When Jeff Bezos, Warren Buffett and Jamie Dimon get together to make an announcement (any kind of announcement), it’s sure to grab attention.

So people perked up Tuesday morning when the CEOs of Amazon, Berkshire Hathaway and JPMorgan Chase said in a press release that their companies are going to partner in a nonprofit venture to figure out “ways to address healthcare for their U.S. employees, with the aim of improving employee satisfaction and reducing costs.”

The details are scarce. The announcement described “technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost.” Those goals are hard to argue with yet have proven difficult to achieve.

Vox health policy guru Sarah Kliff asked one of the smarter “dumb” questions about the companies’ plans on Twitter. She figured it might be a decision to self-insure in a new way or maybe to open their own hospitals creating a National Health Service in miniature. “Who knows!” she concluded.

Who knows is right.

I fired off an email to Amazon’s PR hotline. And in less time than it takes to stream Episode 1 of The Man in the High Castle, an email landed in my inbox from Amazon’s Ty Rogers:

“We’re not commenting at this point beyond what’s in the press release, but I appreciate you reaching out and we’ll keep you in mind if that changes.”

On business news channel CNBC soon after the announcement, Brent Saunders, CEO of Botox maker Allergan, gave his back-of-the-envelope analysis. “My sense is, and I’m only speculating, is that they’re looking at their own health care costs, and they’re all large employers and they’re saying, ‘How do we manage this better?’ ” he said. “The key is, you put the patient, which in their case is the employee, at the center of it and you try to bring down costs,” he said. Health care, he added, is “certainly ripe for disruption.”

Nobody would dispute that assessment. But where would the companies start?

The press release, such as it is, said technological solutions would be the “initial focus” of the venture’s work.

All three companies have a lot of experience using technology to make life easier for consumers. Amazon’s online reach and experience may be the most obvious. But Berkshire Hathaway owns Geico, a juggernaut in direct-to-consumer sales of insurance. And JPMorgan Chase’s consumer finance services — from mortgages and credit cards to traditional banking — give it expertise in dealing with people about complex decisions in person and online.

Think then of an online app that might help employees shop for health care with information about prices and quality. What if the app helped them book appointments with doctors and nurse practitioners, too?

Would an app that eases the way for employees to more easily choose health services that offer better value make much difference in how much the companies spend on care? Maybe a little, but probably not a lot.

In California, a health care pricing tool launched in 2014 for government employees and retirees didn’t really catch on. Only 12 percent of employees used the tool to shop better for lab tests, office visits and imaging services, according to a paper published by the journal Health Affairs in August.And the tool didn’t reduce overall spending on the services it included.

With hundreds of thousands of employees in the U.S., this Amazon-Berkshire-JPMorgan triumvirate would have real buying clout and the ability to command public attention, as the immediate buzz over the announcement showed.

Yet this wouldn’t be the first time that employers have banded together to improve health care quality and do something about costs. It has happened many times before, in fact.

Two prominent examples in recent years include the Leapfrog Group, founded by big companies in 2000 to spur hospitals to improve quality and patient safety, and the more recent Health Transformation Alliance, a corporate consortium that emerged publicly in 2016.

Neither of those efforts could be said to have fundamentally changed how health care is delivered or paid for, even if they have made a difference on the margins.

But as the Kaiser Family Foundation’s Larry Levitt said on Twitter, there is no chance the nation can budge health spending without the big bosses at least trying.

Still, the skepticism is strong, especially when the particulars haven’t even been sketched out by the companies. “It will be interesting to see them try,” said Donald H. Taylor, a health care economist at Duke University and member of the National Academies Committee on Health Care Utilization. “Everybody wants a unicorn. But people have been chasing this unicorn for a long time.”

NPR health policy correspondent Alison Kodjak contributed to this report.

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For the past year, the Trump administration and Republicans in Congress have led a charge to roll back the Affordable Care Act, signaling an openness to changes at the state level.

Now, Idaho has jumped in, with the insurance department saying Wednesday it will allow insurers to ignore some ACA rules on plans not sold on the marketplace. The department aims to make these state-based plans less costly. Several of the changes are viewed by the health law’s supporters as hits to its core consumer protections.

Critics say Idaho can’t unilaterally skip provisions of federal law, including some of the ACA’s protections for pre-existing conditions and its limits on how much more insurers can charge older or sick people.

Idaho’s approach has national implications because of a key underlying question: Will the administration compel Idaho to follow the ACA or offer a green light that could prompt other states to take even more sweeping action?

Idaho argues its aim is to bring people back into the market, particularly the young, the healthy and those who can’t afford an ACA plan.

“Our goal is not to take away from the ACA, but to add to it or complement it,” said Dean Cameron, director of the state’s Department of Insurance. For instance, insurers could veer from the ACA rules in creating the new plans, so long as they offer other ACA-compliant policies.

Premiums for marketplace policies have risen sharply amid continuing GOP efforts to undermine the ACA. Middle-income Americans who don’t get subsidies are struggling to afford coverage.

“States are trying to figure out what they can do,” said Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation. “How do you provide them with cheaper insurance?”

Idaho says the answer is to skip some of the ACA rules.

Here is a quick look at some of the questions that approach raises:

1. Can Idaho do this?

Many experts say no. Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, tweeted early Thursday that the move was “crazypants illegal.”

In a follow-up call, he explained that the ACA created rules that — among other things — prevent insurers from discriminating against people based on their health or excluding coverage for those conditions.

“I’m completely flummoxed,” he said. “Idaho appears to be claiming they do not have to adhere to federal law.”

But Idaho officials believe there’s precedent for what they are doing, pointing to actions taken by President Obama when he promised people that if they liked their health plans, they could keep them. Obama issued an executive order directing his agencies to allow the continuance of some plans purchased before the marketplaces opened— even though they fell short of ACA rules, Cameron noted.

Additionally, Cameron pointed to state laws that allow insurers to sell short-term policies that don’t meet all the ACA rules.

“We have tried to do everything we can to adhere to and follow the requirements,” said Cameron, who added that the state consulted with administration officials as it developed its plan.

“I recognize we are pushing the envelope a bit,” he said. “We think this is what is needed.”

2. What might happen?

A lawsuit challenging Idaho’s move seems likely, perhaps on behalf of someone with a pre-existing condition alleging harm because the state-based plans will cost the sick more or limit coverage in other ways.

Secondly, some experts say the argument might include concerns that the state-based plans could pull healthy people out of the ACA market and drive up premiums there.

Cameron expects the effect will be the opposite, helping stabilize those premiums by bringing more healthy people into insurers’ risk pools through the state-based plans. Insurers would have to pool their claims from both ACA and state-based plans.

3. How different are these plans from ACA coverage?

Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, said they are “in the middle in terms of the consumer protections they provide, but they’re not as good as the ACA.”

They’re better than some non-ACA compliant alternatives already on the market, such as limited-benefit plans, which can be really skimpy — paying paltry amounts or nothing at all toward hospital care or drugs, for example.

By contrast, Idaho’s directive says the new plans must cover outpatient services, emergency care, hospitalization, mental health and substance abuse treatment, drugs, rehabilitation, lab services and preventive care. Insurers must include maternity coverage in at least one state-based plan.

“Setting aside the question of whether a state can do this, it would not be a radical change,” said Haislmaier at Heritage.

But, unlike ACA plans, the state plans could cap coverage at $1 million annually. They could charge older people up to five times more than younger ones (the ACA limits the ratio to 3-to-1) and sick people could be charged up to 50 percent more for premiums than standard rates. On the flip side, very healthy people could have rates of up to 50 percent below standard rates.

On pre-existing conditions — which is among the ACA’s most popular provisions — the Idaho rules would require insurers to accept people with medical problems, but they could exclude coverage for those specific conditions if the person were uninsured within 63 days of the new plan taking effect.

Still, Cameron argues that the rules of the Idaho plan — in practice — would not be much different than what people face now.

Those who fail to sign up during the annual open enrollment period for the ACA then find out they have a health problem have few other options and would have to wait until the next ACA open enrollment, he noted.

Under Idaho’s plan, such consumers could buy a state-based plan and “have coverage on everything else, except for the ‘pre-ex’ [pre-existing condition], until the next open enrollment period,” Cameron said.

4. What could happen legally?

At a minimum, states must follow federal law, although they generally can set more stringent standards. Some states, for example, are considering putting in place their own “individual mandate” to replace the ACA tax penalty for those who are uninsured. The tax bill Congress passed in December removes that federal penalty as of 2019.

But states cannot create rules that fall short of federal law. If the state doesn’t enforce federal rules, the ACA grants the federal government authority to step in.

Idaho may be “banking on … the Trump administration [not enforcing] the ACA,” said Bagley.

This could be one of the first tests for new Health and Human Services Secretary Alex Azar.

“If HHS does not go in and enforce the federal floor… then Idaho can do whatever it wants. Any other state can do whatever it wants,” said benefits attorney Christopher Condeluci,who formerly served as the tax and benefits counsel to the Senate Finance Committee.

“If HHS declines to step in to enforce the law, the executive branch headed by the president is responsible for enforcing the law,” Bagley said. “Trump’s job is to make sure his agencies enforce federal law.”

5. Insurers have not said if they will offer such plans. What are their liabilities?

The ACA set fines of $100 per day, per enrollee, for violating provisions of the law. Multiplied by thousands of enrollees across several violations, that could quickly add up. The state may allow the plans, but “it’s not clear that a future administration could be prevented from looking back at past violations and imposing pretty significant penalties,” said Georgetown’s Corlette.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt of Everett, Wash., waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top of her head.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” says Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, which is more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Designed for Medicaid’s most fragile

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. It requires the transport of certain people to and from medical services like mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” says Holt. “Now that she’s older and more disabled, it’s crucial.”

However, citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. That includes nearly 104 million NEMT trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

Current flexibility through waivers

But there is some flexibility for states already. Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March 2017 letter.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states — Iowa, Indiana and Kentucky — have received federal waivers and extensions allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” says Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, says Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman calls the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

In a 2014 survey of Medicaid users, CMS found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman says. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is often cost-effective because patients who got to a health appointment stayed healthier.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Left out and struggling

Still, some Medicaid clients struggle without transport services. Fallon Kunz, 29, of Mishawaka, Ind., has cerebral palsy, migraine headaches and chronic pain. She uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she says.

Kunz is studying psychology online at Southern New Hampshire University. She lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she says. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The only way I can get rides to and from my doctor’s appointment is to ride the two miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she says. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she says on a Tuesday in December. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” says Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick adds. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients and bad for the country.

“[Ninety] percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” Verma notes in a 2016 Health Affairs essay.

But there are some who can’t.

“I’m a college student, I have a cat,” says Kunz. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Updated at 10:35 a.m. ET

Cecile Richards, the longtime president of Planned Parenthood, will step down later this year, the organization announced on Friday.

“Planned Parenthood has been a trusted resource in this country for more than a century, and I will be leaving the organization well-positioned to serve and fight for our patients for a century more,” Richards said in a statement. “Every day we see the incredible power that grassroots voices can have — there has never been a better moment to be an activist. You can bet I’ll be marching right alongside them, continuing to travel around the country advocating for the basic rights and health care that all people deserve.”

Planned Parenthood will announce its future plans after the board of directors meets next week, the organization says.

For more than a decade, Richards has held down a tough job as the group’s most high-profile spokeswoman.

She’s been called upon repeatedly to defend the reproductive rights organization’s work, which includes providing contraception and health screenings to women around the country, as well as about a third of the nation’s abortions.

“It’s a shame to think that there are people in this country who are so committed to ending women’s access to both birth control, and safe and legal abortion, that they’ll really resort to any means to try to entrap people, twist the truth, in order to reach their ends,” Richards toldthe House Committee on Oversight and Government Reform in 2015.

Her testimony followed the release of secretly recorded sting videos by the anti-abortion group Center for Medical Progress. The organization accused Planned Parenthood of selling fetal body parts. Richards said the videos were deliberately misleading.

Planned Parenthood has long been a lightning rod for criticism from abortion-rights opponents, who’ve made cutting public funding for the group a major priority. Under current law, it’s illegal for federal funds to pay for abortions in most cases. But Planned Parenthood does receive about half a billion dollars per year in public money, largely to provide services such as contraception and cancer screenings for low-income women, who make up a majority of patients served by the organization’s health centers.

Richards’ departure from Planned Parenthood comes at a time when many abortion-rights opponents are feeling optimistic about advancing their goals: President Donald Trump’s first year in office has given abortion opponents several victories and put Planned Parenthood on the defensive.

The news of a leadership transition was greeted with celebration and calls for change at Planned Parenthood by abortion rights opponents.

Penny Nance, CEO of the conservative group Concerned Women for America, which opposes abortion rights, says whoever takes over for Richards is likely to face more battles with activists who want to see more legal restrictions on abortion.

“This is a very sad legacy, and I hope that whoever comes after her will reconsider the direction and mission of Planned Parenthood,” Nance told NPR.

Meanwhile, abortion rights advocates are praising her leadership. In a statement to NPR, Ilyse Hogue, president of NARAL Pro-Choice America, called Richards “a force” who “fights to make this country a better place for women and families.”

Even before coming to Planned Parenthood, Richards was no stranger to Capitol Hill or political action. She was a top staffer to House Democratic Leader Nancy Pelosi, and before that, a grassroots organizer for progressive causes.

Richards, who’s 60 and married with three children, got the taste for politics from her mother, former Texas Gov. Ann Richards, famous for her wit and sharp-tongued criticism of George H.W. Bush.

In an interview with NPR’s Michel Martin in 2014, Cecile Richards talked about growing up with parents for whom political activism was in the water.

“They were into politics like other couples were into bowling,” Richards said, “Every movement that came through town – whether it was the farmworkers movement, the labor movement, the women’s movement – they were into, and so were all their friends.”

In 2016, a year where gender issues were often at the center of the political debate, Richards spoke out in support of Democratic nominee Hillary Clinton at the party’s national convention in Philadelphia, heralding the “glass ceiling” she believed Clinton was about to break by becoming the first female President of the United States.

That ceiling, of course, did not fall, but Richards has remained an active voice for reproductive rights and against President Trump. In the days after Trump’s inauguration, she addressed the 2017 Women’s March in Washington, D.C.

At this year’s march in Las Vegas, Richards admonished white women to “listen up,” alluding to recent electoral victories for Democrats in states including Alabama, where black women and other voters of color turned out in large numbers to support Democratic candidates like Sen. Doug Jones.

“We’ve got to do better,” Richards told the crowd. “It is not up to women of color to save this country from itself. That’s on all of us.”

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Dr. Andrey Ostrovsky’s family did not discuss what killed his uncle in 2015. The man was young, not quite two weeks past his 45th birthday, when he died, and had lost touch with loved ones in his final months. At the time, Ostrovsky wondered if his uncle had perhaps killed himself.

Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling professionally with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle had died of a drug overdose.

Family members knew the uncle’s life had been turbulent for a while before his death; they’d watched as he divorced his wife and became estranged from his 4-year-old daughter and eventually lost his job as a furniture store manager.

But Ostrovsky wanted to better understand what had happened to the man — his stepfather’s younger brother. So last fall, when he found himself in southeastern Florida, where his uncle had died, Ostrovsky contacted one of the uncle’s friends for what he expected would be a quick cup of coffee.

Instead the friend “let loose,” revealing that he and Ostrovsky’s uncle had been experimenting with a variety of drugs the night of the death. It was the tragic culmination of more than a decade of substance abuse — a pattern of behavior much of the family knew nothing about. An autopsy showed there were opiates and cocaine in his uncle’s system, Ostrovsky later learned.

The revelation shook Ostrovsky — he’s a pediatrician who was appointed to the Centers for Medicare & Medicaid Services in 2016. As chief medical officer of the agency, Ostrovsky had championed getting better drug treatment programs for the 74 million people on Medicaid; it’s a task that became increasingly difficult after Republicans signaled they would trim the program under President Donald Trump.

Within his own agency, Ostrovsky felt he’d become something of a pariah. After he posted a tweet against a Republican plan to repeal and replace the Affordable Care Act, he was reprimanded and removed from his major projects. A conservative group known as America Rising filed a Freedom of Information Act request for his email correspondence, a move seen as an attempt to intimidate Ostrovsky.

But that revelation over coffee in Florida made the drug crisis deeply personal for Ostrovsky and his family, and led him to make a change. He realized that solutions are not just about money, but also about combating stigma — the stain he believes prevented his uncle from getting help.

So, Ostrovsky quit his government job last month and has begun speaking publicly about his family’s experience, to remove the shame of drug addiction.

It may not literally be what killed him, Ostrovsky says, referring to the stigma. “But that’s what killed him.” NPR agreed not to disclose the uncle’s name out of respect for his family’s privacy.

Last fall, the Trump administration declared the opioid crisis a public health emergency, stopping short of allocating more funding for an “epidemic” that killed more than 42,000 in 2016 — more than any year on record, according to the Centers for Disease Control and Prevention. And early numbers released this month indicate 2017 may even have outpaced 2016 in drug deaths.

In one of the latest attempts to manage the crisis, Democratic Gov. Tom Wolf of Pennsylvania recently declared the opioid epidemic a statewide disaster emergency. For the first time, Pennsylvania officials will direct emergency resources toward a public health crisis in the same way they would a natural disaster.

The uncle’s story offers an intimate look at a crisis that has vexed officials on the local, state and national level, strained public health resources — and infiltrated not just America’s streets and drug dens, but also workplaces and successful middle-class families like Ostrovsky’s.

The uncle immigrated to the United States from Azerbaijan when he was 16, seeking a brighter future than the one that stretched before him in the crumbling Soviet Union, Ostrovsky says. The family settled in Baltimore, where the Uncle married and started his own family. When he wasn’t working, he grilled lamb kebabs and danced to music from his home country. He was a warm, welcoming host, insisting guests have at least a cup of tea.

“Even when he had nothing, he would take that last piece of bread and offer it to you,” Ostrovsky says.

To Ostrovsky, the man was the “cool uncle,” always bringing his nephew trinkets from his travels. When Ostrovsky was in seventh grade, his uncle returned from Jamaica with a shirt that read: “See no evil, hear no evil, speak no evil, s—- happens mon.” Ostrovsky wore the shirt to school — and says he happily suffered the inevitable punishment. “I love him for that and was proud to get in trouble,” he says.

Sometime around the early 2000s, the uncle and his wife divorced. The man began drinking more — a vice Ostrovsky attributed in part to the family’s cultural heritage, but that he now suspects grew into alcoholism.

It is unclear to the family when, exactly, drugs came into the uncle’s life, though his problems seem to have escalated in his 30s. His drug of choice was cocaine, Ostrovsky learned from his uncle’s friend, who frequently took drugs with the uncle over the years.

The uncle’s worsening ability to function at work and other financial strains eventually drove him to crack cocaine, an especially addictive, cheaper form of the drug that produces an instant, intense high when smoked.

Months before his death, the uncle lost his job and grew depressed. He began using drugs more heavily and trying new ones. He dabbled in benzodiazepines — the class of psychoactive drugs that includes Xanax and Valium — and in opioids.

Opioids, which broadly include both illegal drugs like heroin and prescription painkillers like OxyContin, can be particularly perilous when misused, because they suppress the ability to breathe. Those who use opioids also build up a tolerance over time, which leads some people to use more of the drug to achieve the same high.

These facts are especially problematic, considering that street drugs are often cut with more powerful opioids — such as fentanyl, a fast-acting painkiller — to intensify the high.

Eventually, Ostrovsky’s uncle began living with his drug dealer. On the night of his death, he and his friend went through the dealer’s stash when he was out, trying pills and other drugs. When the dealer returned, after the friend had left, the uncle didn’t answer the door.

He was found on the couch, looking “at peace,” his friend recounted to Ostrovsky. They tried to resuscitate him and called for help. Sitting on the curb outside, his friend watched the paramedics carry the uncle away.

The uncle’s friend says he has since then quit using drugs and is enrolled in a methadone program — a treatment option that uses another opioid to reduce withdrawal symptoms.

Ostrovsky says his former agency, the Centers for Medicare and Medicaid Services, is “ill-equipped” right now to handle the problem of addiction; it’s hampered, he says, by a White House that is putting more emphasis on overhauling Medicaid benefits. So, for now, Ostrovsky is working outside the government.

This month, he announced he’s joining Concerted Care Group, an addiction treatment program based in Baltimore whose patients are mostly covered by Medicaid; the organization is looking to expand, and Ostrovsky will serve as CEO.

Ostrovsky says he first noticed Concerted Care Group when it was part of a CMS pilot program. The program stood out, he says, because it eschews what he calls the grab-and-go approach of most outpatient addiction centers.

Instead, it offers patients private spaces to take their medicine; security guards to ensure their safety; even coffee while they wait. The approach preserves at least a modicum of patient dignity, he says. In the same spirit, Ostrovsky hopes that sharing his personal story about his uncle will help combat the stigma that makes patients and their loved ones ashamed to reach out for help.

“I think this is really important,” Ostrovsky says. “That people hear about his story and talk — and get over that feeling of not wanting to have that uncomfortable conversation with my family member who needs help.”

Kaiser Health News (KHN) is a nonprofit news service covering health issues. It’s an independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.

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A tobacco product that its maker claims to be safer than cigarettes won qualified support from a Food and Drug Administration advisory panel Thursday.

The advisers voted 8-1 to support cigarette giant Philip Morris’ claim that its “iQOS” system “significantly reduces your body’s exposure to harmful or potentially harmful chemicals.” The device heats tobacco but doesn’t ignite it.

But on the question of whether that approach translates into a reduction in the risk for tobacco-related diseases, the panel said the tobacco company’s studies didn’t demonstrate that. The vote was eight against, with one abstention.

Similarly, they said Philip Morris hadn’t proved that reducing harmful exposure would necessarily “translate to a measurable and substantial reduction in morbidity and/or mortality.” The vote was 5-2 against, with one abstention.

There was some support for the company’s claims that “switching completely to iQOS presents less risk of harm than continuing to smoke cigarettes.” But the measure failed on a vote of 4-5 against.

The FDA doesn’t have to follow the advisory panel‘s advice but usually does.

During the two-day hearing, the company presented claims that iQOS poses less danger because the device heats tobacco, instead of igniting it, to produce an aerosol that contains 90 percent lower levels of dangerous chemicals than found in cigarette smoke.

If the agency grants the company’s request and approves the product, iQOS would become the first tobacco product authorized by the FDA to be marketed as causing less harm than regular cigarettes.

Advocates and some smoking-cessation counselors urged the committee to endorse the product to make an alternative they consider to be safer available to millions of U.S. smokers. But some anti-smoking advocates question whether the device really is safer and fear it could hook more people on nicotine, including children.

Philip Morris argued the device would be exclusively marketed to smokers and estimates the iQOS could save 90,000 lives over 20 years in the United States.

“IQOS emits toxicants and is not risk-free,” Manuel Peitsch, Philip Morris’ chief scientific officer, said on the opening day of the hearing. “Nevertheless, iQOS emits significantly lower levels of toxicants than regular cigarettes. Switching to iQOS can significantly reduce the risk of disease compared to regular smoking.”

The device could be more appealing to many smokers than electronic cigarettes because the iQOS heats tobacco instead of a liquid containing nicotine. That gives the user more of the taste and experience of regular cigarettes, the company argues.

Critics, however, questioned Philip Morris’s safety claims.

“I think the whole thing is a scam,” said Stanton Glantz, a prominent anti-smoking advocate at the University of California, San Francisco, to NPR before the hearing. “When you look at the actual evidence that Philip Morris has submitted to the FDA, it doesn’t support the claim that these things are any better than cigarettes in terms of health effects in people.”

Glantz noted that the tobacco industry has a long history of selling products that it claimed were safer, such as cigarettes marketed as “light,” “mild” or “low-tar,” that turned out to be just as dangerous.

“What we’re seeing is just a replay of the old light and mild scam,” Glantz said.

One study conducted in Switzerland found that while the iQOS produces many toxic chemicals at lower levels than cigarette smoke, some are higher than the company claims. Philip Morris disputes that research.

Some of the chemicals found are components of smoke, the researchers say. “We found lower concentrations of these compounds; however, we found them. And because we found them, we think this is smoke,” Reto Auer, an assistant professor at the University of Bern in Switzerland who conducted the study, said in an interview before the hearing. “We disagree with the claim that it’s smokeless. People should be aware there are still toxic substances in the iQOS.”

Auer and Glantz’s concerns were echoed by several people who spoke during a public comment period on the second day of the hearing.

The iQOS looks suspiciously similar to the most popular e-cigarettes among children, Matthew Myers, president of the Campaign for Tobacco-Free Kids, told the committee.

“It is high-tech. It is sleek. It is designed in exactly the way that would appeal to young people,” Myers told the committee.

If the iQOS wereapproved, it could hook children and teenagers on nicotine, reversing the progress that has been made to reduce smoking among young people, Myers fears.

But most of the speakers at the hearing urged the committee to recommend approval to give smokers a potentially safer alternative to cigarettes. More than 36 million Americans currently smoke.

“There is no health threat that compares to smoking,” said Hank Campbell, president of the American Council on Science and Health. “Even though we have been opposed to smoking for 40 years, we support these devices.”

“Patients who smoke clearly need more tools to help them quit,” said Jeff Fortenbacher, president and CEO of Access Health in Muskegon, Mich.

In an interview before the hearing, Jonathan Foulds, a professor of public health sciences and psychiatry at Penn State University, agreed.

“I think it’s a step in the right direction for tobacco companies to be developing products that have the probability of being significantly less harmful than conventional cigarettes,” Foulds says.

Philip Morris is already selling iQOS in more than 30 countries and argued there was no evidence it was enticing children to use the product or start smoking. In fact, the company said, cigarette smoking had dropped dramatically since the device was introduced in Japan.

The iQOS consists of several parts. One part is called a “heatstick,” which is made from compressed wads of tobacco. If approved, three versions would be sold: Marlboro HeatSticks, Marlboro Smooth Menthol HeatSticks and Marlboro Fresh Menthol HeatSticks.

The iQOS device is reusable, but the heatsticks are not.

Users would insert a heatstick into a holder that has a blade that penetrates the middle of the tobacco wad. When the user presses a button, the blade heats the tobacco to temperatures only capable of producing an aerosol that contains nicotine, according to the company.

The tobacco never gets hot enough to combust, according to Philip Morris. Burning tobacco produces far greater levels of potential toxic substances than just heating it, the company says. The devices stay on for six minutes or 14 puffs, whichever comes first, before shutting off automatically.

Philip Morris hasn’t said how much the device would cost in the United States. But in Japan, the device sells for about $80, and a pack of heatsticks costs about the same as a pack of cigarettes.

The FDA advisory committee’s recommendation Thursday pertains only to the company’s claims about the safety of the product. Philip Morris would still have to get the FDA to sign off on a separate application to actually sell the devices in the United States for the first time.

The hearing comes after the FDA announced plans to eventually reduce the amount of nicotine in regular cigarettes in the hopes of weaning more Americans off cigarettes. As part of that effort, the FDA has said the agency hopes to offer more alternative sources of nicotine that would be safer than cigarettes.

Separately, the FDA has begun reviewing the safety of electronic cigarettes. Those devices heat fluid containing nicotine to produce a vapor that users inhale. E-cigarettes have become increasingly popular, especially among young people. The growth in use has alarmed many public health experts.

While e-cigarettes may be safer than regular cigarettes, experts say e-cigarettes aren’t completely safe and fear they are hooking a new generation of children on nicotine and acting as a gateway to traditional cigarettes.

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Philadelphia is a step closer to opening what could be the nation’s first supervised site for safe drug injection. But turning the idea into reality won’t be easy.

City officials gave the proposition the green light Tuesday. They were armed with feasibility studies, harrowing overdose statistics and the backing of key leaders, including the mayor and a newly elected district attorney.

“There are many people who are hesitant to go into treatment, despite their addiction, and we don’t want them to die,” said Dr. Thomas Farley, Philadelphia’s health commissioner and co-chair of the city’s opioid task force. Supervised safe injection sites, he said, save lives by preventing overdose deaths and connecting people with treatment.

While one big hurdle has now been cleared, the details of how safe injection sites would actually work in Philadelphia have yet to be figured out. Who will actually fund and operate a site? Where will it be located? Will users really be safe there?

“We have a long way to go,” said Brian Abernathy, first deputy managing director for the city.

Neither city council approval nor special zoning ordinances would required to proceed, Abernathy said, but the city doesn’t plan to actually operate or pay for any sites. Instead Philadelphia officials would play the roles of facilitator and connector with providers of addiction services.

In that way, Tuesday’s announcement by the city was more like an open call to potential investors and operators than it was the roll out of a specific plan.

“We took a really really big first step,” said Jose Benitez, executive director of Prevention Point Philadelphia, a large nonprofit needle exchange. “It’s early to talk about our involvement at this particular point. As the city officials said, there’s a lot to consider.”

Broadly, the city envisions a place where people would be allowed to bring in drugs and inject them using clean equipment. If someone overdosed, trained staff would respond to prevent death. The sites could save lives and money otherwise lost to hospitalizations and emergency response efforts. Advocates say the sites also could reduce neighborhood problems associated with addiction, like people injecting in public and discarding needles.

A safe, supervised site wouldn’t just be about a spot to inject, Farley stressed, but also somewhere people could connect with other services and treatment.

Still, the effort to open a site will likely face many additional hurdles and unknowns, from community buy-in to legal concerns.

For one, Councilwoman Maria D. Quiñones-Sánchez, who has voiced opposition to a safe injection site in her district (one at the heart of the crisis), is wary of the city’s plan.

“This notion of letting a private developer or a private person come tell us how this could be done, we’re not paying for it, we’ll do wrap-around services, so much of that is just up in the air,” Quiñones-Sánchez said. “So why make an announcement with no answers?”

Another question: Could such a site be immune from federal prosecution? Realistically no, said Philadelphia official Abernathy, though some legal scholars are exploring potential safeguards.

The city’s police commissioner, Richard Ross, has gone from “adamantly against” any injection site to having an open mind. Whether police will take a hands-off approach remains to be seen. So would what the department’s role would be, what police officers would be asked to do, and how that would affect the policing of narcotics?

“I don’t have a lot of answers,” he said.

One point of clarity: Philadelphia’s Distract Attorney, Larry Krasner, has no plans to prosecute.

“What will we do? We will allow God’s work to go on,” Krasner said, citing state laws of justification that allow the committing of minor violations in the interest of preventing greater harms. “We will make sure that idealistic medical students don’t get busted for saving lives and that other people who are trying to stop the spread of disease don’t get busted.”

After all this, it should come as no surprise that the timeline is really unclear, too. Rollout will take months, at least, leaders have said. Though if it were up to Krasner, one would had opened years ago.

“My biggest concern moving forward with harm reduction is that government takes forever,” he said. “When we have three or four people dying every day, nobody can afford to wait.”

This story is part of a reporting partnership with NPR, WHYY’s health show The PulseandKaiser Health News.

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A former pharmaceutical industry official who says drug prices are too high will now be in charge of buying more medications than anyone in the world.

Alex Azar, former president of the U.S. arm of Eli Lilly & Co., was confirmed Wednesday as the secretary of health and human services.

In that role, he’ll oversee the Food and Drug Administration, which regulates prescription drugs including those produced by his former employer. He’ll also oversee Medicare and Medicaid, which together spend hundreds of billions of dollars each year on prescription medications.

He’ll take over the agency at a time when rising drug prices are a huge political issue.

Azar acknowledged as much in his confirmation hearing in early January. He told members of the Senate Finance Committee that dealing with high drug prices would be a priority.

But Azar won’t have the power to get Congress to change the law to let Medicare negotiate prices directly with manufacturers. He told senators that allowing the insurance companies that contract with Medicare is more effective.

“These are incredibly powerful negotiators who get the best rates available,” he said.

Azar spent five years at Eli Lilly, which makes several blockbuster medications, including Cialis, which treats erectile dysfunction; the antidepressant Cymbalta; and several forms of insulin. Insulin prices have drawn particular fire because they keep spiraling higher, even though insulin has been around for almost a century.

The prices of Lilly’s insulin drugs Humalog and Humulin, for instance, have both risen about 225 percent since 2011, according to data from the investment research firm Bernstein.

Before his stint at Eli Lilly, Azar served in HHS under President George W. Bush, so he is familiar with the sprawling agency that also includes the National Institutes of Health, the Indian Health Service and the U.S. Public Health Service.

Azar replaces Tom Price, who resigned from HHS in September after a Politico investigation found that he had taken private charter aircraft on work-related trips at times when cheaper commercial flights were available.

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When parts of the federal government ground to halt this past weekend, Linda Nablo, who oversees the Children’s Health Insurance Program in Virginia, had two letters drafted and ready to go out to the families of 68,000 children insured through the program, depending on what happened.

One said the federal government had failed to extend CHIP after funding expired in September and the stopgap funding had run out. The program would be shutting down and families would lose their insurance.

The other letter said they didn’t need to worry anymore because federal funding had finally come through and the program’s future was assured.

Since Monday’s deal to end the shutdown included a six-year reauthorization of CHIP, enrolled families in Virginia will get that second letter. The program will go on and no children will lose their health insurance.

Taking Stock Of Costs

After months of uncertainty, Nablo said she’s relieved. “Hugely relieved. It’s over and the program is safe, and we can all go back to our normal jobs,” she laughed.

Preparations to shut down the program in Virginia down began over the summer, even before funding expired. Staff spent untold hours getting ready to end the program, retooling enrollment systems, changing contracts and more.

“Those aren’t huge dollar amounts,” Nablo said. “I think the cost more is in the worry from parents.”

CHIP covers children in low-income families — most can’t afford private insurance and their children might have had to go uninsured. Nationally, about 9 million children get health coverage through CHIP.

An Unprecedented Situation

In its 20-year history, CHIP had always been uncontroversial, even popular in both parties. Its funding needs to be periodically renewed, and it always had been taken care of well in advance of the money running out.

CHIP is a match program — states and the federal government split the cost. When states made their budgets for this year, they assumed federal funding for CHIP would be there, so they were blindsided by the funding gap.

Every state’s calculus for how long they could run on leftover money was different. In Texas, Hurricane Harvey threw off that state’s projections. Because of the disaster, it waived fees for CHIP and enrollment spiked, so it had less money coming in and more going out.

A handful of states — including Virginia — sent out letters warning families their coverage was in jeopardy because of the uncertainty in Congress.

“One state — Connecticut — did freeze enrollment between the week of Christmas and New Year’s,” said Joan Alker of the Georgetown University Center For Children and Families, which monitored CHIP funding closely during the last few months.

Virginia’s Nablo said there might be other, more subtle, costs from all the uncertainty.

“I can’t quantify it, but I am sure there are states that held off on things like mounting an outreach program to encourage people to enroll because they didn’t know if the program was going to be there for them,” she said. “There may have been states that were thinking of implementing some efficiencies or innovations, but didn’t because — again — is the program going to be there?”

Six Years Of Certainty

Alker is happy with the CHIP deal Congress passed. She does point out it’s the same one they agreed on in September, so she’s not sure why it took a shutdown to finally get it through.

The deal keeps the federal investment in the program at its current level for two fiscal years. After that, the amount that states have to pay for the program will increase.

“At least states now have time to plan for that,” Alker said. “Overall, it really was a fair and reasonable compromise.”

She is puzzled, though, as to why it was only a six-year extension when the Congressional Budget Office estimated extending CHIP for 10 years would save the federal government $6 billion.

“The six-year [extension] is a small saver — it saves just under a billion dollars,” Alker said. “Now there’s nothing preventing Congress from coming back as they move ahead with the bigger budget deal — they could come back and extend CHIP for four more years and grab those savings.”

Impact On Children’s Uninsured Rate

Alker does worry that the months of uncertainty around CHIP may have already caused children to drop out of the program, increasing the uninsured rate among children. That should become clear in the fall, when the Georgetown Center For Children and Families does its annual assessment of the children’s uninsured rate.

If that trend develops nationally, it hasn’t been the case in Virginia, where CHIP enrollment went up this past fall.

“We actually saw a boost in enrollment,” Nablo said. “I can’t really quite explain it.”

Maybe, she said, it was all the attention the unprecedented funding crisis brought to CHIP. A silver lining, perhaps, to many months of anxiety.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s All Things Considered, currently on an exchange with Washington, D.C. member station WAMU.

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