A Texas Lawsuit Being Heard This Week Could Mean Life Or Death For The ACA

KFF Health News, September 4, 2018

Even if the judge were to rule in favor of the Republicans' request to stop the law's enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

This article first appeared September 04, 2018 on Kaiser Health News.

By Julie Rovner

Wednesday is looking like yet another pivotal day in the life-or-death saga that has marked the history of the Affordable Care Act.

In a Texas courtroom, a group of Republican attorneys general, led by Texas' Ken Paxton, are set to face off against a group of Democratic attorneys general, led by California's Xavier Becerra, in a lawsuit aimed at striking down the federal health law. The Republicans say that when Congress eliminated the penalty for not having health insurance as part of last year's tax bill, lawmakers rendered the entire health law unconstitutional. The Democrats argue that's not the case.

But first, the sides will argue before U.S. District Judge Reed O'Connor in Fort Worth, Texas, whether the health law should be put on hold while the case is litigated. The GOP plaintiffs are seeking a "preliminary injunction" on the law.

Ending the health law, even temporarily, "would wreak havoc in our health care system," said Becerra in a call with reporters last week. "And we don't believe Americans are ready to see that their children are no longer able to see a doctor or that they cannot get treated for a preexisting health condition."

Here are five questions and answers to help understand the case, Texas v. U.S.

1. What is this suit about?

In February, 18 GOP attorneys general and two GOP governors filed the suit in federal district court in the Northern District of Texas. They argue that because the Supreme Court upheld the ACA in 2012 by saying its requirement to carry insurance was a legitimate use of Congress' taxing power, eliminating the tax penalty for failure to have health insurance makes the entire law unconstitutional.

"Texans have known all along that Obamacare is unlawful and a divided Supreme Court's approval rested solely on the flimsy support of Congress' authority to tax," Paxton said in a statement when the suit was filed. "Congress has now kicked that flimsy support from beneath the law."

The lawsuit asks the judge to prohibit the federal government "from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA."

2. Why are Democratic attorneys general defending the law?

The defendant in the case is technically the Trump administration. But in June, the administration announced it would not fully defend the law in court.

The Justice Department, in its filing in the case, did not agree with the plaintiffs that eliminating the tax penalty should require that the entire law be struck down. But it did say that without the tax, the provisions of the law requiring insurance companies to sell to people with preexisting conditions and not charge them more should fall, beginning Jan. 1, 2019. That is when the tax penalty goes away.

The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.

The Democratic attorneys general applied to "intervene" in the case to defend the law in its entirety. They say they needed to step forward to protect the health and well-being of their residents. The judge granted them that status on May 16.

3. What would happen if the judge grants a preliminary injunction?

The GOP plaintiffs say the law needs to be stopped immediately, "both because individuals will make insurance decisions during fall open-enrollment periods and because the States cannot turn their employee insurance plans and Medicaid operations on a dime," according to their brief.

But setting aside the ACA while the case proceeds "would throw the entire [health] system into chaos," Becerra said. That's because the ACA made major changes not just to the insurance market for individuals, but also to Medicare, Medicaid and the employer insurance market.

Even in 2012, when the Supreme Court was considering the constitutionality of the law before much of it had taken effect, some analysts from both parties predicted that finding the law unconstitutional could have serious repercussions for the Medicare program and the rest of the health care system.

In practice, however, even if Judge O'Connor were to rule in favor of the Republicans' request to stop the law's enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

4. Is this case purely Republicans versus Democrats?

The case is largely partisan — with Republicans who oppose the health law arguing for its cancellation and Democrats who support it fighting to keep it in place.

But a friend-of-the-court brief filed by five law professors who disagree on the merits of the ACA said that, regardless, both the GOP states and the Justice Department are wrong to conclude that eliminating the tax penalty should result in the entire law being thrown out.

In this case, "Congress itself has essentially eliminated the provision in question and left the rest of a statute standing," so courts do not need to guess whether lawmakers intended for the rest of the law to remain, they wrote.

5. What is Congress doing about this?

Technically, Congress is watching the case just as everyone else is. But Republicans in particular, while they mostly oppose the health law, are aware that the provisions protecting people with preexisting conditions are by far the most popular part of the ACA. And Democrats are already using the issue to hammer opponents in the upcoming midterm elections.

Last month, 10 GOP senators introduced legislation they said would maintain the ACA's preexisting condition protections in the event the lawsuit succeeds.

"This legislation is a common-sense solution that guarantees Americans with preexisting conditions will have health care coverage, regardless of how our judicial system rules on the future of Obamacare," said Sen. Thom Tillis (R-N.C.), the bill's lead sponsor, in a statement.

Critics, however, were quick to point out that the bill doesn't actually offer the same protections that are embodied in the ACA. While the health law requires coverage for all conditions without extra premiums, the GOP bill would require that insurers sell to people with preexisting conditions, but not that those policies actually cover those conditions.

Creating Rituals To Honor The Dead At Long-Term-Care Facilities

KFF Health News, September 4, 2018

Fraught reactions to loss and death are common among nursing assistants and other staff in long-term-care facilities, research shows. When feelings aren’t acknowledged, grief can go underground and lead to a host of physical and psychological symptoms, including depression, distancing, and burnout.

This article first appeared September 04, 2018 on Kaiser Health News.

By Judith Graham

GRAY, Ga. — One by one, their names were recited as family members clutched one another's hands and silently wept.

Seventeen men and women had died within the past year at Gray Health & Rehabilitation, a 58-bed nursing home. Today, their lives were being honored and the losses experienced by those who cared for them recognized.

Death and its companion, grief, have a profound presence in long-term-care facilities. Residents may wake up one morning to find someone they saw every day in the dining room gone. Nursing aides may arrive at work to find an empty bed, occupied the day before by someone they'd helped for months.

But the tides of emotion that ripple through these institutions are rarely openly acknowledged.

"Long-term care administrators view death as something that might upset residents," said Dr. Toni Miles, a professor of epidemiology and biostatistics at the University of Georgia. "So, when someone passes away, doors are closed and the body is wheeled discretely out the back on a gurney. It's like that person never existed."

At Gray Health's memorial service on this warm, sunny day, a candle was lit for each person who had died. Their images — young and vibrant, then old and shrunken — flashed by in a video presentation. "Our loved ones continue to live on in the memories in your hearts," Rev. Steve Johnson, pastor of Bradley Baptist Church, said from a podium.

Dozens of family members gathered outside, each holding a white balloon. At the count of three came the release. Cries of "I love you" echoed as the group turned their faces to the sky.

Miles wants to see bereavement openly acknowledged at facilities throughout Georgia to end what she calls "the silence surrounding loss and death in long-term care." Following in-depth discussions with more than 70 staffers, residents and family members at nine facilities in central Georgia, she has created two handbooks on "best practices in bereavement care" and is gearing up to offer educational seminars and staff training in dozens of nursing homes and assisted living residences across the state.

"Dr. Miles' work is incredibly important" and has the potential to ease end-of-life suffering, said Amanda Lou Newton, social services team leader at Hospice of Northeast Georgia Medical Center.

Fraught reactions to loss and death are common among nursing assistants and other staff in long-term-care facilities, research shows. When feelings aren't acknowledged, grief can go underground and lead to a host of physical and psychological symptoms, including depression, distancing and burnout.

Joanne Braswell, director of social services at Gray Health, remembers a resident with intellectual disabilities who would stay in Braswell's office much of the day, quietly looking at magazines. Over time, the two women became close and Braswell would buy the resident little gifts and snacks.

"One day, I came in to work and they told me she had died. And I wanted to cry, but I couldn't," Braswell recalled, reflecting on her shock, made more painful by memories of her daughter's untimely death several years earlier. "I promised myself never again to [become] attached to anyone like that." Since then, when residents are actively dying, "I find myself pulling away," she said.

Sylvia McCoullough, 56, came to Gray Health's memorial ceremony for her father, Melvin Daniels, who died on April 19 at age 84.

Two years earlier, not long before her mother passed away, McCoullough had realized that her father had dementia. "He was the strong one in our family. … He always took care of us," she said, explaining that her father's confusion and hallucinations shook her to her foundation.

"I cry all the time," McCoullough continued, looking distressed. "It's like I'm lost without my mom and dad." But Gray's ceremony, she said, brought some comfort.

Edna Williams, 75, was among dozens of residents at the event, sitting quietly in her wheelchair.

"I love to recall all the people that have passed away through the year," said Williams, who sends sympathy cards to family members every time she learns of a fellow resident's death. On these occasions, Williams said, she's deeply affected. "I go to my room" and "shed my own private tears" and feel "sadness for what the family has yet to go through," she said.

Chap Nelson, Gray Health's administrator, has instituted several policies that Miles' bereavement guide recommends as best practices. All staff members are taught what to do when a resident dies. When possible, they're encouraged to attend the off-site funerals. Every death is acknowledged inside the building, rather than hidden away.

If one of his staff members seems distressed, "I go out and find them and talk to them and ask how I can help them with the feelings they may be having," Nelson said.

Other best practices include offering support to grieving residents and relatives of the deceased, recognizing residents' bereavement needs in care plans, and having a protocol to prepare bodies for final viewing.

Some facilities go further and create unique rituals. In one Georgia nursing home, staff members' hands are rubbed with essential oils after a resident's death, Miles said. In Ontario, Canada, St. Joseph's Health Centre Guelph holds a "blessing ritual" in the rooms where people pass away.

Fifteen miles away from Gray, in Macon, Ga., Tom Rockenbach runs Carlyle Place, an upscale facility with four levels of care: independent living, assisted living, memory care and skilled nursing services. Altogether, about 325 seniors live there. Last year, 40 died.

"We don't talk about it enough when someone passes here; we don't have a formal way of expressing grief as a community," Rockenbach said, discussing what he learned after Miles organized listening sessions for staff and residents. "There are things I think we could do better."

When a death occurs at this continuing care retirement community, an electric candle is lit in the parlor, where people go to pick up their mail. If there's an obituary, it's placed in a meditation room, often with a sign-in book in which people can write comments.

Since working with Miles, Rockenbach has a keener appreciation for the impact of death and loss. He's now considering starting a support group for staff and hosting a death cafe for residents where "people could come and hear what other people have gone through and how they got through it."

Tameka Jackson, a licensed practical nurse who has worked at Carlyle Place for eight years, became distraught after the death of one resident, in his 90s, with whom she had grown close.

"Me and him, we were two peas in a pod," she said, recalling the man's warmth and sense of humor.

Over time, the old man confided in the nurse that he was tired of living but holding on because he didn't want family members to suffer. "He would tell me all kinds of things he didn't want his family to worry about," Jackson said. "In a way, I became his friend, his nurse and his confidante, all in one."

One morning, she found his room was bare: He'd died the night before, but no one had thought to call her. Jackson's eyes filled with tears as she recalled her hurt. "I'm a praying person, and I had to ask God to see me through it," she said. "I found comfort in knowing he knew I genuinely loved him."

Jan Peak, 81, was dealing with grief of a different sort in mid-May: Her husband, David Reed, who had rapidly advancing Parkinson's disease, had recently moved to Carlyle Place's assisted living section from their independent-living apartment— signaling the end of their time living together.

Like other people at Carlyle Place, Peak had a lot of adjusting to do when she moved into the facility five years ago after her first husband had died. "Lots of people here have come here from somewhere else and given up their homes, their friends and their communities, often after the death of a spouse," Peak said. "Once you're here, loss — either your own or someone else's — is around you continually."

She found herself turning to David, whose first wife had died of a brain tumor and whom she describes as a "soft, sweet, wise man." Before they married, they talked openly about what lay ahead, and Peak promised she would carry on.

"No one can stop the heartache that accompanies loss," but "my friends and family still need me," she said.

In late May, David sustained a severe head injury after falling and died. "I miss him greatly as we were very happy together," Peak wrote in an email. "I am doing as well as I can."

Low-Income Californians Feel Twice The Burn From Wildfires

KFF Health News, September 4, 2018

Officials across the West have issued health warnings to alert sensitive groups—such as young children, older adults and people with respiratory diseases—of the potential risks.

This article first appeared September 04, 2018 on Kaiser Health News.

By Ana B. Ibarra

EAST BAKERSFIELD, Calif. — Viviana Aguirre, 14, knows the air is bad when she has to reach for her inhaler once, maybe twice a week.

But this summer, the high school freshman has relied on her inhaler almost every day to keep her asthma under control.

The air in her low-income neighborhood has been thick with smoke for weeks, she said, forcing her to remain indoors most of the time. It's hard for Viviana to tell whether the smoke is coming from the usual controlled burns in the farmers' fields surrounding her home — or from the record-breaking wildfires blazing to the north and south of her, she said.

"I do see smoke," Viviana said, "but I see smoke most of the time."

People like Viviana and her family are hit disproportionately when wildfires ignite — because smoke adds another layer of toxic substances to the already dirty air, experts say.

"Without a doubt, these communities are at higher risk" when fires break out, said Emanuel Alcala, a postgraduate fellow with the Central Valley Health Policy Institute at California State University-Fresno. "Especially because you already have other environmental hazards: toxic waste sites, poor quality of water, and sometimes no air conditioning."

More than a dozen major blazes still rage across California, including the two Mendocino Complex fires in the northern part of the state that together have charred nearly 460,000 acres. One of those fires, the Ranch Fire, is the largest in state history.

Fires are also burning in Colorado, Oregon, Washington and Idaho. Smoke from these blazes has drifted as far as Ohio. Portions of northern Nevada recorded some of their worst ozone pollution ever last month because of the fires, and officials across the West have issued health warnings to alert sensitive groups — such as young children, older adults and people with respiratory diseases — of the potential risks.

In neighborhoods like Viviana's, which lies within a few miles of dairy farms, packing sheds and oil fields, particulate and ozone pollution already poses a health threat. The air is sullied by a constant, diesel-spewing stream of big rigs as well as pesticides and dust from agricultural operations.

The smell of petroleum and cows saturates the neighborhood, said Gustavo Aguirre, Viviana's dad, and creates a toxic brew with the wildfire smoke.

"When I go outside just to hang out with my friends, I start coughing and I have to come back in," Viviana said.

About 26 percent of school-aged children in the San Joaquin Valley have asthma — the highest rate in the state, according to California Health Interview Survey.

Cities in the San Joaquin Valley, the state's agricultural heartland, top the list of those with the worst air pollution in the country. The valley is also home to some of the state's poorest communities: Seven of the 10 California counties with the highest child poverty rates are there, according to a 2017 report by the San Joaquin Valley Health Fund.

"The geography and climate of the valley can trap unhealthy air for days, if not weeks," said Will Barrett, clean-air advocacy director for the American Lung Association in California.

The combination of industrial ozone and fine particulate matter from wildfire smoke becomes trapped between the mountains surrounding the valley and pushes air quality to dangerous levels. "You're combining two of the most widespread and pervasive pollutants," Barrett said. "It really is a double whammy."

Adding smoke to existing pollution can not only exacerbate someone's asthma symptoms, but also trigger new cases of the respiratory disease, said Dr. Kari Nadeau, director of the Sean N. Parker Center for Allergy & Asthma Research at Stanford University.

In some cases, all it takes is about five days of exposure to wildfire smoke for people without asthma, especially children, to develop wheezing, coughing and other symptoms, she said.

In already polluted places like the San Joaquin Valley, "the wildfires worsen your rates of asthma by fourfold and increase the rate of heart attack by 42 percent," she said. "This is just going to make it exponentially worse."

In southwest Fresno, a community dense with public housing, Maria Garcia, 62, lives within 2 miles of a poultry processing plant, warehouses and Highway 99.

Garcia considers herself healthy, but a persistent cough this summer left her gasping for air.

She compares some of her recent symptoms — such as chest pressure and headaches — to those experienced by her adult son, who has asthma.

"My guess is it's probably the smoke," Garcia said.

Other regions in the state also are suffering. Smoke from the Mendocino Complex fires has drifted into the San Francisco Bay Area, about a three-hour drive south of the blazes.

A mobile asthma clinic called the Breathmobile provides free appointments and pulmonary function tests for children at East Bay schools with a high number of students enrolled in Medi-Cal, California's Medicaid program for low-income residents, said Mary Frazier, a registered nurse and project director of the Northern California Breathmobile program.

"Kids on Medi-Cal have more asthma," she said. "It can be because they are exposed to more triggers. They live in low-income housing, which has some poor indoor-air quality and the houses are near freeways or industry."

When she starts visiting kids again in September after classes resume, Frazier knows she will encounter many children who have been coughing and wheezing because of the smoke.

Back in southwest Fresno, Gary Hunt, 54, has remained mostly housebound this summer, leaving only for important errands and medical appointments. Even then, he wears a mask.

Pollution from fires are "definitely making a drastic difference," worsening Hunt's asthma, causing more fatigue, chest pain and headaches, he said.

But extinguishing wildfires doesn't guarantee relief. There is a meat-rendering plant near his home, and busy state Route 41 is about a quarter-mile away.

"Because of where we are, we don't really get a break," he said.

Three years ago, Hunt had a severe asthma attack that sent him to the hospital. He had to leave his job as a school maintenance worker and lost his job-based insurance. He enrolled in Medi-Cal, and soon learned that not all doctors accept public insurance — which means that getting quick access to care during fire season can be a problem.

For instance, he said, he needs to see a pulmonologist — but has to wait three months for an appointment.

People with Medi-Cal or those without insurance can in some cases wait up to a year for treatment, said Kevin Hamilton, a respiratory therapist and CEO of the Central California Asthma Collaborative.

Hunt said he is frequently asked, even by doctors, why he and his family don't move to a healthier community. The answer is that he simply can't afford it.

"If I could, I wouldn't be here," he said.

For Nursing Home Patients, Breast Cancer Surgery May Do More Harm Than Good

KFF Health News, August 30, 2018

Some experts question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

This article first appeared August 29, 2018 on Kaiser Health News.

By Liz Szabo

Surgery is a mainstay of breast cancer treatment, offering most women a good chance of cure.

For frail nursing home residents, however, breast cancer surgery can harm their health and even hasten death, according to a study published Wednesday in JAMA Surgery.

The results have led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

The study examined the records of nearly 6,000 nursing home residents who had inpatient breast cancer surgery the past decade. It found that 31 to 42 percent died within a year of the procedure. That's significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Although her study doesn't include information about the cause of death, Tang said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients. Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It's unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

"When someone gets breast cancer in a nursing home, it's very unlikely to kill them," said study co-author Dr. Laura Esserman, director of the UCSF breast cancer center. "They are more likely to die from their underlying condition."

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform "activities of daily living," such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.

The high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure, said Dr. Deborah Korenstein, chief of general internal medicine at New York's Memorial Sloan Kettering Cancer Center.

The paper provided an example of how sick, elderly people can suffer from surgery. An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again. The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One-third of Medicare patients undergo surgery in the year before they die, according to a 2011 study in The Lancet. Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer's disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn't include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women may fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

"People think, 'Oh, a lumpectomy is nothing,'" Esserman said. "But it's not nothing in someone who is old and frail."

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive, a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in this study didn't mention whether any of the patients had chemotherapy, radiation or other outpatient care. So the UCSF researchers acknowledged that they can't rule out the possibility that some of the women suffered complications due to these other therapies. In general, however, authors noted that only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, doctors could offer to simply treat symptoms as they appear.

The new study raises questions about the value of screening nursing home residents for breast cancer, Korenstein said. Although the American Cancer Society hasn't set an upper age limit for breast cancer screening, it advises women to be screened as long as they're in good health and expected to live at least another decade.

Residents of nursing homes generally can't expect to live long enough to benefit from breast screening, Korenstein said.

"It makes no sense to screen people in nursing homes," Korenstein said. "The harms of doing anything about what you find are far going to outweigh the benefits."

The Doctors Want In: Democratic Docs Talk Health Care On The Campaign Trail

KFF Health News, August 27, 2018

Democrats hope to gain control of Congress by harnessing what polls show to be voters’ dissatisfaction with both Capitol Hill and President Donald Trump.

This article first appeared August 27, 2018 on Kaiser Health News.

By Shefali Luthra

Dr. Rob Davidson, an emergency physician from western Michigan, had never considered running for Congress. Then came February 2017. The 46-year-old Democrat found himself at a local town-hall meeting going toe-to-toe with Rep. Bill Huizenga, his Republican congressman of the previous six years.

"I told him about my patients," Davidson recalled. "I see, every shift, some impact of not having adequate health care, not having dental insurance or a doctor at all."

His comments triggered cheers from the audience but didn't seem to register with Huizenga, a vocal Obamacare critic. And that got Davidson thinking.

"I've always been very upset … about patients who can't get health care," he said. But it never inspired him to act. Until this June, that is, when the political novice joined what is now at least eight other Democratic physicians running in races across the country as first-time candidates for Congress.

Democrats hope to gain control of Congress by harnessing what polls show to be voters' dissatisfaction with both Capitol Hill and President Donald Trump. The president maintains Republican support but registers low approval ratings among Americans overall, according to news organization FiveThirtyEight. Democrats also see promise in candidates such as Davidson, a left-leaning physician who may have a special advantage: firsthand health system experience.

Polls by Quinnipiac University, The Wall Street Journal and the Kaiser Family Foundation suggest health care is among voters' top concerns as midterm elections approach. (Kaiser Health News is an editorially independent project of the foundation.)

Of the Democratic doctors running for office, all but one are seeking House seats. In addition to the nine newcomers, there are two incumbents up for re-election. Each candidate is campaigning hard on the need to reform the health care system.

And they present a stark contrast to Congress' current physician makeup.

Twelve of the 14 doctors now in Congress are Republicans. Three are senators. Half of the 14 practice in high-paying specialties such as orthopedic surgery, urology and anesthesiology.

By contrast, these stumping Democratic physicians hail predominantly from specialties such as emergency medicine, pediatrics and internal medicine, though one is a radiologist. They're fighting to represent a mix of rural, urban and suburban districts.

"Electing Democratic doctors would certainly change the face of medicine in Congress, and perhaps lend more credence in that body to more liberal health care policies," said Dr. Matthew Goldenberg, a psychiatrist at Yale School of Medicine who has researched political behavior and advocacy among doctors.

Physicians once trended Republican. The infusion of female and minority doctors, experts said, has changed this. Now, more than 50 percent of party-affiliated doctors are Democrats, and the medical establishment has — following Republican efforts to undo Obamacare — emerged as a staunch defender of the law.

Indeed, many doctor-candidates point to the GOP's repeal-and-replace efforts as their motivation.

"It's at a boiling point for many of these physicians," said Jim Duffett, executive director of the left-leaning Doctors for America, which supports universal health care.

While health care consistently emerges as a top issue, Democrats are more likely to rank it No. 1. For independents and Republicans, though, it's neck and neck with the economy — and some political analysts question how effective it will be in flipping conservative districts.

"Democrat voters blame Republicans for the problems with health care right now. Republicans blame Democrats. Independents say, 'A pox on both your houses,'" argued Jim McLaughlin, a Republican pollster working on several 2018 races who has previously worked with Trump. "They're making a big mistake thinking they can run on [health care]."

That said, doctors can be effective messengers, especially in their communities.

Research suggests Americans hold their own physicians in high regard.

"Voters listen carefully to what physicians have to say about health policy," said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina. "In a district that's not so one-sided red or blue, there's no question that the white coat confers prestige. It's something physician candidates can speak to with authority."

Davidson, for instance, supports a "Medicare-for-all"-style overhaul, an approach that involves expanding the federal insurance program for seniors and disabled people to all Americans. If elected, he said, he intends to join Democrats' burgeoning support for a single-payer system, in which the government runs the sole health insurance program, guaranteeing universal coverage. He did not have a primary challenge and is running against Huizenga, the Republican incumbent, in the general election for Michigan's 2nd Congressional District.

Or there's Dr. Kyle Horton, an internist running in the North Carolina 7th District. She supports expanding Medicare, by lowering the eligibility age from 65 to 50. She also supports a "public option" health insurance plan sold by the government.

Dr. Hiral Tipirneni, an emergency physician in Arizona's 8th Congressional District, asserts all Americans should be able to buy in to Medicare.

Physicians can have an advantage on other controversial topics, by casting them as public health issues, said Howard Rosenthal, a political scientist at New York University.

Davidson's campaign, for instance, posts videos on Facebook in which he talks about topics such as health care access and gun violence. One — filmed after an overnight ER shift — has gotten 41,000 views so far.

Also spurring physicians: concerns about abortion access.

Dr. Cathleen London, a Maine doctor, launched her campaign against four-term incumbent GOP Sen. Susan Collins for the 2020 election. She said she had been considering a run, but the upcoming vote for a justice to replace Anthony Kennedy on the Supreme Court — which could have sweeping implications for reproductive health law — pushed her to declare.

"Doctors are really frustrated with Washington, frustrated with the lack of listening to us," London said.

Many of these Democrats face steep climbs.

Of races featuring newcomer physicians, the Cook Political Report, which analyzes elections, rates only Arizona's 2nd Congressional District as leaning Democratic, and the doctor in that race is just one of seven candidates in the primary. The outcome for Washington's 8th District, where Dr. Kim Schrier, a pediatrician, is a candidate, is considered a toss-up and a Democratic pickup target.

Tipirneni is the only non-incumbent doctor to have a fundraising advantage so far, according to data from Open Secrets, a nonpartisan, nonprofit project tracking campaign-finance records.

Regardless of electoral results, many observers say the potential implications are sizable — even if few doctors go to Washington.

"They are planting a flag, and they're going to be raising some important issues — not just health care, but health care is going to be front and center," said Duffett, from Doctors for America. "That will help change the political debate and political landscape."

McCain's Complicated Health Care Legacy: He Hated the ACA. He Also Saved It.

KFF Health News, August 27, 2018

McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs.

This article first appeared August 25, 2018 on Kaiser Health News.

By Emmarie Huetteman

There are many lawmakers who made their names in health care, seeking to usher through historic changes to a broken system.

John McCain was not one of them.

And yet, the six-term senator from Arizona and decorated military veteran leaves behind his own health care legacy, seemingly driven less by his interest in health care policy than his disdain for bullies trampling the "little guy."

He was not always successful. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990, most of the health initiatives he undertook failed after running afoul of traditional Republican priorities. His prescriptions often involved more government regulation and increased taxes.

In 2008, as the Republican nominee for president, he ran on a health care platform that dumbfounded many in his party who worried it would raise taxes on top of overhauling the U.S. tradition of workplace insurance.

Many will remember McCain as the incidental savior of the Affordable Care Act, whose late-night thumbs-down vote halted his party's most promising effort to overturn a major Democratic achievement — the signature achievement, in fact, of the Democrat who beat him to become president. It was a vote that earned him regular — and biting — admonishments from President Donald Trump.

McCain died Saturday, following a battle with brain cancer. He was 81. Coincidentally, his Senate colleague and good friend Ted Kennedy died on the same date, Aug. 25, nine years ago, succumbing to the same type of rare brain tumor.

Whether indulging in conspiracy theories or wishful thinking, some have attributed McCain's vote on the ACA in July 2017 to a change of heart shortly after his terminal cancer diagnosis.

But McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system's ballooning costs.

His prey were the sort of boogeymen that made for compelling campaign ads in a career stacked with campaigns. But McCain was "always for the little guy," said Douglas Holtz-Eakin, the chief domestic policy adviser on McCain's 2008 presidential campaign.

"John's idea of empathy is saying to you, 'I'll punch the bully for you,'" he said in an interview before McCain's death.

McCain's distaste for President Barack Obama's health care law was no secret. While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace the law with something better.

After Republicans spent months bickering amongst themselves about what was better, McCain was disappointed in the option presented to senators hours before their vote: hobble the ACA and trust that a handful of lawmakers would be able to craft an alternative behind closed doors, despite failing to accomplish that very thing after years of trying.

What bothered McCain more, though, was his party's strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory.

In his 2018 memoirs, "The Restless Wave," McCain said even Obama called to express gratitude for McCain's vote against the Republican repeal bill.

"I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare," McCain wrote. "That had not been my goal."

Better known for his work on campaign finance reform and the military, McCain did have a hand in one landmark health bill — the Americans with Disabilities Act of 1990, the country's first comprehensive civil rights law that addressed the needs of those with disabilities. An early co-sponsor of the legislation, he championed the rights of the disabled, speaking of the service members and civilians he met in his travels who had become disabled during military conflict.

McCain himself had limited use of his arms due to injuries inflicted while he was a prisoner of war in Vietnam, though he was quicker to talk about the troubles of others than his own when advocating policy.

Yet two of his biggest bills on health care ended in defeat.

In 1998, McCain introduced a sweeping bill that would regulate the tobacco industry and increase taxes on cigarettes, hoping to discourage teenagers from smoking and raise money for research and related health care costs. It faltered under opposition from his fellow Republicans.

McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients' bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies, said Sonya Elling, who served as a health care aide in McCain's office for about a decade. But he came around.

"It was the human, the personal aspect of it, basically," said Elling, now senior director of federal affairs at Eli Lilly. "It was providing him some of the real stories about how people were being hurt and some of the barriers that existed for people in the current system."

The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed.

McCain's health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate's Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans' care measures he undertook.

It was McCain's relationship with Kennedy that stood out, inspiring eerie comparisons when McCain was diagnosed last year with glioblastoma — a form of brain cancer — shortly before his vote saved the Affordable Care Act.

That same aggressive brain cancer killed Kennedy in 2009, months before the passage of the law that helped realize his work to secure better access for Americans to health care.

"I had strenuously opposed it, but I was very sorry that Ted had not lived to see his long crusade come to a successful end," McCain wrote in his 2018 book.

While some of his biggest health care measures failed, the experiences helped burnish McCain's résumé for his 2000 and 2008 presidential campaigns.

In 2007, trailing other favored Republicans, such as former New York City mayor Rudy Giuliani in early polling and fundraising, McCain asked his advisers to craft a health care proposal, said Holtz-Eakin. It was an unusual move for a Republican presidential primary.

The result was a remarkable plan that would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued employer-provided plans were driving up costs, as well as keeping salaries lower.

The plan was controversial, triggering "a total freakout" when McCain gained more prominence and scrutiny, Holtz-Eakin said. But McCain stood by it.

"He might not have been a health guy, but he knew how important that was," he said. "And he was relentless about getting it done."

Tuition-Free Med School Touches Off Multimillion-Dollar Debate

KFF Health News, August 24, 2018

Not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.

This article first appeared August 08, 2018 on Kaiser Health News.

By Julie Rovner

New York University's School of Medicine is learning that no good deed goes unpunished.

The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018.

NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place.

"A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt," Dr. Robert Grossman, the dean of the medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans.

The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.

"As I start rank ordering the various charities I want to give to, the people who can pay for medical school in cash aren't at the top of my list," said Craig Garthwaite, a health economist at Northwestern University's Kellogg School of Management.

"If you had to find some cause to put tons of money behind, this strikes me as an odd one," said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University.

Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000.

But it is less clear how much of an impact that debt has on students' choice of medical specialty. The AAMC's data suggests debt does not play as big a role in specialty selection as some analysts claim.

If debt were a huge factor, one would expect that doctors who owed the most would choose the highest-paying specialties. But that's not the case.

"Debt doesn't vary much across the specialties," said Julie Fresne, AAMC's director of student financial services and debt management.

Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. "No one [who chooses a higher-paying job] says they did it because they want two Teslas," he said. "They say they have all this debt."

Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. "Doctors in general do just fine," he said. "The idea we should pity physicians or worry about them strikes me as odd."

Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted for pediatrics, calling it a "garbageman" specialty.

There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers.

Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master's degree.

This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings.

In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia's program is based on students' financial need.

The programs are funded, in whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU.

Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all "is not the most target-efficient way to reach that goal."

A Black Eye For Blue Shield: Consumers Lash Out Over Coverage Lapses

KFF Health News, August 23, 2018

Consumers with individual Blue Shield policies say they have been subject to sudden, erroneous cancellations, especially in recent months.

This article first appeared August 23, 2018 on Kaiser Health News.

By Chad Terhune

Ashley Summers said she got an unpleasant surprise in February when she tried to pick up a prescription for her rheumatoid arthritis: Her pharmacy said her insurance had been canceled, even though her premiums were paid.

Summers called Blue Shield of California and got her policy reinstated — then she said it happened again in March and this time, the lapse in coverage dragged on for three months.

Without insurance to cover her medications and doctor visits, her arthritis and fibromyalgia worsened to the point that she could barely walk, she said. In June, she said, the state granted her permission to switch to another insurer.

"This entire mess has been so incredibly stressful," said Summers, 49, a personal assistant in Los Angeles who had paid $593 a month in premiums. For Blue Shield just to pull the plug like this is infuriating."

Around the state, consumers with individual Blue Shield policies, like Summers, say they have been subject to sudden, erroneous cancellations, especially in recent months, forcing them to go without heart medicine, skip vaccinations for their children and pay hundreds of dollars out-of-pocket for other medical care. On social media, customers have described frantic attempts to get their coverage reinstated.

@BlueShieldCA Blueshield keeps failing to process my auto-pay and then canceling me. Sure feels like they don’t like insuring me. Asked on Facebook and many people are having this problem. How about you?

— Peter Schink (@PeterRSchink) July 2, 2018

@BlueShieldCA If you ended my insurance on May1 why withdrew $779.14 on may1 then $392.91 on May30 & $392.91 on June29. my next auto payment is on August1 I am not letting this go You will pay back every penny this is illegal! #askfinney @MFinney #insurancefraud pic.twitter.com/FUdnIgw6Dv

— Cali.Girl.Bee (@WhiteMintyCandy) July 31, 2018

Oh yay, it’s been another 6 months or so of paying in full for insurance and again @BlueShieldCA randomly retroactively cancels our coverage 🎉 cc @CoveredCA this has been happening for nearly 5 years now.

— CALawMama (@CALawMama) July 30, 2018

Blue Shield has acknowledged failures in enrollment and billing for some customers who purchased individual policies since 2014, both inside and outside the Covered California exchange. The company declined to specify how many customers were affected. The problems don't appear to involve people with employer coverage or enrolled in government health programs.

In a June 22 lawsuit, the San Francisco insurer blamed many of these problems on an outside contractor it had hired in preparation for the launch of the Affordable Care Act in 2014. In a countersuit, the contractor, HealthPlan Services, denied the allegations and accused Blue Shield of sharing inaccurate customer data.

In a statement, Blue Shield said: "The roll out of the Affordable Care Act was hard on the entire health care system. Our vendor failed to provide the support it promised and we spent millions of dollars to mitigate the impacts to our members."

On Friday, Summers sued Blue Shield in Los Angeles County Superior Court, alleging breach of contract and seeking class-action status on behalf of other customers. The insurer couldn't be reached for comment about the complaint.

Scott Glovsky, a Pasadena, Calif., attorney representing Summers, said Blue Shield has known about these problems for years. "Blue Shield is taking people's hard-earned dollars and then abandoning them when they're sick," he said.

Tina Hoover, 47, a horse trainer in Sherman Oaks, Calif., said Blue Shield canceled her policy twice in two months, even though she'd been paying her premiums faithfully for years.

Blue Shield denied more than $1,000 in doctor visits, saying she'd been terminated. After four calls, inconsistent responses, non-responses and a pointed comment by her husband on Twitter, she finally got her insurance back, she said.

"It was frightening that Blue Shield could be so disorganized on something so important like my health care," said Hoover, who pays $858 a month in premiums and has been a policyholder with the insurer for 15 years.

All health insurers face complaints, from improper denials of care to annoying customer service. But some experts say these persistent breakdowns in customer service at Blue Shield represent a black eye for California's third-largest health insurer, which has 460,000 customers on the Covered California exchange and 3.8 million enrollees overall.

"I've never seen anything on this scale for such basic insurance operations," said Paula Wade, an industry analyst at Decision Resources Group in Nashville, Tenn. "Honest to goodness, if you can't take people's money and credit their account — that's incredibly simple."

Here's me calling @BlueShieldCA AGAIN so I can renew my heart meds after they managed to screw up my automatic payments & never notified me until they cancelled my policy. How hard is to TAKE MY DAMN MONEY?

— 💋 Beth Yarnall 💋 (@BethYarnall) July 25, 2018

@BlueShieldCA I’ve been trying to add my infant son to my policy since 5/21. I’ve paid his premiums and no one on your staff can explain to me why he still has no coverage. His shots are now delayed and noone on the phone seems to know what’s happening. Completely unacceptable.

— Aleesa Miller (@alliemegs) July 1, 2018

I rarely tweet, but @BlueShieldCA has the absolute worst customer service. They accidentally terminated my insurance, and apologized for the error. After losing approx. 13 hours of work time on the phone, still no solution. What the heck??

— Paris Hotel Boutique (@parishotel) January 3, 2018

Across its plans last year, Blue Shield had the highest complaint rate per 10,000 enrollees among the eight largest health insurers statewide, according to the California Department of Managed Health Care. Blue Shield had 7.43 complaints per 10,000 enrollees, followed by Anthem Blue Cross (5.83), UnitedHealthcare (4.72) and Kaiser Permanente (4.6). (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

For its individual market plans, Blue Shield chose to outsource sign-ups, billing and payment processing to HealthPlan Services, a major contractor for insurers industrywide. In its breach-of-contract lawsuit against the contractor, Blue Shield said it needed outside help to handle the dramatic overhaul of the individual market in 2014 under the ACA.

By June 2014, Blue Shield said it had formed a team of people "whose sole job was to address the failures in HPS' services to ensure that Blue Shield's customers' interests were not impacted," according to the lawsuit.

But the glitches persisted, and Blue Shield said in its lawsuit that it has lost tens of millions of dollars due to the contractor's "egregious" failures on billing, refunds and related matters.

HealthPlan Services' "data was ever-changing, inconsistent and flat-out incorrect," Blue Shield said in the 15-page complaint in San Francisco federal court.

In a statement to California Healthline, HealthPlan Services called Blue Shield's claims "baseless" and said it has a "successful track record of providing quality services to its clients and their members."

But in court papers, Blue Shield said the problems went beyond the sudden cancellations.

For instance, about 14,000 Blue Shield customers experienced "multiple attempted charges on their bank accounts" over one weekend, according to the insurance company's lawsuit. About half the time, Blue Shield alleged, its contractor proposed refunds or credits that were excessive or had no basis at all. One time, a $27,000 refund went to the wrong customer, according to the lawsuit.

In April 2017, Blue Shield said, it initiated termination of the vendor's contract.

In an Aug. 13 counterclaim, HealthPlan Services said "Blue Shield's highly unusual data maintenance and transmission methods and business processes resulted in customer-facing errors that were directly attributable to Blue Shield's conduct."

In a statement, Blue Shield countered that "HPS' allegations are unfounded and we look forward to responding to them in the legal proceedings."

Meantime, San Francisco resident Burcu Sivrikaya, 32, said she found out late last month that Blue Shield had canceled her coverage — effective May 1. She spent hours on the phone talking to seven different company representatives trying to get her policy reinstated, only to be told it would take 30 days, she said. "Are they using pen and paper? Why does it take 30 days? It's insane."

Now Sivrikaya, a social media manager, is trying to get Blue Shield to refund the $1,179 she said she paid in premiums for the three months the company withdrew coverage.

The Department of Managed Health Care fined Blue Shield and a subsidiary $557,500 last year for improper cancellations and a variety of customer grievance violations. Blue Shield is contesting some of those allegations and penalties, according to the state.

Blue Shield noted that it performed well on certain categories in the state data, such as an extremely low complaint rate among medical providers.

The company also said its customer satisfaction score improved in a recent consumer survey by Forrester Research, increasing by nearly 2 percentage points to 63.6 out of 100. Forrester still labeled Blue Shield's performance as "poor," putting it in ninth place out of 17 health insurers that were rated this year.

The Man Who Sold America On Vitamin D — And Profited In The Process

KFF Health News, August 20, 2018

The doctor most responsible for turning the sunshine supplement into a billion-dollar juggernaut has received hundreds of thousands of dollars from the vitamin D industry, according to government records and interviews.

This article first appeared August 20, 2018 on Kaiser Health News.

By Liz Szabo

Dr. Michael Holick's enthusiasm for vitamin D can be fairly described as extreme.

The Boston University endocrinologist, who perhaps more than anyone else is responsible for creating a billion-dollar vitamin D sales and testing juggernaut, elevates his own levels of the stuff with supplements and fortified milk. When he bikes outdoors, he won't put sunscreen on his limbs. He has written book-length odes to vitamin D, and has warned in multiple scholarly articles about a "vitamin D deficiency pandemic" that explains disease and suboptimal health across the world.

His fixation is so intense that it extends to the dinosaurs. What if the real problem with that asteroid 65 million years ago wasn't a lack of food, but the weak bones that follow a lack of sunlight? "I sometimes wonder," Holick has written, "did the dinosaurs die of rickets and osteomalacia?"

Holick's role in drafting national vitamin D guidelines, and the embrace of his message by mainstream doctors and wellness gurus alike, have helped push supplement sales to $936 million in 2017. That's a ninefold increase over the previous decade. Lab tests for vitamin D deficiency have spiked, too: Doctors ordered more than 10 million for Medicare patients in 2016, up 547 percent since 2007, at a cost of $365 million.

But few of the Americans swept up in the vitamin D craze are likely aware that the industry has sent a lot of money Holick's way. A Kaiser Health News investigation found that he has used his prominent position in the medical community to promote practices that financially benefit corporations that have given him hundreds of thousands of dollars — including drugmakers, the indoor-tanning industry and one of the country's largest commercial labs.

In an interview, Holick acknowledged he has worked as a consultant to Quest Diagnostics, which performs vitamin D tests, since 1979. Holick, 72, said that industry funding "doesn't influence me in terms of talking about the health benefits of vitamin D."

There is no question that the hormone is important. Without enough of it, bones can become thin, brittle and misshapen, causing a condition called rickets in children and osteomalacia in adults. The issue is how much vitamin D is healthy, and what level constitutes deficiency.

Holick's crucial role in shaping that debate occurred in 2011. Late the previous year, the prestigious National Academy of Medicine (then known as the Institute of Medicine), a group of independent scientific experts, issued a comprehensive, 1,132-page report on vitamin D deficiency. It concluded that the vast majority of Americans get plenty of the hormone through diet and sunlight, and advised doctors to test only patients at high risk of vitamin D-related disorders, such as osteoporosis.

A few months later, in June 2011, Holick oversaw the publication of a report that took a starkly different view. The paper, in the peer-reviewed Journal of Clinical Endocrinology & Metabolism, was on behalf of the Endocrine Society, the field's foremost professional group, whose guidelines are widely used by hospitals, physicians and commercial labs nationwide, including Quest. The society adopted Holick's position that "vitamin D deficiency is very common in all age groups" and advocated a huge expansion of vitamin D testing, targeting more than half the United States population, including those who are black, Hispanic or obese — groups that tend to have lower vitamin D levels than others.

The recommendations were a financial windfall for the vitamin D industry. By advocating such widespread testing, the Endocrine Society directed more business to Quest and other commercial labs. Vitamin D tests are now the fifth-most-common lab test covered by Medicare.

The guidelines benefited the vitamin D industry in another important way. Unlike the National Academy, which concluded that patients have sufficient vitamin D when their blood levels are at or above 20 nanograms per milliliter, the Endocrine Society said vitamin D levels need to be much higher — at least 30 nanograms per milliliter. Many commercial labs, including Quest and LabCorp, adopted the higher standard.

Yet there's no evidence that people with the higher level are any healthier than those with the lower level, said Dr. Clifford Rosen, a senior scientist at the Maine Medical Center Research Institute and co-author of the National Academy report. Using the Endocrine Society's higher standard creates the appearance of an epidemic, he said, because it labels 80 percent of Americans as having inadequate vitamin D.

"We see people being tested all the time and being treated based on a lot of wishful thinking, that you can take a supplement to be healthier," Rosen said.

Patients with low vitamin D levels are often prescribed supplements and instructed to get checked again in a few months, said Dr. Alex Krist, a family physician and vice chairman of the U.S. Preventive Services Task Force, an expert panel that issues health advice. Many physicians then repeat the test once a year. For labs, "it's in their financial interest" to label patients with low vitamin D levels, Krist said.

In a 2010 book, "The Vitamin D Solution," Holick gave readers tips to encourage them to get their blood tested. For readers worried about potential out-of-pocket costs for vitamin D tests — they range from $40 to $225 — Holick listed the precise reimbursement codes that doctors should use when requesting insurance coverage. "If they use the wrong coding when submitting the claim to the insurance company, they won't get reimbursed and you will wind up having to pay for the test," Holick wrote.

Holick acknowledged financial ties with Quest and other companies in the financial disclosure statement published with the Endocrine Society guidelines. In an interview, he said that working for Quest for four decades — he is currently paid $1,000 a month — hasn't affected his medical advice. "I don't get any additional money if they sell one test or 1 billion," Holick said.

A Quest spokeswoman, Wendy Bost, said the company seeks the advice of a number of expert consultants. "We feel strongly that being able to work with the top experts in the field, whether it's vitamin D or another area, translates to better quality and better information, both for our patients and physicians," Bost said.

Since 2011, Holick's advocacy has been embraced by the wellness-industrial complex. Gwyneth Paltrow's website, Goop, cites his writing. Dr. Mehmet Oz has described vitamin D as "the No. 1 thing you need more of," telling his audience that it can help them avoid heart disease, depression, weight gain, memory loss and cancer. And Oprah Winfrey's website tells readers that "knowing your vitamin D levels might save your life." Mainstream doctors have pushed the hormone, including Dr. Walter Willett, a widely respected professor at Harvard Medical School.

Today, seven years after the dueling academic findings, the leaders of the National Academy report are struggling to be heard above the clamor for more sunshine pills.

"There isn't a 'pandemic,'" A. Catharine Ross, a professor at Penn State and chair of the committee that wrote the report, said in an interview. "There isn't a widespread problem."

Ties To Drugmakers And Tanning Salons

In "The Vitamin D Solution," Holick describes his promotion of vitamin D as a lonely crusade. "Drug companies can sell fear," he writes, "but they can't sell sunlight, so there's no promotion of the sun's health benefits."

Yet Holick also has extensive financial ties to the pharmaceutical industry. He received nearly $163,000 from 2013 to 2017 from pharmaceutical companies, according to Medicare's Open Payments database, which tracks payments from drug and device manufacturers. The companies paying him included Sanofi-Aventis, which markets vitamin D supplements; Shire, which makes drugs for hormonal disorders that are given with vitamin D; Amgen, which makes an osteoporosis treatment; and Roche Diagnostics and Quidel Corp., which both make vitamin D tests.

The database includes only payments made since 2013, but Holick's record of being compensated by drug companies started before that. In his 2010 book, he describes visiting South Africa to give "talks for a pharmaceutical company," whose president and chief executive were in the audience.

Holick's ties to the tanning industry also have drawn scrutiny. Although Holick said he doesn't advocate tanning, he has described tanning beds as a "recommended source" of vitamin D "when used in moderation."

Holick has acknowledged accepting research money from the UV Foundation — a nonprofit arm of the now-defunct Indoor Tanning Association — which gave $150,000 to Boston University from 2004 to 2006, earmarked for Holick's research. The International Agency for Research on Cancer classified tanning beds as carcinogenic in 2009.

In 2004, the tanning-industry associations led Dr. Barbara Gilchrest, who then was head of Boston University's dermatology department, to ask Holick to resign from the department. He did so, but remains a professor at the medical school's department of endocrinology, diabetes and nutrition and weight management.

In "The Vitamin D Solution," Holick wrote that he was "forced" to give up his position due to his "stalwart support of sensible sun exposure." He added, "Shame on me for challenging one of the dogmas of dermatology."

Although Holick's website lists him as a member of the American Academy of Dermatology, an academy spokeswoman, Amanda Jacobs, said he was not a current member.

Dr. Christopher McCartney, chairman of the Endocrine Society's clinical guidelines subcommittee, said the society has put in place stricter policies on conflict of interest since its vitamin D guidelines were released. The society's current policies would not allow the chairman of the guideline-writing committee to have financial conflicts.

A Miracle Pill Loses Its Luster

Enthusiasm for vitamin D among medical experts has dimmed in recent years, as rigorous clinical trials have failed to confirm the benefits suggested by early, preliminary studies. A string of trials found no evidence that vitamin D reduces the risk of cancer, heart disease or falls in the elderly. And most scientists say there isn't enough evidence to know if vitamin D can prevent chronic diseases that aren't related to bones.

Although the amount of vitamin D in a typical daily supplement is generally considered safe, it is possible to take too much. In 2015, an article in the American Journal of Medicine linked blood levels as low as 50 nanograms per milliliter with an increased risk of death.

Some researchers say vitamin D may never have been the miracle pill that it appeared to be. Sick people who stay indoors tend to have low vitamin D levels; their poor health is likely the cause of their low vitamin D levels, not the other way around, said Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women's Hospital in Boston. Only really rigorous studies, which randomly assign some patients to take vitamin D and others to take placebos, can provide definitive answers about vitamin D and health. Manson is leading one such study, involving 26,000 adults, expected to be published in November.

A number of insurers and health experts have begun to view widespread vitamin D testing as unnecessary and expensive. In 2014, the U.S. Preventive Services Task Force said there wasn't enough evidence to recommend for or against routine vitamin D screening. In April, the task force explicitly recommended that older adults outside of nursing homes avoid taking vitamin D supplements to prevent falls.

In 2015, Excellus BlueCross BlueShield published an analysis highlighting the overuse of vitamin D tests. In 2014, the insurer spent $33 million on 641,000 vitamin D tests. "That's an astronomical amount of money," said Dr. Richard Lockwood, Excellus' vice president and chief medical officer for utilization management. More than 40 percent of Excellus patients tested had no medical reason to be screened.

In spite of Excellus' efforts to rein in the tests, vitamin D usage has remained high, Lockwood said. "It's very hard to change habits," he said, adding: "The medical community is not much different than the rest of the world, and we get into fads."

Babies Dependent On Opioids Need Touch, Not Tech

KFF Health News, August 20, 2018

The science-based treatment methods for neonatal abstinence syndrome, involve keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities.

This article first appeared August 20, 2018 on Kaiser Health News.

By Alex Smith, KCUR

Dr. Jodi Jackson has worked for years to address infant mortality in Kansas. Often, that means she treats newborns in a high-tech neonatal intensive care unit with sophisticated equipment whirring and beeping. And that is exactly the wrong place for an infant like Lili.

Lili's mother, Victoria, used heroin for the first two-thirds of her pregnancy and hated herself for it.

"When you are in withdrawal, you feel your baby that's in withdrawal too," said Victoria, recalling sensations during her pregnancy. (Kaiser Health News is using her first name only because she has used illegal drugs.) "You feel your baby uncomfortable inside of you, and you know that. And then you use and then the baby's not [uncomfortable], and that's a really awful, vulgar thought, but it's true. That's how it is. It's terrible."

Though Victoria went into recovery before giving birth, Lili was born dependent on the methadone Victoria took to treat her opioid addiction. Treatment for infants like Lili has evolved, Jackson said.

"What happened 10, 15 years ago, is [drug-dependent] babies were immediately removed from the mom, and they were put in an ICU warmer with bright lights with nobody holding them," said Jackson, who is a neonatologist at Children's Mercy Hospital in Kansas City, Mo. "Of course, they are going to be upset about that! And so the risk of withdrawal is much higher."

Jackson now leads a statewide effort to get hospitals in Kansas to use the science-based treatment methods for neonatal abstinence syndrome, as the condition is formally known. The symptoms include high-pitched screams, clenched muscles and trouble sleeping. The treatment involves keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities to ease the baby's symptoms until she can be weaned off of them.

It's estimated that around 2 percent of infants are now born drug-dependent. In areas gripped by the opioid crisis, the rate is even higher.

The low-tech, high-touch treatment approach that Lili received in the first weeks of her life is one that health experts encourage hospitals everywhere to adopt as they grapple with increasing numbers of infants born with drug dependencies.

In many parts of the state, Jackson said, she's starting from scratch.

"Many hospitals have no standard of practice. No standard approach," Jackson said.

But improving outcomes for opioid-dependent babies will probably take more than just educating hospital staff.

Dr. Elisha Wachman, who is a neonatalogist at Boston Medical Center and teaches pediatrics at Boston University, said that providing this kind of care is a big adjustment for many hospitals.

"It really depends on the capacity of the hospital and where they house the babies for monitoring," Wachman said. "Some of them don't have room for the mothers to stay with the babies."

Compounding the problem, the matter of exactly what are the "best practices" is far from settled.

For example, new research suggests that methadone may be a better recovery drug for newborns than morphine, which Wachman said is most often used, even though doctors are still unsure about morphine's long-term effects.

"There are very few high-quality clinical trials that have been done in this population of infants," Wachman said. "If you can imagine, this is an incredibly difficult population to study. To do a randomized, controlled trial, for instance, of opiates and neonates is incredibly challenging."

Jackson acknowledged the challenges, but she said establishing consistent practices based on what doctors do know is an important first step toward getting answers.

Victoria said she did everything she could to help newborn Lili get healthy in the hospital, with no idea whether they'd be together in the long term.

"I was trying not to be connected with her, because, I thought, they're probably going to take her," Victoria said. "I haven't been clean that long. So I was trying to not, like, be in love with her. But I was so in love with her." Lili is her fourth child.

Victoria has continued to show state officials that she is committed to staying off drugs. She has been allowed to raise Lili at Amethyst Place, a recovery home in Kansas City.

Lili is now a 16-month-old girl who shares her mother's blond hair, bright eyes and big smile. Despite her difficult start in life, the toddler is in good health, and her mom has been drug-free for a more than a year and a half.

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