system can still track them.

Nontribal members are never put in jail, because the tribe lacks jurisdictional authority over them. Instead, a police officer ends up sitting with them in the hospital — sometimes for days — until they can be evaluated.

Not every suicide threat or attempt ends in an aggravated disorderly conduct charge. Ideally, a person in crisis is immediately evaluated by a mental health professional at the Indian Health Service or a telemedicine provider who can refer them to emergency care, if needed.

“Even though there’s difficulties in trying to get care for them, we still persevere,” said Sylvia Longknife, an IHS mental health specialist in Poplar. Longknife is IHS’ only mental health worker on the Fort Peck reservation since two other providers quit this year, meaning she can’t always immediately see somebody in crisis.

Longknife said she sees between two and five emergency cases a week. If the situation is deemed an emergency, the patient is referred to a facility four hours away in Billings. IHS doesn’t have its own transportation, so it either asks family members to drive the patient or requests transportation funds from the tribe.

If a suicide attempt occurs on a weekend, after hours or when a mental health worker is unavailable, police officers who respond may end up taking the person to a hospital for medical treatment, if necessary, and then to jail.

Lisa Dailey, executive director of the Treatment Advocacy Center, a national nonprofit that pushes for access to mental health treatment, said jailing people for attempting suicide criminalizes mental illness. “Prison or jail are the worst settings you can possibly be because you’re in a psychiatric crisis,” she said. Even if the care is good, she said, “being incarcerated is a traumatizing experience.”

Studies have shown that the risk of self-harm in prison increases if someone has been held in solitary confinement or has previously attempted suicide.

The Fort Peck reservation isn’t the only jurisdiction where people can be jailed after a suicide attempt. In New Hampshire, suicidal people often end up in the state’s only secure facility: the men’s prison.

After the Fort Peck tribes approached Carpenter’s Native American politics class last year for ideas, he and his undergraduate students began consulting with tribal members and others in Montana and working to research potential alternatives to jail.

The Flathead tribe in western Montana, for instance, specifies that people should be held in the “least restrictive environment” possible to protect their well-being, short of a jail cell. Carpenter said this could take the form of a “safe house” that separates a person from weapons.

Other potential fixes include requiring that a mental health worker accompany police during interactions with a suicidal person to ensure that jail is the last resort, and creating a new “mental health code” that would treat suicidal people differently from those who pose a threat to others.

The state of Colorado put $9.5 million toward community-based health treatment in 2017, then made it illegal to jail people awaiting mental health evaluations who hadn’t been charged with a crime.

But places like reservations may have no choice. “With no resources, there’s very little you can do about any of those issues,” Dailey said.

The IHS office has sufficient funds to hire four more mental health workers for Fort Peck. “We’re definitely aggressively trying to fill empty vacancies,” said Steve Williamson, chief medical officer of the IHS’ Billings area office.

But the positions have been difficult to fill. IHS and other health providers in northeastern Montana struggle to attract candidates to live in a region 70 miles from the nearest Walmart, with few jobs or entertainment options for families.

FourStar said the tribes hope to use covid relief aid to improve behavioral health services so that suicide attempts can be treated as civil cases instead of criminal ones. “I think this will go somewhere, as long as we can get the manpower,” she 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.

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KHN’s ‘What the Health?’: Dems Agree to Agree, But Not on What to Agree On

Kaiser Health News - Thu, 10/21/2021 - 2:45pm

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Negotiations over what to include in — and cut from — the domestic spending package on Capitol Hill are reportedly making progress, but so far all Democrats have to show for their efforts to enact President Biden’s health and other social spending agenda is a continuing promise to keep trying.

Meanwhile, Biden administration officials unveil plans to provide covid-19 vaccines to younger children without looking like they are prejudging the science, in an attempt to avoid the mixed messaging that presaged the rollout of booster doses for adults.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Johns Hopkins, Tami Luhby of CNN and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode:

  • While there is a different feeling among Democrats on Capitol Hill right now, meeting the goal of both the House and Senate passing the social spending legislation by the end of October still seems very unlikely. What might be possible is that negotiators could agree on a framework by that deadline that would allow Congress to go back to pass an infrastructure bill while they continue fleshing out the social spending bill. Also, things are likely to fall apart a few more times before anything is finally accomplished.
  • The Congressional Budget Office this week estimated the effect on health insurance that the House Committee version of the bill would produce. It found a big boost in insurance coverage but a decrease in employer-provided coverage. The CBO also predicted a big loss in employer coverage when the Affordable Care Act passed, but that did not happen.
  • Neither the House nor the Senate version of the annual spending bill (not the same as the social spending bill) for the Department of Health and Human Services includes the Hyde Amendment language that bans federal funding for most abortions. But the bill cannot pass the Senate without the language, as it would need 60 votes. This is really an example of virtue signaling for progressives, though it is hard to predict how the abortion debate will continue to play out if the Supreme Court, as expected, overrules Roe v. Wade this term.
  • The Biden administration has until Nov. 15 to name someone to run the FDA. The leading candidate is reportedly Robert Califf, who led the agency during the last year of President Barack Obama’s administration. Yet he has baggage similar to that of Janet Woodcock, the current acting commissioner, whom the Biden administration had first eyed for the job. Some Senate Democrats oppose Woodcock for her permissive attitude toward the approval of opioids in years past.
  • Speaking of the FDA, the agency released long-awaited regulations this week to allow for the over-the-counter sale of hearing aids. The idea has had bipartisan support and the OTC sale will make a big difference in affordability and accessibility. Without these regulations, people in many states needed to see an audiologist to get hearing aids. Some places simply have no audiologists.
  • On covid, the White House seems to be a bit more careful this time on messaging its plans for vaccinating children under 12 than they were in unveiling their plans for boosters. Officials made a mess of communications surrounding boosters for adults. This time they are emphasizing they won’t prejudge the science and will leave the actual medical decisions up to the FDA and Centers for Disease Control and Prevention.
  • With a few exceptions, vaccine mandates seem to be working. Some of the places that initially offered their workers a testing option — including New York City — are now taking that away. Ultimately, though, the vaccine mandates are again causing fissures in the nation’s social fabric.
  • Nurses are a big part of the “Great Resignation.” They are also leaving traditional staff positions to make much more money as travel nurses. This contributes to health care cost inflation and disrupts continuity of care. It’s a huge issue.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: KHN’s “Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice Laws,” by Giles Bruce.

Tami Luhby: Modern Healthcare’s “Rural Reckoning: COVID-19 Highlights Long-Standing Challenges Facing Rural Hospitals. Will It Create Momentum for Change?” by Jessie Hellmann.

Joanne Kenen: The Atlantic’s “‘I Don’t Know That I Would Even Call It Meth Anymore,’” by Sam Quinones.

Rachel Cohrs: U.S. News & World Report’s “Debt After Death: The Painful Blow of Medicaid Estate Recovery,” by Sarah True.

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

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