At a tiny kiosk on a Mumbai lane choked with rickshaws, Chandrabhaan Chaurasia is selling paan – betel leaves sprinkled with spices. They’re a cheap street snack across South Asia.

Chaurasia, 51, spreads a leaf with spicy herbal paste and then sprinkles it with dried tobacco. He folds the leaf into an edible little parcel, and sells it for 8 rupees — about $0.11. He also sells single-serving packs of chewing tobacco. Another kiosk nearby sells hand-rolled leaf cigarettes, called beedis.

India banned electronic cigarettes last month. With about 100 million smokers, India has the second-largest smoking population in the world, after China. Amid global reports of deaths and illnesses linked to vaping, India decided to ban e-cigarettes preventatively. They had yet to become popular.

But other forms of tobacco already are. In fact, twice as many Indians (about 200 million) use smokeless tobacco — like paan or chewing tobacco — than cigarettes. That’s the most in the world. Those products are harder to regulate because they’re mostly sold at street kiosks, for a fraction of the price of cigarettes.

Chaurasia’s tobacco kiosk is right outside Tata Memorial Hospital, one of the best cancer research facilities in India. Inside the hospital, Dr. Gauravi Mishra, a preventative oncologist, sees the harmful effects of those tobacco products on a daily basis.

“India has the highest number of oral cavity cancers. In fact, one-third of the global burden comes from only one country — and that’s India,” Mishra notes.

In the United States, oral cavity cancer represents 3% of all malignancies. But in India, it accounts for over 30% of all cancers.

When NPR visited her office, Mishra had just biopsied a boil inside the mouth of a patient who’s been chewing tobacco for 10 years.

“I had some idea that it was bad, but I didn’t know it could be so serious,” says Madhukar Patil, 42, his mouth filled with sterile gauze.

Patil is waiting for results to determine whether he has oral cancer. A father of two, he vows to quit tobacco now, for good.

“I realize now that if you want to be there for your family and enjoy precious moments with them, then you must leave this bad habit,” Patil says.

More than one in five Indians over the age of 15 uses some form of smokeless tobacco. (The figure is nearly one-third for men.) Poor laborers often chew tobacco as a stimulant, like chewing gum, to kill their appetite. Some even use tobacco ash as toothpaste. Patil used to chew gutka, a mixture of granular tobacco, betel nuts and spices.

Part of the problem is awareness.

“If someone is smoking, they might be looked down upon. But smokeless tobacco is culturally accepted. If you visit any rural area, people will greet you with paan,” Mishra says.

Another part of the problem is packaging.

Indian law requires cigarette companies to print health warnings on cigarette packs. Often, they carry graphic photos of tobacco-related tumors. So people know that smoking cigarettes is bad.

But other tobacco products are sold loose. Hand-rolled leaf cigarettes, or beedis, are green. They look organic. And they’re seven to eight times more common in India than conventional cigarettes, according to the World Health Organization.

Beedis also provide a livelihood to millions of mostly female, first-time workers.

In Mumbai’s oldest red light district, Balamani Sherla rolls beedis on the floor of her one-room home. At 60, Sherla has been doing this for half a century. It’s the only job she’s ever held.

She buys the ingredients wholesale: tendu leaves, dried loose tobacco, and string to tie off the rolled beedis. Sherla soaks the leaves in water to soften them, then cuts them round with giant shears, lines them with tobacco, and rolls them into short green cigarettes. She sells them to a middle man who then distributes them to street kiosks.

“It’s tedious work,” she says. “My arms ache, trying to roll the beedis very thin.”

Sherla doesn’t smoke. But studies show that beedi rollers often suffer from respiratory problems, burning eyes and asthma – just from breathing tobacco dust.

Nevertheless, it’s considered such a lucrative skill that women who can roll beedis are coveted as brides. Sherla makes about $0.14 an hour, which is a big help for her family, she says.

But wages used to be higher. The Indian government has repeatedly hiked tax on all tobacco products, including beedis — and that has cut into Sherla’s profits.

Most of the revenue India collects from taxing tobacco comes from packaged cigarettes, even though they’re less popular than beedis and smokeless tobacco. Tax rates on all tobacco products in India fall below the WHO’s recommendation of 75-percent of retail price.

Levying taxes on tobacco has long been considered an effective strategy to discourage its use and improve public health. But in India, where beedi workers often come from very low socio-economic backgrounds, that tax itself could be deadly, says Umesh Vishwad, general secretary of the Akhil Bharatiya Beedi Mazdoor Mahasangh (All India Beedi Workers Union).

If taxes on beedis keep rising, workers could “become homeless and starve to death,” Vishwad says.

They live that close to the bone, he says. His group wants the Indian government to retrain beedi workers for other jobs, before it chips away at their livelihood.

While Sherla and some of her neighbors roll beedis at home in urban Mumbai, the industry employs more people in rural areas, especially in the southern Indian states of Telangana and Andhra Pradesh. In central India, some of the beedi workers come from tribal areas where communist guerrillas are active. Vishwad worries that if their livelihoods are threatened, they could be vulnerable to insurgent recruiters.

“If these people lose their jobs as beedi rollers or beedi leaf collectors, they could be forced to join the militancy and pick up arms to survive,” he warns.

For Sherla, rolling beedis is a calculated decision. She knows that handling tobacco may not be good for her health. But she’s trading a long-term health risk for the ability to feed her family tomorrow.

“What other job can I do? I’m an old lady,” Sherla says. “This is the only option for me.”

As she works, Sherla’s 10-year-old granddaughter Siri bounces around the dank little room. The girl goes to school, and has learned English well. She interrupts often to tease her grandmother and translate for her. She’s the same age Sherla was when she started doing this work.

Will Siri follow in her grandmother’s footsteps?

“No way!” Sherla exclaims. “This little girl wants to be a doctor.”

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Vowing to protect Medicare with “every ounce of strength,” President Donald Trump last week spoke to a cheering crowd in Florida. But his executive order released shortly afterward includes provisions that could significantly alter key pillars of the program by making it easier for beneficiaries and doctors to opt out.

The bottom line: The proposed changes might make it a bit simpler to find a doctor who takes new Medicare patients, but it could lead to higher costs for seniors and potentially expose some to surprise medical bills, a problem from which Medicare has traditionally protected consumers.

“Unless these policies are thought through very carefully, the potential for really bad unintended consequences is front and center,” says economist Stephen Zuckerman, vice president for health policy at the Urban Institute.

While the executive order spells out few details, it calls for the removal of “unnecessary barriers” to private contracting, which allows patients and doctors to negotiate their own deals outside of Medicare. It’s an approach long supported by some conservatives, but critics fear it would lead to higher costs for patients. The order also seeks to ease rules that affect beneficiaries who want to opt out of the hospital portion of Medicare, known as Part A.

Both ideas have a long history, with proponents and opponents duking it out since at least 1997, even spawning a tongue-in-cheek legislative proposal that year titled, in part, the “Buck Naked Act.” More on that later.

“For a long time, people who don’t want or don’t like the idea of social insurance have been trying to find ways to opt out of Medicare and doctors have been trying to find a way to opt out of Medicare payment,” says Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia.

The specifics will not emerge until the Department of Health and Human Services writes the rules to implement the executive order, which could take six months or longer. In the meantime, here are a few things you should know about the possible Medicare changes.

What are the current rules about what doctors can charge in Medicare?

Right now, the vast majority of physicians agree to accept what Medicare pays them and not charge patients for the rest of the bill, a practice known as balance billing. Physicians (and hospitals) have complained that Medicare doesn’t pay enough, but most participate anyway. Still, there is wiggle room.

Medicare limits balance billing. Physicians can charge patients the difference between their bill and what Medicare allows, but those charges are limited to 9.25% above Medicare’s regular rates. But partly because of the paperwork hassles for all involved, only a small percentage of doctors choose this option.

Alternatively, physicians can “opt out” of Medicare and charge whatever they want. But they can’t change their mind and try to get Medicare payments again for at least two years. Fewer than 1% of the nation’s physicians have currently opted out.

What would the executive order change?

That’s hard to know.

“It could mean a lot of things,” says Joseph Antos at the American Enterprise Institute, including possibly letting seniors make a contract with an individual doctor or buy into something that isn’t traditional Medicare or the current private Medicare Advantage program. “Exactly what that looks like is not so obvious.”

Others say eventual rules might result in lifting the 9.25% cap on the amount doctors can balance-bill some patients. Or the rules around fully “opting out” of Medicare might ease so physicians would not have to divorce themselves from the program or could stay in for some patients, but not others. That could leave some patients liable for the entire bill, which might lead to confusion among Medicare beneficiaries, critics of such a plan suggest.

The result may be that “it opens the door to surprise medical billing if people sign a contract with a doctor without realizing what they’re doing,” says Jost.

Would patients get a bigger choice in physicians?

Proponents say allowing for more private contracts between patients and doctors would encourage doctors to accept more Medicare patients, partly because they could get higher payments. That was one argument made by supporters of several House and Senate bills in 2015 that included direct-contracting provisions. All failed, as did an earlier effort in the late 1990s backed by then-Sen. Jon Kyl, R-Ariz., who argued such contracting would give seniors more freedom to select doctors.

Then-Rep. Pete Stark, D-Calif., opposed such direct contracting, arguing that patients had less power in negotiations than doctors. To make that point, he introduced the “No Private Contracts To Be Negotiated When the Patient Is Buck Naked Act of 1997.”

The bill was designed to illustrate how uneven the playing field is by prohibiting the discussion of or signing of private contracts at any time when “the patient is buck naked and the doctor is fully clothed (and conversely, to protect the rights of doctors, when the patient is fully clothed and the doctor is naked).” It, too, failed to pass.

Still, the current executive order might help counter a trend that “more physicians today are not taking new Medicare patients,” says Robert Moffit, a senior fellow at the Heritage Foundation, a conservative think tank based in Washington, D.C.

It also might encourage boutique practices that operate outside of Medicare and are accessible primarily to the wealthy, says David Lipschutz, associate director of the Center for Medicare Advocacy.

“It is both a gift to the industry and to those beneficiaries who are well off,” he says. “It has questionable utility to the rest of us.”

KHN is a nonprofit, editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Lawmakers in Congress are calling on the Department of Labor to do more to protect workers who may be unsafely cutting “engineered stone” used for countertops.

The material contains high levels of the mineral silica, and breathing in silica dust is dangerous. While silica is found in natural stones, like granite, engineered stone made of quartz can be more than 90% silica.

This type of artificial stone has become increasingly popular among Americans for kitchen and bathroom countertops in recent years.

Even though adequate dust control can completely eliminate the risk of silica-related disease, at least 18 workers in California, Colorado, Texas and Washington who cut slabs of this material to order have recently suffered severe lung damage, according to physicians and public health officials.

Two of the workers died of their silicosis, a lung disease that can be progressive and has no treatment except for lung transplant. That has occupational safety experts worried about the nearly 100,000 people who work in this industry.

And it’s gotten the attention of the House Committee on Education and Labor. Its chairman, Bobby Scott, and Alma Adams, who chairs a subcommittee on workforce protections, have now written to Labor Department Secretary Eugene Scalia.

The lawmakers say the department’s Occupational Safety and Health Administration needs to create a new National Emphasis Program that will make it easier to for the agency to inspect workplaces that cut engineered stone, to make sure levels of silica dust are within allowable limits.

“We are calling on OSHA to issue, without delay, a new NEP that focuses on engineered stone fabrication establishments,” the lawmakers write. “Absent timely action, OSHA will be failing these stone finishing workers and failing in its mission.”

Without this new program, they say, “it is difficult for OSHA to enter a workplace without a worker complaint, injury, or referral.”

The two lawmakers also call on OSHA to work with the CDC and state health departments to improve surveillance for silica-related diseases. They say they want an update on the plans to protect workers in the engineered stone fabrication industry by Oct. 21.

A trade organization for makers of engineered stone, A.St.A. World-Wide, has told NPR that “these risks are not specific to engineered stone” and that dust related diseases “preceded the invention of engineered stone by many decades.”

The group said engineered stone surfaces “are totally safe in their fabrication and installation if it is performed according to the recommended practices,” and that manufacturers have been working to educate fabricators about these practices.

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Dean Ernest had been living in a nursing home about a year when his son, John, got a call last winter asking if his father was experiencing back pain and would like a free orthotic brace.

The caller said he was with Medicare. John Ernest didn’t believe him, said “no” to the brace and hung up. He didn’t give out his father’s Medicare number.

And yet, not just one, but 13 braces addressed to Dean arrived soon afterward at the younger Ernest’s house in central Pennsylvania — none of which Dean Ernest wanted or needed.

Telemedicine scams on the rise

Medicare, the federal, taxpayer-supported health care insurance program for older Americans, had paid more than $4,000 for 10 of the braces: a back brace, two knee braces, two arm braces, two suspension sleeves, an ankle brace, a wrist brace and a heel stabilizer — none of which Dean Ernest wanted or needed..

The orders came from four different medical equipment companies and were prescribed by four health care professionals —a prescription is required to receive an orthotic brace. But John Ernest says he didn’t talk to any doctors during the phone call.

That’s how the latest Medicare frauds work, says Ariel Rabinovic, who works with Pennsylvania’s Center for Advocacy for the Rights & Interests of the Elderly. He helped report the Ernests’ fraud case to authorities at Medicare. Rabinovic said the fraudsters enlist unscrupulous health professionals ?doctors, physician assistants, nurse practitioners ? to contact people they’ve never met by telephone or video chat under the guise of a telemedicine consultation.

“Sometimes the teledoctors will come on the line and ask real Mickey Mouse questions, stuff like, “Do you have any pain?” explained Rabinovic. “But oftentimes, there is no contact between the doctor and the patient before they get the braces. And in almost all of the cases, the person prescribing the braces is somebody the Medicare beneficiaries don’t know.”

While prescriptions for durable medical equipment, such as orthotic braces or wheelchairs, have long been a staple of Medicare fraud schemes, the manipulation of telemedicine is relatively new. The practice appears to be increasing as the telemedicine industry grows.

“This has put telemedicine scams on Medicare’s radar with growing urgency,” says James Quiggle, director of communications for the Coalition Against Insurance Fraud.

In the past year, the Department of Health and Human Services Office of Inspector General, the Department of Justice and, in some cases, the FBI, have busted at least six health care fraud schemes that involved telemedicine. Typically, in these schemes, scammers use sham telemedicine companies to scale up their operations quickly and cheaply, because they can have a couple of doctors remotely writing a large number of prescriptions.

Often the doctors working for these outfits don’t perform medical consultations, but rather write prescriptions without talking to patients, as in Ernest’s case. Of course, that is not how telemedicine is designed to work.

International fraud

In April 2019, the DOJ announced investigators had disrupted what they called “one of the largest Medicare fraud schemes in U.S. history.” “Operation Brace Yourself” cracked an international scheme allegedly defrauding Medicare of more than $1.2 billion by using telemedicine doctors to prescribe unnecessary back, shoulder, wrist and knee braces to beneficiaries.

The DOJ charged 24 people, including three medical professionals and the corporate executives of five telemedicine companies.

According to federal court documents, Willie McNeal of Spring Hill, Fla., owned two of the “purported” telemedicine companies, WebDoctors Plus and Integrated Support Plus.

Federal investigators allege that through Integrated Support Plus, McNeal hired and paid a New Jersey doctor, Joseph DeCorso, to write prescriptions for braces. DeCorso recently pleaded guilty to one count of conspiracy to commit health care fraud.

DeCorso admitted to writing medically unnecessary brace orders for telemedicine companies without speaking to beneficiaries or doing physical exams. He also admitted that his conduct resulted in a $13 million loss to Medicare. He has agreed to pay more than $7 million in restitution to the federal government.

McNeal got the Medicare beneficiaries’ information for DeCorso to write the prescriptions from telemarketing companies, according to the indictment. Then, authorities allege, McNeal sent the prescriptions back to the same telemarketing companies in exchange for payments described as kickbacks and bribes.

Federal investigators allege these telemarketing companies sold the prescriptions to the durable medical equipment companies, who, as part of the scheme, fraudulently billed Medicare for the braces.

McNeal’s lawyer says he can’t discuss his client’s case for this story because of the pending lawsuit. DeCorso’s lawyer did not respond to multiple requests for comment.

The U.S. attorneys allege the money made from the scheme was hidden through international shell corporations and used to buy luxury real estate, exotic automobiles and yachts.

Taxpayers on the hook for millions

It’s clearly a profitable business. Taxpayers are the ones who ultimately pay for Medicare fraud, which often leads to higher health care premiums and higher out-of-pocket costs.

Medicare spending on the sorts of braces highlighted in the inspector general’s investigations increased by more than $200 million from 2013 to 2017, according to an analysis of Medicare data by Kaiser Health News. While the number of Medicare fee-for-service beneficiaries increased only slightly (by 5%) from 2013 to 2017, spending on the three types of braces increased by 51% during that same period.

In an April news release about Operation Brace Yourself, Assistant Attorney General Brian Benczkowski, of the DOJ’s Criminal Division, called the Medicare scheme “an expansive and sophisticated fraud to exploit telemedicine technology meant for patients otherwise unable to access health care.”

Nathaniel Lacktman, a lawyer who represents telemedicine companies and organizations, was quick to point out that the industry does not recognize the fraudsters involved in these schemes as legitimate businesses.

“These are actually really sketchy online marketing companies participating in these schemes, who are billing themselves as telemedicine,” says Lacktman, who works in the Tampa office of the law firm Foley & Lardner. “But in fact, they’re companies we’ve never heard of.”

All of this comes at a time when Medicare and Medicare Advantage are expanding their use of telemedicine, though the federal programs have been slower to adopt the practice than the private sector, says Laura Laemmle-Weidenfeld, a health care lawyer at the law firm Jones Day.

“I would hate for Medicare to fall even further behind with telehealth,” says Laemmle-Weidenfeld, who previously worked in the Fraud Section of the DOJ’s Civil Division. “The vast majority of telehealth providers are legitimate but, as with anything, there are a few bad apples.”

Even with the recent federal busts, the scams continue. And they’re not isolated to durable medical equipment. A $2.1 billion scheme was busted by the DOJ in September which involved telemedicine doctors authorizing unnecessary genetic tests.

Travis Trumitch, who works for the Illinois nonprofit AgeOptions, which helps report Medicare fraud in the state, says he received three voicemails over a recent weekend reporting suspected durable medical equipment scams.

John Ernest says he still receives calls every day with individuals on the line who say they work for Medicare and ask for Dean Ernest’s information ? though his father died in April.

But Ernest can’t change his phone number, because it’s the main line associated with his painting business.

“It really drives me crazy,” Ernest says. “How many people are they ripping off?”

Kaiser Health News data editor Elizabeth Lucas contributed to this report.

KHN is a nonprofit, editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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