Let’s block ads! (Why?)

First there was Medicare, then Medicaid, and then Obamacare. Now we move to Trumpcare, or whatever it eventually is labeled, which seems to be turning into another big federal program to pay the bills for people with expensive illnesses.

House Republicans, trying to gather enough support to get their health care bill passed, keep adding pots of money to the proposal to pay the costs of people with high medical costs. The cash would very likely go to “high-risk pools,” which pay the expenses of the very sick so that insurance companies don’t have to.

House Speaker Paul Ryan made the case for high-risk pools on the Charlie Rose television show in January.

“By having taxpayers, I think, step up and focus on, through risk pools subsidizing care for people with catastrophic illnesses, those losses don’t have to be covered by everybody else [buying insurance] and we stabilize their plans,” Ryan said.

The original version of the House bill, called the American Health Care Act, includes a “Patient and State Stability Fund” with $100 billion over 10 years that would allow states to help defray their citizens’ health costs or lower their premiums.

Later amendments added an additional $30 billion to create a federal “invisible” high-risk pool, with money to reimburse insurers who cover patients with expensive illnesses and to pay for prenatal and childbirth care.

And on Tuesday night, Rep. Fred Upton, R-Mich, proposed adding an additional $8 billion over five years to ensure that sick people get adequate coverage through high-risk pools.

“It’s our understanding that the $8 billion over the five years will more than cover those that might be impacted,” Upton said Wednesday after a meeting at the White House. “And as a consequence, [it] keeps to our pledge for those that in fact would be otherwise denied because of pre-existing illnesses.”

Ryan says the goal of the Republican bill is to offer more and cheaper health insurance choices. By separating out those who have expensive medical conditions, the remaining customers for individual insurance could buy stripped-down policies with fewer benefits at a lower price.

Several states have tried high-risk pools in the past, but they were typically underfunded, leaving millions of people with no access to adequate health care. Lawmakers hope that by putting the heft and money of the federal government behind them, they may work better.

The federal government is already in the business. It pays for the health care of more than 40 percent of the population, through Medicare, Medicaid, the military and the Department of Veterans Affairs, according to the Census Bureau.

Medicare is essentially a giant high-risk pool. The program, which pays for health care for people over 65, was created in 1965 because that population couldn’t get affordable private health insurance precisely because their health costs were too high.

Last year the federal government spent about $591 billion on Medicare, according to the Kaiser Family Foundation.

Medicaid, which covers the poor or disabled, is essentially another high-risk pool, paid for with about $550 billion in tax money in 2016.

And then there’s the Veterans Health Administration, which pays for the care of many people who have served in the military.

Covering the people that commercial insurance left behind was also the goal of the Affordable Care Act, also known as Obamacare.

The law was designed to ensure that people in the individual insurance market who have pre-existing medical conditions, who were often shut out of traditional insurance plans, could get coverage. Obamacare tries to achieve that goal by requiring everyone, sick and healthy, to buy insurance so that the cost is spread among a broad population.

That led to higher premiums for many people who are young and healthy because they subsidize those who are sicker and older, and also because they have to buy insurance with a generous menu of benefits mandated by the government.

The Republican plan aims to cut those premiums by getting rid of Obamacare rules requiring that policies offer a broad menu of benefits, including prescription coverage and maternity care; limit how much more companies can charge older people; and require insurers to charge the same price for people with existing medical conditions.

But many Republican members of Congress, including Upton, aren’t willing to see those with more medical needs shut out of the system once again.

“We’re talking about some way to finance a social goal that was established by the Affordable Care Act,” says Joe Antos, a resident scholar at the conservative American Enterprise Institute. “I don’t think Republicans want to go back on that. They agree that we’ve turned that corner.”

Antos says the big difference between what’s being contemplated by the House Republicans this week and Medicare or other government health programs is that high-risk pools or subsidies would very likely still be run through private health insurers, which have incentives to save money and be efficient.

Zack Cooper, a professor of health policy and economics at Yale, agrees.

“Once you’ve decided to cover everybody, you’re sort of arguing over where the money comes from,” he says. “The ACA makes me subsidize you. The high-risk pools are simply doing that through taxation.”

So far the House GOP bill doesn’t require states to create high-risk pools, but some of the money is allocated specifically to that purpose. Such pools could be separate state-run insurance programs similar to traditional Medicare or Medicaid, or “invisible” systems where individuals buy their insurance on the regular market but the government pays the expenses of the people deemed high risk.

Maine has an invisible risk pool where insurance companies have to turn over to the state 90 percent of the premium paid by anyone the company deems high risk. That prevents companies from abusing the high-risk status, Antos says, because insurers would be forgoing income from patients who don’t have high medical costs.

After Maine established its high-risk pool, premiums for people in their 20s fell an average $5,000 a year, and people in their 60s saw their costs decline by about $7,000. At the same time, enrollment in private insurance rose, according to a study in Health Affairs.

The Republican bill doesn’t mandate a Maine-like system. And the flexibility in the bill, combined with limits on the money available, could be a problem, says Linda Blumberg, a senior fellow at the left-leaning Urban Institute. Especially since the pot of money is limited.

“We’re going to provide X dollars, then we’ll let the states figure out what benefits they can get for these people for the money that we’re providing,” Blumberg says.

Emily Gee, a health economist at the Democrat-allied Center for American Progress, says the Republican proposal needs about $20 billion more per year to adequately pay the costs of high-risk patients.

And that’s a real risk, says Yale’s Cooper.

Government has a track record of creating programs to help the needy but not funding them adequately to ensure that they offer quality services, he says. It’s a common complaint about Medicaid, where lawmakers frequently point out that it doesn’t pay doctors enough.

“This is trying to get people off the books,” Cooper says. “The fear is once you get them off the books, you forget about them.”

Let’s block ads! (Why?)

President Trump personally lobbied House Republicans on Wednesday to vote for the revised GOP plan to repeal and replace the Affordable Care Act.

Let’s block ads! (Why?)

All four of Anab Gulaid’s children have received their vaccinations on the recommended schedule. As Somali-American residents of Minneapolis, that puts them in the minority.

Fewer than half of Minnesota children of Somali descent have received the MMR shot that protects against measles, mumps and rubella, according to the Minnesota Department of Public Health, which is now working to combat a growing measles outbreak in the Twin Cities.

As of Wednesday, the case count was up to 34 — all but two unvaccinated, almost all Somali-American, and mostly children ages 5 and under.

Even in the midst of the outbreak, Somali resistance to vaccination remains strong in Minneapolis. Minnesota is home to the largest Somali population in the United States. It’s a relatively recent attitude that emerged alongside escalating fears about links between MMR and autism among the immigrant group.

Understanding the history behind those fears — and the culture that reinforces them, contrary to abundant scientific evidence — is an important step toward overcoming them, research suggests, and not just in Minnesota.

“There is a context; this didn’t just come out of nowhere,” says Gulaid, who studies autism as a public health researcher at the University of Minnesota’s Institute on Community Integration in Minneapolis. Her own children range in age from 8 to 17. “In my public health opinion, you can have a message, but if you come across as not listening, you can also lose that message.”

Roots of Resistance

Vaccine resistance has been an issue since the technology was widely introduced in the early 1800s, says Eve Dubé, a medical anthropologist and public health researcher at Laval University in Quebec City. Since then, people have cited concerns about vaccine safety, sterilization conspiracies, and government control over their bodies and rights.

Today, Dubé estimates, about one third of North American parents are hesitant to get their children vaccinated. Some but not all of those end up delaying or refusing shots.

Reasons for that wariness vary, and concerns often cluster within regional subcultures, and not just among immigrants. In France, for example, worries persist about an unsubstantiated link between the Hepatitis B vaccine and multiple sclerosis. Various religious groups oppose vaccines, as do certain groups who favor organic and natural lifestyles. In developed countries, some experts argue, support for vaccines has also declined alongside a fading memory of the diseases they were created to prevent.

And while multiple studies have shown spikes in vaccine-preventable diseases (including pertussis, polio, mumps and measles) in schools and regions around the world with low vaccination rates, such as affluent neighborhoods in Northern California and an Amish community in Ohio, it is extremely challenging to change people’s opinions about vaccines, Dubé says. Attitudes are often deeply ingrained.

She once interviewed a mother whose baby was in the hospital, extremely sick with pertussis, but the mom still believed that not vaccinating was the right choice. Dubé has also interviewed people who had bad reactions to vaccines but have no regrets.

And even when vaccination campaigns win over people in one place, the same strategy can fail elsewhere.

“It’s like there’s a predisposition to be mistrusting of these types of interventions,” she says. “There’s not much strong evidence in the literature or magic bullet ideas that can solve this issue.”

Somali-Minnesotans and autism concerns

Complexities are widespread among the Somali community in Minneapolis, where concerns about autism emerged around 2008, after Somali parents expressed concerns about disproportionately high numbers of Somali preschoolers in special education classes who were receiving services for autism spectrum disorder, according to the Minnesota Department of Health.

Parents had lots of questions, particularly about what was causing the disorder, says Asli Ashkir, a senior RN consultant with the Minnesota Department of Health in St. Paul.

“We don’t have a word in our language that translates to autism,” Ashkir says. “So when this started, we were like, ‘What is this?’ “

Around the same time, Andrew Wakefield, a British scientist who used fraudulent research to argue that the MMR vaccine causes autism, visited Minneapolis. He also teamed up with vaccine-skeptical groups to raise concerns about the shots, Ashkir says, fueling fear within an immigrant community that was already up against language barriers in a country that was new to them.

Concerns quickly influenced behavior. In 2004, according to the Minnesota Department of Health, 92 percent of Somali-Minnesotan children were vaccinated with MMR. After 2008, Ashkir says, rates of vaccination with the so-called “triple-letter vaccine” dropped by 5 to 7 percent each year. As of 2013, just 45 percent of Somali-American children in Minnesota had been vaccinated.

“We communicate orally,” Ashkir says. “The words fly.”

Alleviating those concerns happens more slowly, she says. In collaboration with the Minnesota Department of Health, she is using a variety of strategies to educate the local Somali community about both vaccines and autism, including advocacy for early intervention therapies for children with autism. She is also working with health clinics to give patients more time with doctors so they can get their questions answered with help from an interpreter.

“When a Somali person sees that a doctor is in a hurry, they don’t want to ask questions anymore,” she says. “In a clinic visit with three people, 15 minutes is not enough.”

Eventually, Ashkir would like to involve influential community members and religious leaders in public health efforts. It’s a strategy that has worked elsewhere, including a region in Western Australia where vaccine coverage was among the lowest in the country, in part because of a locally popular alternative lifestyle that valued home births, breastfeeding, cloth diapers and not vaccinating.

In 2014, a campaign there called “I Immunise” enlisted help from six locals who were featured on posters, billboards, signs and online about how vaccination fit into their alternative lifestyles. Among about 300 people who were surveyed about the campaign, researchers reported in 2015, more than 75 percent said it made them think more positively about vaccination. Still, nearly 70 percent people who had refused vaccines in the past gave negative reviews, illustrating how polarizing the issue remains.

Ultimately, researchers say, compassion may be one of the most powerful tools for spreading public health messages in hesitant communities.

It’s not fair to characterize people who question vaccines as “selfish or dumb,” says Dubé, who has studied MMR resistance among Somali immigrants in Sweden, among other groups. “These are well informed people that want to do what’s best for their families, with questions and concerns that have not been resolved.”

“The idea is to listen to the community’s specific concerns,” she adds. “It’s something that seems obvious but that public health is really bad at doing.”

Empathy can go a long way, Gulaid agrees. Her 8-year-old twin daughters were born around the time that fears of autism emerged among Somali-Americans in Minneapolis. And while she decided to move ahead with the recommended vaccination schedule, many of her friends have delayed their children’s shots. She doesn’t fault them for it.

“The Somali community is resilient and strong, and they’ve gone through a lot of hardships,” she says. “They just want healthy children. I understand their concerns.”

Let’s block ads! (Why?)

The House may yet pass its bill to repeal and replace parts of the Affordable Care Act. But Republicans’ options to fulfill their seven-year effort to undo the federal health law are getting narrower by the day.

“As of now, they still don’t have the votes,” said Rep. Pete King (R-N.Y.) as he was leaving a meeting of GOP members Tuesday. King has been heavily lobbied by both sides.

The latest snag is over whether people with pre-existing health conditions should have guaranteed access to affordable coverage, as the ACA mandates. An amendment that would let states waive some of those requirements has garnered the votes of reluctant conservatives but left more moderate Republicans concerned.

“I’ve supported the practice of not allowing pre-existing conditions to be discriminated against from the very get-go,” Rep. Fred Upton (R-Mich.), a former chairman of the House committee that handles most health issues, told a Michigan radio station Tuesday in explaining his decision not to support the bill. “This amendment torpedoes that.”

House leaders stressed that they are still working to muster a majority to pass the bill, which was originally scheduled for a full floor vote in March.

Here are some possible ways the effort could play out:

1. The House passes its bill soon.

Approval in the House would send the measure to the Senate, where the fight will be very different. Congress is using a special budget procedure that allows the bill to pass with 51 votes. There are only 52 Republicans in the Senate, so they can’t afford to lose more than two GOP votes, assuming every Democrat opposes the measure. In that case, Vice President Mike Pence would be needed to break a tie.

While this special procedure makes it easier for Republicans to pass their bill, the Senate’s budget “reconciliation” process must follow a series of specific rules that exclude any provision in the bill that doesn’t directly affect the federal budget.

Various parts of the House bill, including the recent change to let states waive some coverage rules — a provision that has ignited concerns about preexisting conditions — have been mentioned as possible violations of those Senate rules and would have to be taken out in order to qualify for the protections of reconciliation.

The Senate may also amend the bill and the House would have to approve those changes, which could again break the delicate coalition of House GOP support.

2. The House walks away from the debate.

In theory, the House could just leave health care for another day — or another year. That would be a huge setback for President Donald Trump, who campaigned on a pledge to “repeal and replace” the health law, as well as for congressional Republicans, who have been promising to do the same since the bill became law in 2010.

But if the law truly implodes for 2018, meaning insurers drop out of so many areas that millions of people have no insurance options, it could trigger an entirely different health debate.

3. The House decides to switch gears to tax reform.

Health care is not the Republicans’ only high priority. So is an overhaul of the federal tax code.

But Republicans want to use the same budget reconciliation procedure to pass their tax plan. That’s a problem.

In order to make sweeping tax changes under expedited budget rules, the House and Senate would have to move on to a fiscal 2018 budget resolution, which would override the 2017 budget blueprint. But as soon as it does, the protections for the health bill would expire.

There is another option. Each budget resolution can allow one spending bill and one tax bill to be protected by reconciliation rules. So Congress could simply start the process over in a 2018 budget resolution that would allow it to move on tax reform and changes to the health law simultaneously.

4. Congress tries to overhaul the health law incrementally.

The House could abandon the budget process and simply pass bills without regard to whether they have an effect on the budget. The first step, though, would likely be for the House to repeal the ACA wholesale — giving Republicans political cover. Then they could take up smaller pieces of legislation, such as a bill that would allow health insurance to be purchased across state lines, a favorite idea of Trump’s. Those bills, however, would require 60 votes in the Senate, which seems unlikely given the opposition from Democrats.

If the GOP efforts to bring wholesale change to the ACA are exhausted, though, it may be possible for some moderate Republicans to work with Democrats to craft legislation to fix some of the issues that both parties see in the law.

5. The Senate gets rid of the legislative filibuster.

The Senate earlier this year abolished the need for 60 votes to fill a Supreme Court seat, and that got Trump’s nominee, Neil Gorsuch, approved. Trump has been calling for Republicans to also get rid of the filibuster for legislation. “Either elect more Republican Senators in 2018 or change the rules now to 51%,” he tweeted on Tuesday.

But the legislative filibuster is the last protection for a Senate minority party, and Republicans know they will someday be in the minority again. Senate Majority Leader Mitch McConnell (R-Ky.) has said repeatedly he has no intention of taking this step, telling reporters Tuesday it “would fundamentally change the way the Senate has worked for a very long time.” And even if he changed his mind, he might have trouble persuading some of his Republican colleagues to go along.

Let’s block ads! (Why?)

Your child is diagnosed with a serious autoimmune disease and conventional treatments aren’t proving to be effective. Doctors prescribe powerful medications that don’t seem to work. Not only is your child not responding as hoped, he’s withering from the side effects. What do you do? Journalist Susannah Meadows found herself having to answer this question when her son, Shepherd, was diagnosed at age 3 with juvenile idiopathic arthritis, joint inflammation that can last a lifetime.

When the drugs didn’t work, Meadows was persuaded to look at his condition through a different prism and to consider the possibility that medications might not be the only answer. Meadows began speaking to parents who had sleuthed out alternative theories and tried things like radically changing their kids’ diets and giving them Chinese herbal medicines. Like many parents of sick children, Meadows grew increasingly willing to venture outside of the standard treatments.

Her experiences spurred her to seek other stories of people with illnesses ranging from multiple sclerosis to epilepsy to ADHD who pursued unproven methods of treating their diseases. Their stories, as well as an account of her son’s case, are compiled in The Other Side of Impossible: Ordinary People Who Faced Daunting Medical Challenges and Refused to Give Up, published Tuesday by Random House.