When Food Stamps Pass As Tickets To Better Health

KFF Health News, January 17, 2018

The goal of the four-year program, like that of its counterparts in other states, is to improve diets and overall health by making fresh produce more affordable.

This article first appeared January 17, 2018 on Kaiser Health News.

By Courtney Perkes

Rebeca Gonzalez grew up eating artichokes from her grandmother’s farm in the central Mexican state of Tlaxcala. But for years after emigrating to the U.S., she did not feed them to her own kids because the spiky, fibrous vegetables were too expensive on this side of the border.

When she prepared meals at her family’s home in Garden Grove, Calif., Gonzalez would also omit avocados, a staple of Mexican cuisine that is often costly here.

“I saw the prices and I said, ‘No, never mind,’” said Gonzalez, a 47-year-old child care worker who receives about $500 a month in food stamps.

But those items are no longer out of reach for her family. Since enrolling last year in a program that rewards food stamp beneficiaries for buying more fresh produce, Gonzalez has regularly filled her shopping cart with the fruits and vegetables of her childhood — not only avocados and artichokes, but pomegranates, various types of squash and more.

Participation in the program, called “Más Fresco,” or “More Fresh” in English, gives Gonzalez an additional $40 a month to spend on produce, allowing her to broaden the palates of her three U.S.-born children. “The good thing is my family likes to try the new vegetables,” she said. “Now I can buy them because I have the extra money.”

The University of California-San Diego is administering Más Fresco and studying its results with a $3.4 million grant from the U.S. Department of Agriculture, which has funded similar efforts in other states, including Illinois, Georgia, Pennsylvania, Minnesota and New Mexico. The dollars invested in those states have been aimed at inducing food stamp recipients to buy more produce at farmers markets or at mobile markets that visit low-income neighborhoods.

Más Fresco is open to Southern Californians in Los Angeles, Orange and San Diego counties who are enrolled in the Supplemental Nutrition Assistance Program, or SNAP — the official name for food stamp benefits.

The goal of the four-year program, like that of its counterparts in other states, is to improve diets and overall health by making fresh produce more affordable.

“We know food insecurity and, unfortunately, chronic disease go hand in hand,” said Joe Prickitt, a UC-San Diego dietitian who is senior director of Más Fresco. “For SNAP participants, there’s a real cost barrier to buying fruits and vegetables. They say they’re just too expensive.”

Rebeca Gonzalez holds a copy of her grocery receipt and her Northgate González loyalty card. The loyalty card tracks her purchases and redemptions through Más Fresco, a program that urges food stamp recipients to buy produce. (Courtney Perkes for KHN)

Since Más Fresco began in February 2017, it has enrolled 1,153 participants, who receive an average of $329 a month in food stamps and typically live in households of five or six people. Ninety percent of them are Latinos, but adults from any ethnic background can join provided they are willing to shop at a participating Northgate González Market – an Anaheim, Calif.-based Latino grocery chain that is Más Fresco’s retail partner.

For every dollar worth of food stamps enrollees spend on fresh produce in a given month, they receive a one-to-one match, up to $10, $20 or $40, which they can spend only on more fruits and vegetables. The UC-San Diego researchers who are studying the program varied the maximum reward amounts and assigned them randomly to participants to help determine the optimal dollar level for changing people’s dietary habits.

The six participating Northgate stores — two in each of the three participating counties — use loyalty cards to tally produce purchases and distribute the credits. The amount of credit participants have earned and redeemed is itemized at the bottom of their receipts, and the credit carries over from month to month.

Research has shown that affordability is an obstacle to healthier eating for people of modest means. A 2013 study by researchers at Harvard and Brown universities estimated that a healthful diet costs about $550 a year more per person than an unhealthy one. “For many low-income families, this additional cost represents a genuine barrier to healthier eating,” the authors concluded. “Yet, this daily price difference is trivial in comparison with the lifetime personal and societal financial burdens of diet-related chronic diseases.”

A 2016 report by the U.S. Department of Agriculture revealed that food stamp recipients spend a smaller percentage of their grocery budgets on fruits and vegetables than other Americans do.

Financial incentives like the ones being tested in California can help narrow that gap.

A 2011 study of an incentive program in Massachusetts found that people on food stamps who got an extra 30 cents for every dollar they spent on fruits and vegetables consumed nearly a quarter-cup, or 26 percent, more fresh produce per day than recipients who did not get such an incentive.

Last week, Más Fresco began to enroll a second round of up to 2,000 people who will receive the incentive for one year. The current participants will continue in the program through June.

Prickitt said he hopes that even after their financial incentives end, participants will retain what they have learned about healthy eating and continue buying produce.

Rebeca Gonzalez says she can now afford pomegranates for her family because of the extra money she receives through Más Fresco, an incentive program for purchasing produce. (Courtney Perkes for KHN)

Food policy experts note that many other factors can influence a family’s food choices, including lack of time.

“If parents are working more than one job or children are in more than one school or activity, how do you teach the skills of how you can prepare food, even on a busy weeknight?” said Dean Sidelinger, a pediatrician and child health medical officer for San Diego County.

Some advocates for healthful diets have argued that government should not only encourage people to buy healthier food but also discourage unhealthful habits.

A 2014 Health Affairs study by Stanford University researchers showed that banning the purchase of soda with food stamps would reduce rates of obesity and diabetes, while a credit of 30 cents on the dollar for buying fresh produce alone would not.

In 2017, more than a dozen researchers from different universities urged SNAP to eliminate diet-related health disparities among programs for low-income people. They noted, for example, that the federal food-assistance program known as Women, Infants and Children, or WIC, excluded soda and candy but that people could still buy those products with food stamps.

“There are generations of unhealthy people who are overweight with diabetes and hypertension,” said Jim Floros, president and CEO of the San Diego Food Bank, which has advertised the Más Fresco program to its clients. “That’s completely linked back to a poor diet, which is linked back to poverty.”

Rebeca Gonzalez, who moved to the U.S. at age 18, decided to overhaul her family’s eating habits after her husband, Javier Landeros, was diagnosed with diabetes two years ago. Instead of buying cookies, she now keeps chopped fruits and veggies in the fridge for snacks.

She said she wants to instill the same healthy habits her grandmother passed on to her.

“I know she gave us good food,” Gonzalez said, “because she lived 105 years.”

In Wisconsin, Hopes Rise For Production Of A Lifesaving Radioactive Isotope

KFF Health News, January 16, 2018

Delays that pose an inconvenience for other commercial goods are existential threats in the daily global relay race of medical isotopes that disappear hour by hour.

This article first appeared January 16, 2018 on Kaiser Health News.

By Sarah Varney

JANESVILLE, Wis. — In a cornfield here, past the shuttered General Motors plant and the Janesville Terrace trailer home park, a facility not seen in the United States in three decades could soon rise: a manufacturing plant that will make a vital radioactive isotope used to detect cancer and other potentially fatal maladies in millions of people every year.

Nuclear medicine imaging, a staple of American health care since the 1970s, runs almost entirely on molybdenum-99, a radioisotope produced by nuclear fission of enriched uranium that decays so rapidly it becomes worthless within days. But moly-99, as it’s called, is created in just six government-owned nuclear research reactors — none in North America — raising concerns about the reliability of the supply and even prompting federal scientists to warn of the possibility of severe shortages.

Some 50,000 Americans each day depend on a strange and precarious supply chain easily disrupted by a variety of menaces: shipments grounded by fog in Dubai, skittish commercial airline pilots who refuse to carry radioactive material and unplanned nuclear reactor shutdowns, including one in South Africa when a mischievous baboon sneaked into a reactor hall.

Delays that pose an inconvenience for other commercial goods are existential threats in the daily global relay race of medical isotopes that disappear hour by hour. “It’s like running through the desert with an ice cream cone,” said Ira Goldman, senior director of global strategic supply at Lantheus Medical Imaging in North Billerica, Mass.

But that race may soon be shortened. Propelled by persistent supply problems and fears that terrorists could seize American uranium en route to foreign facilities, President Barack Obama signed legislation in 2013 prodding American companies into the medical-isotope business.

The $100 million Janesville plant, in the hometown of Rep. Paul Ryan, speaker of the House, is the first construction project to pass through the labyrinthine nuclear regulatory approval process since 1985 and is being built by SHINE Medical Technologies with $25 million in federal funds.

Greg Piefer, the company’s founder and a nuclear engineer (he drives a Tesla with the license plate “NEUTRON”), has big plans for the cornfield: a plant that could manufacture up to 50,000 doses of imaging agent a week. “Ryan called me out of the blue and he said, ‘We really want you here,’” Piefer said.

Still, it could be years before moly-99 is manufactured in the United States. SHINE still needs more money to complete its manufacturing plant, and investors are wary of the many problems that can arise during construction. Already, construction deadlines promised by SHINE have come and gone. Other competitors, meanwhile, that received tens of millions of dollars in federal grants to build their own moly-99 manufacturing plants have been thwarted by protracted drug approvals and nuclear regulatory hurdles, and some have given up.

European rivals have also cautioned the American upstarts. At industry presentations, Goldman said, the producers have warned, “This is more difficult than it looks. You can’t come up with a fancy slide that says, ‘I’m going to be producing moly-99 in a couple of years.’”

Birth Of An Isotope

The radioactive isotope injected into the veins of potential heart attack victims or bone cancer patients begins its journey in the heavily guarded American nuclear stockpile.

The Department of Energy’s National Nuclear Security Administration ships Cold War-era uranium overseas, where the containers — sought by terrorists for dirty bombs — are secretively trucked to government-owned nuclear research reactors in the Netherlands, Belgium, Czech Republic and Poland. (South Africa and Australia also use American uranium to produce moly-99 in research reactors.)

Private companies rent time in the reactors to irradiate enriched uranium targets, producing an atomic alphabet soup. Nearby processing facilities fish out the moly-99, and the radioactive material is loaded onto commercial airline flights bound for the United States in protective containers.

Three companies dominate the American market for moly-99 — Lantheus, Curium and GE Healthcare. They distribute the material to specialized pharmacies around the country, where technicians process it into a diagnostic imaging agent called technetium-99. The companies work against a ticking clock: Because of its short half-life, just 66 hours for moly-99 and six hours for the imaging agent, the material must be quickly delivered to hospitals and administered to patients.

“The whole industry is like a duck going on a fast-flowing river,” said Kevin Charlton, an analyst at the Organization for Economic Cooperation and Development’s Nuclear Energy Agency in Paris. “On the surface, it looks like things are going very smoothly, but under the water, their legs are going really fast.”

Countless things can go wrong, starting with the first step.

The worldwide supply of moly-99 relies on a fleet of government-subsidized nuclear research reactors built mostly during the Khrushchev-Eisenhower era.

Regular maintenance and major repairs can shutter the reactors, sometimes for months, and so-called scrams — caused by anything from a hiccup in a reactor’s cooling system to an errant lightning strike — frequently halt production. “It’s a nuclear reactor,” Charlton said. “The only thing you can do is shut it off.”

Even the Mayo Clinic in Rochester, Minn., a prestigious cancer treatment center, can be left waiting for shipments of the generators that contain the imaging agent. “We’ve had days when no generator comes in at all, or it’s been cut in half,” said Andrew Paulsen, supervisor of the clinic’s radiopharmaceutical laboratory.

And the ephemeral nature of moly-99 always looms. On a recent afternoon, inside a locked laboratory at Stanford Hospital’s nuclear medicine department in Palo Alto, Calif., a technician held a lead-lined, plastic cylinder containing a syringe of fragile atoms that had traveled around the globe.

Once the imaging agent is injected into a patient’s body, it emits gamma rays that can be detected by gamma cameras that look like X-ray machines. The radioactive tracer lights up on a computer monitor wherever the heart’s blood vessels are blocked or bones are riddled with potentially cancerous tumors. The imaging agent was first used in medical applications in the 1960s because its short half-life meant that patients were getting less exposure to radioactivity than from other diagnostic tracers.

But at Stanford’s nuclear medicine department that day, a patient had missed his appointment. This meant the dose — which cost the hospital an irretrievable $500 — had decayed and was now useless. The technician threw the syringe in the trash.

The supply chain’s vulnerability, acutely felt during a severe worldwide shortage in 2009 and 2010 when two reactors shut down unexpectedly, has led some doctors to shift to more dependable, but more toxic, imaging agents. “For cardiac imaging, we had to shift to a more expensive agent and expose patients to more radiation,” said Dr. Andrei Iagaru, chief of the division of nuclear medicine at Stanford Health Care.

After the worldwide shortage, the volume of nuclear medicine tests went down, and stayed down. “It definitely had an impact on the way many practices run their cardiac stress tests,” Iagaru said.

Depending On Other Countries

American patients consume nearly half of the world’s supply of moly-99. And despite plans to ramp up production in Australia, reactor construction is notoriously tricky. In addition, reactors that are converting for security reasons to low-enriched uranium have lower yields and more waste, according to nuclear scientists.

Concerns about moly-99 shortages heightened in October 2016, when the Canadian government mothballed a reactor in Chalk River, Ontario, that supplied about 40 percent of the American market. The government’s decision to shutter the plant was, in part, due to frustration that Canada had had to spend $70 million in 2009 to repair the facility — in effect, subsidizing the American health care industry. That is a complaint of European governments as well.

William Magwood, director of the Nuclear Energy Agency in Paris, said that moly-99 production at Chalk River “went from being incidental to being the only reason to operate the reactor.”

“Canadians didn’t want to continue to operate a high-cost reactor to sell isotopes to the U.S.,” he said.

Some European governments have begun charging moly-99 producers higher rates to rent reactor time, and prices are expected to rise sharply when governments strip for-profit companies of subsidies originally meant to support academic research.

“How much will get passed on to the health care providers?” said Leah Gannon, senior portfolio executive of radiopharmaceutical distribution sourcing for Vizient, a company that negotiates contracts for hospitals. “Probably almost all of it.”

With no source of moly-99 anywhere in North America, American nuclear medicine specialists appointed by the National Academies of Sciences, Engineering and Medicine warned in a 2016 report commissioned by Congress of a more than 50 percent likelihood of another severe shortage in the coming years.

Moly-99 suppliers refute the report’s findings, a position echoed by the Nuclear Energy Agency, which has fostered closer ties among producing nations. Reactor operators, the suppliers say, work closely to stagger maintenance shutdowns to minimize shortages and respond to disruptions in production, and producers have increased the number of uranium targets.

“We’re describing a glass that is half-full,” Charlton said, “whereas the National Academy of Sciences sees the glass looking half empty.”

Still, nuclear medicine physicians and nuclear pharmacists charged with filling patient orders each day say the supply remains fragile, especially for smaller pharmacies where the moly-99 imaging agent can account for 95 percent of their business. “It is inconceivable to believe that an outage will never occur on any of these old reactors in the future,” said Dr. Joseph Hung, director of radiopharmaceutical operations at the Mayo Clinic and a member of the government committee.

Wendy Galbraith, a clinical associate professor at the University of Oklahoma College of Pharmacy in Oklahoma City who runs the university’s pharmacy, said she frequently doesn’t know if moly-99 is going to be available until the wee hours of the morning. Even when there are no major outages, she said, “it’s a scramble.”

That uncertainty means delays and on-the-fly triage for patients. “If we have a patient who can wait two days for their cardiac stress test, we’ll put them off,” Galbraith said.

Suppliers want to tamp down fears about reliability, physicians and pharmacists say, to dissuade them from seeking alternative imaging methods when possible, like positron emission tomography, a costly and complex type of medical scan.

“It’s hard to stay relevant in an environment when things are not available every now and then,” said Iagaru at Stanford.

Even more troubling, critics say, is the lack of redundancy in the supply chain. Of the four global suppliers, two rely on a single reactor. “If anything goes wrong with the reactors in South Africa and Australia,” Dr. Hung said, “it will be déjà vu again like in 2009.”

The Wisconsin Project

If the United States is to grow a domestic moly-99 supply, it will probably rise from the corn and soybean fields in America’s Dairyland.

Rock County, Wis., has become the unexpected home to two of the three companies vying for control: NorthStar Medical Radioisotopes in Beloit, which has been awarded $50 million in federal grants, and SHINE, or Subcritical Hybrid Intense Neutron Emitter, in Janesville.

Backed by $25 million in federal support, Piefer, SHINE’s chief executive, has promised to build a nuclear accelerator and produce moly-99 by 2020. (The previous deadline was 2015.) In early 2017, the company opened its headquarters in Janesville above the Time Out Pub & Eatery and down the street from a fishing tackle shop and Speaker Ryan’s district office.

Nuclear engineers have moved en masse to Janesville in recent months, decorating their cubicles with hand-painted signs with sayings like, “Think like a proton, stay positive.”

Piefer zips along Highway 90 in his Model S Tesla between Janesville and Monona, a Madison suburb where his research lab, Phoenix Nuclear Labs is located. There, engineers have built a ghostly particle beam that looks like a giant, purple lightsaber.

Eight particle accelerators have been designed for the Janesville plant, which the Nuclear Regulatory Agency approved for construction in 2016. Piefer still needs to raise considerable private capital, a challenge with eager entrants like NorthStar and Nordion, an Ottawa-based company also with aggressive plans to enter the Moly-99 market.

“If we don’t have significant production soon, we will continue to export highly enriched uranium,” Piefer said. “And the National Nuclear Security Administration will have failed their mission.”

The city of Janesville is banking on Piefer. Its economy reeling from the closing of the General Motors plant in 2008, the City Council aggressively pursued SHINE with a generous economic development package, besting two other Wisconsin cities.

In 2011, over the objections of some residents opposed to a nuclear facility in the town, the council authorized $1.53 million to buy 84 acres of farmland, which it has agreed to turn over to SHINE for $1. The city has also agreed to pay $345,000 to extend utilities to the site, provide $2 million in forgivable loans and co-sign a bank loan with SHINE for up to $4 million that it would have to pay should the company fail, a first for the city.

Gale Price, economic development director for the city of Janesville, said that although it was unusual to put public money into a startup, the city expected to recoup its investment within 10 years. “That’s how we measure whether we’re giving away the farm,” he said.

Ryan has championed the project and spoke at a celebration marking nuclear regulatory approval. But Piefer said, except for the initial phone call urging him to come to Janesville, Ryan has played no part in the federal grant and construction approvals.

SHINE jumped at the chance at federal money for the private plant. But Piefer isn’t solely focused on the need in American hospitals. The company has already announced lucrative deals to ship moly-99 to Chinese hospitals.

But first, it needs to start producing.

“You cannot just open a shop down the street and start nuclear medicine,” said Iaragu, of Stanford. “The public comes with an expectation that if my oncologist wants me to get a bone scan, it’s not big deal. But the truth is, it’s a big deal.”

Kentucky Is First State Granted Approval For Medicaid Work Requirements

KFF Health News, January 15, 2018

The approval comes one day after the Trump administration released guidance to states on how to design and test programs that require work as a condition of receiving Medicaid.

This article first appeared January 12, 2018 on Kaiser Health News.

By Phil Galewitz

Thousands of poor adults in Kentucky will have to find jobs and pay monthly premiums to retain their Medicaid coverage as a result of drastic changes to the state’s health insurance program approved Friday by the Trump administration.

With the long-expected decision, Kentucky becomes the first state to win federal approval to test a new work requirement in Medicaid, a controversial policy shift likely to result in a court battle over whether the administration overstepped its legal authority.

“I was raised by a father who said, ‘Don’t take something that is not earned,’” said Republican Gov. Matt Bevin in announcing the approval of Kentucky’s Medicaid waiver. “The vast majority of able-bodied men and women, able-bodied Kentuckians, they want the dignity associated with being able to earn and have engagement in the very things they are receiving, and an opportunity not to be put in a dead-end entitlement trap but given a path forward and upward.”

Radio story by Jake Harper, Side Effects Public Media, a news collaborative covering public health.

Conservatives say the work requirement can help lead people to employment and off the state-federal health program. Democrats, health providers and patient groups say the measure adds another stumbling block for people to keep their coverage.

“By lessening dependence on government assistance and promoting individual self-sufficiency, Kentucky’s efforts should also help to promote the fiscal sustainability of the program to better protect services for the Commonwealth’s most vulnerable,” Demetrios Kouzoukas, principal deputy administrator of the Centers for Medicare & Medicaid Services, wrote in his Kentucky approval letter. “Overall, CMS believes that Kentucky HEALTH [Helping to Engage and Achieve Long Term Health] has been designed to empower individuals to improve their health and well-being.”

The approval comes one day after the Trump administration released guidance to states on how to design and test programs that require work as a condition of receiving Medicaid.

A study by the Kaiser Family Foundation found that 6 in 10 non-disabled adults on Medicaid already work at least part time, although they often aren’t offered health benefits through those jobs or can’t afford them. (Kaiser Health News is an editorially independent program of the foundation.)

Surveys show that many Medicaid enrollees who don’t work are in job training, go to school or are taking care of a child or an elderly relative, conditions that would make them exempt from the new mandate, according to the CMS guidelines.

Kentucky’s program would require non-disabled adults each month to participate in 80 hours of work, job training, education or other qualified “community engagement.”

Those who are exempted include children and former foster care kids, pregnant women, senior citizens, people who are the primary caretakers for a child or a disabled adult, those who are deemed medically frail or diagnosed with an acute medical condition that would prevent them from working, and full-time students.

Officials acknowledge that the work requirement — coupled with other changes in its waiver request — would lead to about 95,000 fewer people enrolled after five years. But many of those would drop out not because of finding work but because they can’t overcome the new bureaucratic hurdles, say advocates for the poor.

“We expect that fewer people will be able to stay enrolled in coverage due to all of the red tape and penalties they’ll encounter,” said Emily Beauregard, executive director for Kentucky Voices for Health, an advocacy group. “Keeping up with the reporting requirements alone will be enough of a burden on people who have two or three part-time jobs that they’ll either lose coverage at some point or may decide it’s not worth enrolling to begin with.”

The Kentucky approval brings other major changes to the state’s Medicaid program, which has doubled in enrollment to 1.2 million people since the state expanded eligibility in 2014 under the federal Affordable Care Act.

The revisions would cut dental and vision coverage for many adults, although they can regain it by completing health-related activities, such as taking a disease management class or volunteering.

Individuals with income above the poverty level ($12,060) who do not pay their premiums in 60 days will be kicked out of coverage for six months. Enrollees can return to the program earlier if they pay two months of missed premiums and make one new premium payment. They also must complete a financial or health literacy course.

The state also eliminates its non-emergency transportation benefit for some adults in the program.

Under Kentucky HEALTH, enrollees will make a monthly payment ranging from $1 to $15 depending on income. Pregnant women and children will be exempt from that cost sharing.

The Kentucky Medicaid changes generally mimic those of neighboring Indiana, which altered its program in 2015 under then-Gov. Mike Pence.

CMS Administrator Seema Verma recused herself from the Kentucky decision because she had worked with state officials on the waiver request when she was a consultant before joining the Trump administration.

Kentucky is one of 10 states that have applied to CMS to enact a work requirement.

The work requirement is one of the biggest changes in the history of Medicaid, which covers more than 74 million people, or about 1 in 5 Americans. It is the nation’s largest health insurance program.

The majority of enrollees in Medicaid are children, pregnant women and elderly nursing home residents. But the expansion under President Barack Obama led to millions of non-disabled low income adults added to the program.

Update: This story was updated on Jan. 12 to add information from the governor and more details on the Kentucky waiver once they were released.

Banding Together To Stop Opioid Addiction Where It Often Starts - In Hospitals

KFF Health News, January 12, 2018

The largest private U.S. hospital chain is rolling out a new protocol prior to surgery. It includes a warning that patients should expect to feel some pain.

This article first appeared January 12, 2018 on Kaiser Health News.

By Blake Farmer, Nashville Public Radio

Doctors at some of the largest U.S. hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nation's opioid crisis. In an effort to be part of the cure, they've begun to issue an uncomfortable warning to patients: You're going to feel some pain.

Even for people who've never struggled with drug abuse, studies are finding that patients are at risk of addiction anytime they go under the knife.

"I had the C-section, had the kiddo," said Michelle Leavy of Las Vegas. "And then they tell me, ‘It's OK, you can keep taking the pain medications, it's fine.'"

Leavy is a mother of three and a paramedic who has dealt with many patients coping with addiction. She welcomed the high-dose intravenous narcotics while in the hospital and, upon her release, gladly followed doctors' orders to keep ahead of the pain with Percocet pills.

But then she needed stronger doses. Soon, she realized, she was no longer treating pain.

"Before I went to work, I took them, and to get the kids after school, I had to take them," she said. "Then I was taking them just to go to bed. I didn't really realize I had a problem until the problem was something more than I could have taken care of myself."

She said she was becoming like the patients with addiction problems that she transported by ambulance, lying to emergency room doctors to con a few extra doses.

Soon she lost her job and her fiancé, before going to rehab through American Addiction Centers and stitching her life back together.

A 180 On Opioids

Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital. Anesthesiologist David Alfery said he was rarely stingy with the pain medicine.

"If I could awaken them without any pain whatsoever, I was the slickest guy on the block, and it was a matter of enormous pride," he said.

Alfery is part of a working group at the Nashville-based consulting firm Health Trust behind hospital efforts to set aside rivalry and swap ideas about a top priority: reducing opioid use.

"It starts with patient expectations, and I think, over the years, patients have come to expect more and more in terms of, ‘I don't want any pain after surgery,' and it's an unrealistic expectation," Alfery said.

Michelle Leavy had emergency gallbladder surgery in June. She refused opioids before, during and after the procedure. "It hurt," she says, "but I lived." (Courtesy of Michelle Leavy)

That expectation exists in part because pain treatment was institutionalized. Hospitals are graded on how well they keep someone's pain at bay. And doctors can feel institutional pressure, and on a personal level.

"I just wanted my patient not to be in pain, thinking I was doing the right thing for them and certainly not an outlier among my colleagues," said Mike Schlosser, chief medical officer for a division of HCA, the nation's largest private hospital chain.

Schlosser spent a decade as a spinal surgeon putting his patients at HCA's flagship facility in Nashville through some of the most painful procedures in medicine, like correcting back curvature. He said he genuinely wanted to soothe the hurt he caused.

"But now looking back on it, I was putting them at significant risk for developing an addiction to those medications," he said.

Using HCA's vast trove of data, he found that for orthopedic and back surgeries, the greatest risk isn't infection or some other complication — it's addiction.

So the nation's largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.

"We will treat the pain, but you should expect that you're going to have some pain. And you should also understand that taking a narcotic [dose so high] that you have no pain, really puts you at risk of becoming addicted to that narcotic," Schlosser said, recounting the new recommended script for surgeons speaking to their patients.

Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital's part — trying nerve blocks and finding the most effective blend of non-narcotic medicine. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don't need potentially addictive drugs, or at least not in high dosage, he said.

There are potential benefits aside from avoiding addiction.

"I've had people tell me that the constipation [resulting from opioid use] was way worse than the kidney stone," said Valerie Norton, head of the pharmacy and therapeutics council for Scripps Health System in San Diego, which is participating in the Health Trust working group.

"There are lots of other complications from opioids — severe constipation, nausea, itching, hallucinations, sleepiness. We really need to treat these drugs with respect and give people informed consent. And let people know these are not benign drugs."

Managing The Optics

Of course, business-wise, no one wants to be known as the hospital where treatment hurts more.

"You don't want to portray the fact that you're not going to treat people appropriately," said John Young, national medical director of cardiovascular services for LifePoint Health, another player at the table with Health Trust. The Nashville-based hospital chain is putting special emphasis on how it handles people coming into the ER looking for pain medicine.

Young said tightening up on opioids becomes a delicate matter but it's the right thing to do.

"We really do have a lot of responsibility and culpability and this burden, and so we have to make sure we do whatever we can to stem this tide and turn the ship in the other direction," he said.

While hospitals get their ship in order, some patients are taking personal responsibility.

Now that she's in recovery, Michelle Leavy won't touch opioids. That meant she had emergency gallbladder surgery in 2017 without any narcotics. Leavy said she was nervous about telling her doctors about her addiction, but they were happy to find opioid alternatives.

"I mean, it hurt," she said. "But I lived."

Trump Administration Clears Way To Require Work For Some Medicaid Enrollees

KFF Health News, January 11, 2018

Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups.

This article first appeared January 11, 2018 on Kaiser Health News.

By Phil Galewitz

The Trump administration early Thursday initiated a pivotal change in the Medicaid program, announcing that for the first time the federal government will allow states to test work requirements as a condition for coverage.

The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.

The document says who should be excluded from the new work requirements — including children and people being treated for opioid abuse — and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering or caring for a close relative.

“Medicaid needs to be more flexible so that states can best address the needs of this population,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said in a press release. “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”

Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.

Republicans have been pushing for the change since the Affordable Care Act added millions of so called “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138 percent of the federal poverty level (about $16,600 for an individual).

The Obama administration turned down several state requests to add a work requirement.

Ten states have applied for a federal waiver to add a work requirement — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.

An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments, said the agency may approve Kentucky’s request as early as Friday. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.

Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past three years after the state expanded eligibility under the ACA.

While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children — who make up nearly half of Medicaid enrollees — are excluded. So are the more than 10 million people on Medicaid because they have a disability.

More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative or are too sick to work.

Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.

But work requirements have strong public backing. About 70 percent of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year. (KHN is an editorially independent program of the foundation.)

The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.

In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children and elderly families.

CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”

“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.

Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.

“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.

Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.

Fallout From 'Nuclear Button' Tweets: Sales Of Anti-Radiation Drug Skyrocket

KFF Health News, January 11, 2018

'I basically got in a month's supply of potassium iodide and I sold out in 48 hours,' a top U.S. distributor said.

This article first appeared January 11, 2018 on Kaiser Health News.

By JoNel Aleccia

A Twitter battle over the size of each “nuclear button” possessed by President Donald Trump and North Korea’s Kim Jong-un has spiked sales of a drug that protects against radiation poisoning.

Troy Jones, who runs the website www.nukepills.com, said demand for potassium iodide soared last week, after Trump tweeted that he had a “much bigger & more powerful” button than Kim — a statement that raised new fears about an escalating threat of nuclear war.

“On Jan. 2, I basically got in a month’s supply of potassium iodide and I sold out in 48 hours,” said Jones, 53, who is a top distributor of the drug in the United States. His Mooresville, N.C., firm sells all three types of the product approved by the Food and Drug Administration. No prescription is required.

In that two-day period, Jones said, he shipped about 140,000 doses of potassium iodide, also known as KI, which blocks the thyroid from absorbing radioactive iodine and protects against the risk of cancer. Without the tweet, he typically would have sent out about 8,400 doses to private individuals, he said.

Jones also sells to government agencies, hospitals and universities, which aren’t included in that count.

Alan Morris, president of the Williamsburg, Va.-based pharmaceutical firm Anbex Inc., which distributes potassium iodide, said he’s seen a bump in demand, too.

“We are a wonderful barometer of the level of anxiety in the country,” said Morris.

A spokeswoman for a third firm, Recipharm AB, which sells low-dose KI tablets, declined to comment on recent sales.

Jones said this is not the first time in recent months that jitters over growing nuclear tensions have boosted sales of potassium iodide, which comes in tablet and liquid form and should be taken within hours of exposure to radiation.

It's the same substance often added to table salt to provide trace amounts of iodine that ensure proper thyroid function. Jones sells his tablets for about 65 cents each, though they're cheaper in bulk. Morris said he sells the pills to the federal government for about 1 penny apiece.

Yet, neither the FDA nor the Centers for Disease Control and Prevention recommends that families stockpile potassium iodide as an antidote against nuclear emergency.

“KI (potassium iodide) cannot protect the body from radioactive elements other than radioactive iodine — if radioactive iodine is not present, taking KI is not protective and could cause harm,” the CDC’s website states.

The drug, which has a shelf life of up to seven years, protects against absorption of radioactive iodine into the thyroid. But that means that it protects only the thyroid, not other organs or body systems, said Dr. Anupam Kotwal, an endocrinologist speaking for the Endocrine Society.

“This is kind of mostly to protect children, people ages less than 18 and pregnant women,” Kotwal said.

States with nuclear reactors and populations within a 10-mile radius of the reactors stockpile potassium iodide to distribute in case of an emergency, according to the Nuclear Regulatory Commission. An accident involving one of those reactors is far more likely than any nuclear threat from Kim Jong-un, Anbex’s Morris said.

Still, the escalating war of words between the U.S. and North Korea has unsettled many people, Jones said. Although some of his buyers may hold what could be regarded as fringe views, many others do not.

“It’s moms and dads,” he said. “They’re worried and they find that these products exist.”

Such concern was underscored last week, when the CDC announced a briefing on the “Public Health Response to a Nuclear Detonation.” One of the planned sessions is titled “Preparing for the Unthinkable.”

Hundreds of people shared the announcement on social media, with varying degrees of alarm that it could have been inspired by the presidential tweet.

A CDC spokeswoman, however, said the briefing had been “in the works” since last spring. The agency held a similar session on nuclear disaster preparedness in 2010.

“CDC has been active in this area for several years, including back in 2011, when the Fukushima nuclear power plant was damaged during a major earthquake,” the agency’s Kathy Harben said in an email.

Indeed, Jones saw big spikes in potassium iodide sales after the Fukushima Daichii disaster, after North Korea started launching missiles — and after Trump was elected.

“I now follow his Twitter feed just to gauge the day’s sales and determine how much to stock and how many radiation emergency kits to prep for the coming week,” Jones said, adding later:

“I don’t think he intended to have this kind of effect.”

Despite Prod By ACA, Tax-Exempt Hospitals Slow To Expand Community Benefits

KFF Health News, January 9, 2018

The Affordable Care Act was trying to spur more spending on broader community initiatives, which have remained below 1% of operating costs at the hospitals.

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

By Vickie Connor

The federal health law's efforts to get nonprofit hospitals to provide more community-wide benefits in exchange for their lucrative tax status has gotten off to a slow start, new research suggests. And some experts predict that a recent repeal of a key provision of the law could further strain the effort.

The increased emphasis on community-wide benefits was mandated by the Affordable Care Act. The health law required hospitals that meet federal tax standards to be nonprofits to perform a community health needs assessment (CHNA) every three years, followed by implementing a strategy to deal with issues confronting the community, such as preventing violence or lowering the rates of diabetes.

A study released Monday in the journal Health Affairs shows spending in these areas has remained relatively stagnant.

The research showed average spending by tax-exempt hospitals on community benefits in 2010 was 7.6 percent of total operating costs and bumped to 8.1 percent by 2014. But the bulk of that spending goes toward unreimbursed patient care, such as charity care. The ACA was trying to spur more spending on broader community initiatives, which have remained below 1 percent of operating costs at the hospitals.

"This is not easy for hospitals to do," said Gary Young, the study’s lead author and director of the Center for Health Policy and Healthcare Research at Northeastern University in Boston. "By tradition, by the nature of their resources, hospitals have not been oriented to prevention, they’ve been oriented to treatment."

New efforts by the Republican-led Congress may complicate the effort. The repeal last month of the ACA’s penalties for most people who don’t have health insurance has some experts questioning how some of these hospitals will be able to spend more on community benefits. The Congressional Budget Office has estimated that because of that change about 13 million people would give up their coverage by 2027, which could drive up costs for hospitals because there would be more uninsured patients.

"Anything that destabilizes the system and takes money out of the hospitals’ revenue stream is going to negatively impact them," said Gregory Tung, assistant professor at the University of Colorado’s School of Public Health. "It's tough for hospitals to be navigating that uncertainty."

Jill Horwitz, professor of law at UCLA who specializes in health issues, said hospitals have trouble planning community efforts when they are unsure of their finances.

"It's a very difficult context in which to operate a stable system," Horwitz said. "One day to the next, it's hard to know what the rules are, what the reimbursement is going to be and what kind of insurance your patients will have."

More than half of the hospitals in the United States are private, nonprofit organizations that are tax-exempt.

Lawrence Massa, president & CEO of the Minnesota Hospital Association, said the repeal of the ACA’s individual mandate penalties will change hospitals’ calculations.

"We certainly expect to see our uninsured rate go up as a result of repealing the individual mandate," he said, "so that’s going to have an opposite type of effect of where we thought the trend was going to be because we changed the rules in the middle of the game."

But it's too early to tell how hospitals will respond, according to Massa. Many are still grappling with the new requirements.

The ACA was enacted in 2010, but the provision requiring community-based action did not come into effect until the end of March 2012, and enrollment in ACA marketplace plans didn’t begin until 2014. Hospitals began early investments for assembling the needs assessments in 2011 and 2012, Massa said.

"In the later years, they’ll be using that data and comparing and reporting to the IRS how they’ve changed their community benefits spending as a result of those community health needs assessments," he said. "If everything stayed the way it was, I think we would know by 2020 whether this had the kind of impact that was anticipated."

Young and his research colleagues acknowledged in their study that "certainly, more time is needed" to assess the full impact of the law’s requirements on spending for community benefits.

Nonetheless, Young said, many hospitals lack the means to provide greater preventive care in the community.

They don’t have the necessary infrastructure, "the personnel or the knowledge to develop those strategies," he said. "They don't have the resources to necessarily invest in those areas."

Horwitz agreed. "If we’re going to require this high level of spending on community benefits and paying for patients who can’t afford care, something else has to give," she said.

Running On Empty: CHIP Funding Could Run Out Jan. 19 For Some States

KFF Health News, January 8, 2018

Congress extended funding on Dec. 21, but CMS said it could not guarantee that the appropriation will be enough to fund all states through the end of this month.

This article first appeared January 05, 2018 on Kaiser Health News.

By Phil Galewitz

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program (CHIP) despite spending approved by Congress in late December that was expected to keep the program running for three months, federal health officials said Friday.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 and touted that states would have money to last while Congress worked on a long-term funding solution. But CMS said Friday it could only guarantee that the appropriation will be enough to fund all states through Jan. 19.

CMS said the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19th based upon best estimates of state expenditures to date,” said CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate, send letters to families, and re-program their eligibility systems,” said Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act's Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official said Friday. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, said Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he said. “Congress must get this finalized before Jan. 19.”

An Opioid Remedy That Works: Treat Pain And Addiction At The Same Time

KFF Health News, January 8, 2018

The program is designed to educate high-risk opioid patients about pain management.

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

By John Daley, Colorado Public Radio

Seven years ago, Robert Kerley, who makes his living as a truck driver, was loading drywall when a gust of wind knocked him off the trailer. Kerley fell 14 feet and hurt his back.

For pain, a series of doctors prescribed him a variety of opioids: Vicodin, Percocet and OxyContin.

In less than a year, the 45-year-old from Federal Heights, Colo., said he was hooked. "I spent most of my time high, laying on the couch, not doing nothing, falling asleep everywhere," he said.

Kerley lost weight. He lost his job. His relationships with his wife and kids suffered. He remembers when he hit rock bottom: One night hanging out in a friend's basement, he drank three beers, and the alcohol reacted with an opioid.

"I was taking so much morphine that I [experienced] respiratory arrest," Kerley said. "I stopped breathing."

An ambulance arrived, and EMTs administered the overdose reversal drug naloxone. Kerley was later hospitalized. As the father of a 12-year-old boy, he knew he needed to turn things around. That's when he signed up for Kaiser Permanente's integrated pain service. (Kaiser Health News is not affiliated with Kaiser Permanente.)

"After seven years of being on narcotics and in a spiral downhill, the only thing that pulled me out of it was going to this class," he said. "The only thing that pulled me out of it was doing and working the program that they ask you to work."

The program he refers to is an eight-week course, available to Kaiser Permanente members in Colorado for $100. It's designed to educate high-risk opioid patients about pain management. A recent class met at Kaiser's Rock Creek medical offices in Lafayette, Colo., a town east of Boulder. Will Gersch, a clinical pharmacy specialist, taught several patients learning to battle addiction the science behind prescription drugs.

"So, basically the overarching message here is the higher the dose of the opioids, the higher the risk," he told the group, as he jotted numbers on a whiteboard. "If you're over these two doses, that's a risk factor."

Amanda Bye, a clinical psychologist, works as part of an integrated medical team to treat people with chronic pain. (John Daley/Colorado Public Radio)

Upstairs, Gersch's colleague Amanda Bye, a clinical psychologist, highlighted a key element of the program: It's integrated. For patient care, there's a doctor, a clinical pharmacist, two mental health therapists, a physical therapist and a nurse — all on one floor. Patients can meet with this team, either all at once or in groups, but they do not have to deal with a series of referrals and appointments in different facilities. A spokesperson for Kaiser Permanente said researchers tracked more than 80 patients over the course of a year and found the group's emergency room visits decreased 25 percent. Inpatient admissions dropped 40 percent, and patients' opioid use went way down.

"We brought in all these specialists. We all know the up-to-date research of what's most effective in helping to manage pain," Bye said. "And that's how the program got started."

Bye said the team helps patients use alternatives like exercise, meditation, acupuncture and mindfulness. Some patients, though, do need to go to the chemical dependency unit for medication-assisted treatment for their opioid addiction. Benjamin Miller is an expert on integrated care with the national foundation Well Being Trust. Kaiser is on the right track, he said.

"The future of health care is integrated and, unfortunately, our history is very fragmented, and we're just now catching up to developing a system of care that meets the needs of people," he said.

Similar projects in California showed a reduction in the number of prescriptions and pills per patient, said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation. Her group released case studies of three programs similar to Kaiser's Colorado program. (Kaiser Health News produces California Healthline, an editorially independent publication of the California Health Care Foundation.)

"We've seen great success with these models that are integrating complementary therapy, physical therapy, behavioral health and medical care," Pfeifer said. A key strategy is to gradually decrease the amount of opioids a patient takes, rather than cut them off before they're ready. "It works so much better when the patients have access to these complementary therapies," she said. "And it works even better when those complementary therapies are part of an integrated team."

But it can be difficult to implement universally. One challenge is scale: Big systems like Kaiser Permanente have ample resources and enough patients to make the effort work. Another issue is payment. Some insurers won't pay for some alternative treatments; others have separate payment streams for different kinds of care.

"Frequently, behavioral health and medical health are paid for by entirely different systems," Pfeifer said.

Robert Kerley is recovering from an opioid addiction with help from Kaiser Permanente's pain management program in Colorado. (John Daley/Colorado Public Radio)

The need for programs like Kaiser's is urgent. In 2016, a record 912 people died from an overdose in Colorado, according to data recently released by the state health department. Of those, 300 people died from an opioid overdose. Opioid use often leads to an addiction to heroin, which claimed another 228 lives last year in the state. Those two causes together now rival the number of deaths from car accidents in the state.

Colorado faces a severe shortage of treatment options. Making matters worse, the state's largest substance abuse treatment provider, Arapahoe House, decided to close as of Jan. 2.

Kaiser's integrated pain service has given some patients a second chance.

Robert Kerley, now a veteran of the program, recently shared his story with other patients. "I got my life back. I can sleep. I can eat. I can enjoy things," Kerley told them.

To cope with pain, Kerley starts his morning with stretching and a version of tai chi that he calls "my chi." He practices deep breathing. His advice to others suffering from pain or addiction?

"Do whatever it takes to walk away from it, like no matter what," Kerley said. "Trust me, it gets better. It gets 100 percent better than where you're at right now."

Better for Kerley means his relationships with his family have improved. And he's back at work, once again able to make a living as a truck driver.

From Retirement To The Front Lines Of Hepatitis C Treatment

KFF Health News, January 5, 2018

Advancements in treatment options brought one doctor back to clinical care.

This article first appeared January 05, 2018 on Kaiser Health News.

By Julio Ochoa, WUSF

When a hepatitis C treatment called Harvoni was released in 2014, Dr. Ronald Cirillo knew it was a big deal.

"It"s the reason that dragged me out of retirement!" he said.

Cirillo specialized in treating hepatitis C for more than 30 years in Stamford, Conn., before retiring to Bradenton, Fla. During his time in Connecticut, the only available treatment for hepatitis C had terrible side effects and didn"t work well. It cured the viral infection less than half the time. But the newer drugs, Harvoni and Sovaldi, cure almost everybody, with few adverse reactions.

"In my lifetime, I"ve seen it change from a horrible treatment to a manageable treatment," Cirillo says.

His mission is finding the patients.

"The disease is out there," he said. "My job is to get the disease in here, so we can follow them and treat them."

Last year, Cirillo joined the Turning Points free clinic in Bradenton, about an hour south of Tampa. The clinic primarily serves uninsured Floridians who fall into what many call a coverage gap in states like Florida that chose not to expand Medicaid. These are people who make less than about $12,000 a year.

Cirillo is trying to test every high-risk patient he encounters. On a recent weekday in the clinic, his assistant pricked a patient"s finger, and squeezed blood onto the end of a small plastic tube.

"And this little measuring tool goes into the blood and solution mix there," Cirillo said. "We are going to time it — 20 minutes and that"s it. That"s the test."

Nearly 30,000 people in Florida were found to have hepatitis C in 2016. It"s likely that many more are infected, because the virus can lie dormant for decades.

Cirillo spearheaded a partnership with Harvoni"s maker, Gilead Sciences, and that partnership has provided treatment to about 100 patients.

"We treat people without any insurance, that have no hope," Cirillo said."If you qualify to be a patient here, you"ll get tested."

A 57-year-old patient named Patricia discovered she had hepatitis C a few months ago during a trip to the clinic. NPR and Kaiser Health News are not using her last name because the virus is sometimes associated with illegal IV drug use. It can also spread via sex. Patricia said she"s not sure how she got it.

"So, just because of my age, I guess, they went ahead and tested me for it and it blew my mind that I actually had hep C," she said. "And the levels ended up being relatively high."

The virus had started to scar and inflame her liver. But she lacked insurance and a job; the $94,000 Harvoni treatment would have been out of reach if she hadn"t had financial help from the drugmaker.

"I would never have been able to afford that treatment," she said. "Never."

Staff at the clinic help patients fill out the complicated application from Gilead. Only patients who don"t have insurance, have been drug-free for at least six months and who meet income requirements are eligible.

Patricia was able to get the treatment — one pill a day for 12 weeks — and will be tested again in three months to determine whether she is free of hepatitis C.

"Had they not discovered it and gotten me onto the program — really, who knows?" she said.

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