As opioids become harder to get, police said, more people have turned to meth, which is inexpensive and readily available. Hospitalizations and deaths have surged.
The number of people hospitalized because of amphetamine use is skyrocketing in the United States, but the resurgence of the drug largely has been overshadowed by the nation's intense focus on opioids.
Amphetamine-related hospitalizations jumped by about 245 percent from 2008 to 2015, according to a recent study in the Journal of the American Medical Association. That dwarfs the rise in hospitalizations from other drugs, such as opioids, which were up by about 46 percent. The most significant increases were in Western states.
The surge in hospitalizations and deaths due to amphetamines "is just totally off the radar," said Jane Maxwell, an addiction researcher. "Nobody is paying attention."
Doctors see evidence of the drug's comeback in emergency departments, where patients arrive agitated, paranoid and aggressive. Paramedics and police officers see it on the streets, where suspects' heart rates are so high that they need to be taken to the hospital for medical clearance before being booked into jail. And medical examiners see it in the morgue, where in a few states, such as Texas and Colorado, overdoses from meth have surpassed those from the opioid heroin.
Amphetamines are stimulant drugs, which are both legally prescribed to treat attention deficit hyperactivity disorder and produced illegally into methamphetamine. Most of the hospitalizations in the study are believed to be due to methamphetamine use.
Commonly known as crystal meth, methamphetamine was popular in the 1990s before laws made it more difficult to access the pseudoephedrine, a common cold medicine, needed to produce it. In recent years, law enforcement officials said, there are fewer domestic meth labs and more meth is smuggled in from south of the border.
As opioids become harder to get, police said, more people have turned to meth, which is inexpensive and readily available.
Lupita Ruiz, 25, started using methamphetamine in her late teens but said she has been clean for about two years. When she was using, she said, her heart beat fast, she would stay up all night and she would forget to eat.
Ruiz, who lives in Spokane, Wash., said she was taken to the hospital twice after having mental breakdowns related to methamphetamine use, including a monthlong stay in the psychiatric ward in 2016. One time, Ruiz said, she yelled at and kicked police officers after they responded to a call to her apartment. Another time, she started walking on the freeway but doesn't remember why.
"It just made me go crazy," she said. "I was all messed up in my head."
The federal government estimates that more than 10,000 people died of meth-related drug overdoses last year. Deaths from meth overdose generally result from multiple organ failure or heart attacks and strokes, caused by extraordinary pulse rates and skyrocketing blood pressure.
In California, the number of amphetamine-related overdose deaths rose by 127 percent from 456 in 2008 to 1,036 in 2013. At the same time, the number of opioid-related overdose deaths rose by 8.4 percent from 1,784 to 1,934, according to the most recent data from the state Department of Public Health.
"It taxes your first responders, your emergency rooms, your coroners," said Robert Pennal, a retired supervisor with the California Department of Justice. "It's an incredible burden on the health system."
Costs also are rising. The JAMA study, based on hospital discharge data, found that the cost of amphetamine-related hospitalizations had jumped from $436 million in 2003 to nearly $2.2 billion by 2015. Medicaid was the primary payer.
"There is not a day that goes by that I don't see someone acutely intoxicated on methamphetamine," said Dr. Tarak Trivedi, an emergency room physician in Los Angeles and Santa Clara counties. "It's a huge problem, and it is 100 percent spilling over into the emergency room."
Trivedi said many psychiatric patients are also meth users. Some act so dangerously that they require sedation or restraints. He also sees people who have been using the drug for a long time and are dealing with the downstream consequences.
In the short term, the drug can cause a rapid heart rate and dangerously high blood pressure. In the long term, it can cause anxiety, dental problems and weight loss.
"You see people as young as their 30s with congestive heart failure as if they were in their 70s," he said.
Jon Lopey, the sheriff-coroner of Siskiyou County in rural Northern California, said his officers frequently encounter meth users who are prone to violence and in the midst of what appear to be psychotic episodes. Many are emaciated and have missing teeth, dilated pupils and a tendency to pick at their skin because of a sensation of something beneath it.
"Meth is very, very destructive," said Lopey, who also sits on the executive board of the California Peace Officers Association. "It is just so debilitating the way it ruins lives and health."
Nationwide, amphetamine-related hospitalizations were primarily due to mental health or cardiovascular complications of the drug use, the JAMA study found. About half of the amphetamine hospitalizations also involved at least one other drug.
Because there has been so much attention on opioids, "we have not been properly keeping tabs on other substance use trends as robustly as we should," said study author Dr. Tyler Winkelman, a physician at Hennepin Healthcare in Minneapolis.
Sometimes doctors have trouble distinguishing symptoms of methamphetamine intoxication and underlying mental health conditions, said Dr. Erik Anderson, an emergency room physician at Highland Hospital in Oakland, Calif. Patients also may be homeless and using other drugs alongside the methamphetamine.
Unlike opioid addiction, meth addiction cannot be treated with medication. Rather, people addicted to the drug rely on counseling through outpatient and residential treatment centers.
The opioid epidemic, which resulted in about 49,000 overdose deaths last year, recently prompted bipartisan federal legislation to improve access to recovery, expand coverage to treatment and combat drugs coming across the border.
There hasn't been a similar recent legislative focus on methamphetamine or other drugs. And there simply aren't enough resources devoted to amphetamine addiction to reduce the hospitalizations and deaths, said Maxwell, a researcher at the Addiction Research Institute at the University of Texas at Austin. The number of residential treatment facilities, for example, has continued to decline, she said.
"We have really undercut treatment for methamphetamine," Maxwell said. "Meth has been completely overshadowed by opioids."
When Republicans failed to kill the health law last year, they inadvertently may have made it stronger. Insurers banked hefty profits this year, and new companies are moving in.
In recent years, places such as Memphis and Phoenix had withered into health insurance wastelands as insurers fled and premiums skyrocketed in the insurance marketplaces set up by the Affordable Care Act. But today, as in many parts of the country, these two cities are experiencing something unprecedented: Premiums are sinking and choices are sprouting.
In the newly competitive market in Memphis, the cheapest midlevel "silver" plan for next year will cost $498 a month for a 40-year-old, a 17 percent decrease. Four insurers are selling policies in Phoenix, which then-presidential candidate Donald Trump highlighted in 2016 as proof of "the madness of Obamacare" as all but one insurer left the region.
Janice Johnson, a 63-year-old retiree in Arizona's Maricopa County, which includes Phoenix, said her premium for a high-deductible bronze plan will be $207 instead of $270 because she is switching carriers.
"When you're on a fixed income, that makes a difference," said Johnson, who receives a government subsidy to help cover her premium. "I'll know more than a year from now if I'm going to stick with this company, but I'm going to give them a chance, and I'm pretty excited by that."
Across all 50 states, premiums for the average "benchmark" silver plan, which the government uses to set subsidies, are dropping nearly 1 percent. And more than half of the counties that use the federal healthcare.gov exchange are experiencing an average 10 percent price decrease for their cheapest plan.
In most places, the declines are not enough to erase the price hikes that have accrued since the creation in 2014 of the health care exchanges for people who don't get insurance through an employer or the government.
Instead, experts said, next year's price cuts help to correct the huge increases that jittery insurers set for 2018 plans to protect themselves from anticipated Republican assaults on the markets. Although Congress came up one vote shy of repealing the law, Trump and Republicans in Congress did strip away structural underpinnings that pushed customers to buy plans and helped insurers pay for some of their low-income customers' copayments and deductibles. Insurers responded with 32 percent average increases.
"Insurers overshot last year," said Chris Sloan, a director at Avalere, a health care consulting company in Washington, D.C. "We are nowhere close to erasing that increase. This is still a really expensive market with poor benefits when it comes to deductibles and cost."
For 2019, the average benchmark silver premium will be 75 percent higher than it was in 2014, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
When Republicans failed to kill the health law last year, they inadvertently may have made it stronger. Insurers banked hefty profits this year, and new companies are moving in.
All these factors were especially influential in Tennessee, where the average benchmark premium is dropping 26 percent, according to a government analysis. That is more than in any other state.
In 2018, 78 of 95 Tennessee counties had just one insurer. That monopoly allowed the insurer to set the prices of its plans without fear of competition, said David Anderson, a researcher at the Duke-Margolis Center for Health Policy in Durham, N.C. "They were massively overpriced," he said.
But for the coming year, 49 Tennessee counties will have more than one insurer, with a few — like Shelby County, where Memphis is located — having four companies competing. There, Cigna dropped the price of its lowest-cost silver plan by 15 percent. Nonetheless, it was underbid by Ambetter of Tennessee, which is owned by the managed-care insurer Centene Corp.
"We're finally at the point where the market is stabilized," said Bobby Huffaker, the CEO of American Exchange, an insurance brokerage firm based in Tennessee. "From the beginning, every underwriter, and the people who were the architects, they knew it would take several years for the market to mature."
Still, the cheapest Memphis silver premium is nearly three times what it was in 2014, the first year of the marketplaces. A family of four with 40-year-old parents will be paying $19,119 for all of next year unless they qualify for a government subsidy.
"The unsubsidized are leaving," said Sabrina Corlette, a professor at Georgetown University's Health Policy Institute. "They are finding these premiums unaffordable."
The landscape in Phoenix is greatly improved from when Trump visited after the federal government announced a 116 percent premium increase for 2017, as the number of insurers dropped from eight to one.
But now, three new insurers are entering Maricopa County. Ambetter, the only insurer this year, dropped its lowest price for a silver plan for next year by 12 percent and still offers the cheapest such plan.
Ambetter's plan is still 114 percent above the least expensive silver plan in the first year of the exchanges. And none of the insurers are offering as broad and flexible a choice of doctors and hospitals as consumers had back then, said Michael Malasnik, a local broker.
Since the start of the exchanges, he said, insurers have "raised their rates by multiples, and they've figured out you have to be a very narrow network."
Each plan for 2019 contains trade-offs. He said only Bright Health's plan includes Phoenix Children's Hospital. Ambetter's plan includes the most popular hospital and doctor groups, but they are not as conveniently located for people living in the southeastern corner of the county, making other insurers' plans appealing.
"Geography is the name of the game this year," Malasnik said.
Theresa Flood, a preschool teacher who lives outside Phoenix, said none of the plans she considered accepted her doctors, who include a specialist for her spine problems — she has had four surgeries — and a neurologist who monitors a cyst and benign tumor in her brain.
"I have to establish care with a whole new spine doctor and establish care with a whole new neurologist if I want to follow up on these things," Flood, 59, said. "You're going from established care to who in the heck am I going to see?"
The plan she chose would have been too expensive except that she and her husband, John, a pastor, qualified for a $1,263-a-month subsidy that will drop the cost to $207 a month. That bronze plan from Ambetter carries a $6,550-per-person deductible, so she expects she'll still have to pay for her doctors on her own unless she needs extensive medical attention.
"It's gone from being able to have a plan that you could sort of afford and got some benefit from, to putting up with what you can afford and hoping nothing happens that you actually have to use your insurance," she said. "At this point, I'll take what I can get."
The plans can exclude people with preexisting conditions such as cancer or asthma and often don't cover the "essential benefits" required under the health law, including maternity care, prescription drugs or substance abuse treatment.
Supporters of the nation's health law condemn them. A few states, including California and New York, have banned them. Other states limit them.
But to some insurance brokers and consumers, short-term insurance plans are an enticing, low-cost alternative for healthy people.
Now, with new federal rules allowing short-term plans that last up to three years, agents said, some consumers are opting for these more risky policies. Adding to the appeal is the elimination of a federal tax penalty for those without comprehensive insurance, effective next year. Short-term health plans often exclude people with preexisting conditions and do not cover services mandated by the Affordable Care Act.
Colorado resident Gene Ferry, 66, purchased a short-term health plan this month for his wife, Stephanie, who will become eligible for Medicare when she turns 65 in August. The difference in the monthly premium price for her new, cheaper plan through LifeShield National Insurance Co. and the policy he had through the ACA is $650.
"That's a no-brainer," said Ferry, who considers the ACA "atrocious" and supports President Donald Trump's efforts to lower costs. "I was paying $1,000 a month and I got tired of it."
He signed up his wife for a three-month plan and said that if she is still healthy in January, he will purchase another one to last six months. But Ferry, who is covered under Medicare, said if something happens to her before open enrollment ends — which in Colorado is in January — he would buy a policy through the exchange.
There's a lot of "political jockeying" over the value of short-term plans, said Dan Walterman, owner of Premier Health Insurance of Iowa, which offers such policies. "I think people can make their own choices."
Walterman, 42, said he chose a short-term policy for himself, his wife and their 3-year-old daughter — at a sixth of the price of more comprehensive insurance. "The plan isn't for everybody, but it works for me," he said, adding that he gets accident coverage but doesn't need such things as maternity care or prescriptions.
Essentially, short-term plans cost less because they cover less.
Some plans have exclusions that could blindside consumers, such as not covering hospitalizations that occur on a Friday or Saturday or any injuries from sports or exercise, said Claire McAndrew, director of campaigns and partnership for Families USA, a consumer advocacy group.
"People may see a low premium on a short-term plan and think that it is a good option," she said. "But when people actually go to use a short-term plan, it will not actually pay for many — or any — of their medical expenses."
The plans can exclude people with preexisting conditions such as cancer or asthma and often don't cover the "essential benefits" required under the health law, including maternity care, prescription drugs or substance abuse treatment. They also can have ceilings on what they will pay for any type of care. Insurers offering such plans can choose to cover — or not cover — what they want.
"Democrats are condemning them as 'junk plans,' but the adequacy of the health plan is in the eye of the beholder," said Michael Cannon, director of health policy studies for the libertarian Cato Institute. "The only junk insurance is a plan that doesn't pay as it was promised."
The plans originally were designed to fill brief gaps in insurance coverage for people in the individual market. When the ACA went into effect, the Obama administration limited short-term plans to three months, but the Trump administration this year expanded that to 364 days, with possible extensions of up to three years. Critics fear healthy people may abandon the ACA-compliant market to buy cheaper short-term plans, leaving sicker people in the insurers' risk pool, which raises premiums for those customers.
But some agents said the policies may be good for healthy people as they transition between jobs, near Medicare eligibility or go to college — despite significant limitations.
"It's hard to encourage those types of people to spend hundreds of dollars extra on a health insurance plan that they are rarely using," said Cody Michael, director of client and broker services for Independent Health Agents in Chicago.
Michael said agents also get a higher commission on the plans, providing them with more of an incentive to sell them. But he advises clients that if they do have a chronic illness, they may face denials for coverage. "This is old-world insurance," he said. "You basically have to be in perfect health."
Dania Palanker, assistant research professor at Georgetown University's Center on Health Insurance Reforms, said preexisting conditions aren't always well understood — or well explained. A person might discover too late that, for example, they aren't covered if they have a stroke because an old blood test showed they had high cholesterol.
But Ryan Ellis, a 40-year-old lobbyist and tax preparer in Alexandria, Va., who is considering a short-term plan for himself, his wife and his three children, said his decision will be made "very deliberately, with my eyes wide open knowing the advantages and disadvantages."
Some agents said they offer the short-term plan as a last resort — only after warning clients that if they have an accident or get sick, they might not be able to renew their plan. That means they could be stuck without insurance while waiting for the next open-enrollment period.
"They could really be in a world of hurt," said Colorado insurance agent Eric Smith. "This is just a ticking time bomb."
Roger Abel, of Marion, Iowa, said he's willing to take the risk. He has a short-term plan for his 2-year-old daughter. Abel said he pays about $90 a month for her, compared with more than $450 that he would have paid for comprehensive coverage. He and his wife have a separate policy from before the Affordable Care Act took effect.
But Abel, who is an investment adviser, has a backup option. He said he could always start a group health plan under his company that would provide his daughter with more coverage.
Neena Moorjani, 45, said she wanted to buy a short-term plan but can't because she lives in California, where they were prohibited under a law signed by Democratic Gov. Jerry Brown this year. Moorjani, a tax preparer in Sacramento, said she rarely gets sick and doesn't need an ACA plan.
She decided on religious-based health coverage known as a Christian ministry plan. These cost-sharing programs use members' fees to pay for others' medical bills. Such programs are not regulated by government agencies and may not cover preexisting conditions or preventive care.
When California banned short-term plans, "I was really, really upset," Moorjani said. "I wish I had the freedom to choose what health care insurance is appropriate for me."
Some institutions use ads to build national and international brands on niche but high-priced health services. They could lure wealthy patients seeking high-end care and give hospitals some leverage with insurers.
The scene is shadowy, and the background music foreboding. On the TV screen, a stream of beleaguered humans stand in an unending line.
"If you're waiting patiently for a liver transplant, it could cost you your life," warns the narrator.
One man pulls another out of the queue, signaling an escape. Both smile.
Is this a dystopian video game? Gritty drama? Neither. It is a commercial for the living-donor liver transplant center at the University of Pittsburgh Medical Center, an academic hospital embroiled in a high-profile battle with the region's dominant health plan and now making a play to a national audience.
Hospitals are using TV spots like this one to attract lucrative patients into their hospitals as health care costs and industry competition escalate. Some institutions use them to build national and international brands on niche but high-priced health services. They're often procedures involving expensive technology that benefit only a sliver of the population. But they could lure wealthy patients seeking high-end care and can also give hospitals some leverage with insurers.
"Hospitals are competing, just like any other business," said Mark Fratrik, an economist at BIA Advisory Services, a media consulting firm.
UPMC's ad has been airing nationally this year during cable news shows. Advertising research company iSpot.tv estimates the campaign's cost at more than $3 million since it first aired in early September. The commercial is aimed at the estimated 14,000 people on the United States liver transplant list, hospital officials said.
But some analysts worry that these hospital advertisements are incomplete or misleading.
"We have choices about where we seek medical care," said Yael Schenker, a palliative care doctor at UPMC, who has researched hospital advertising but was not involved with the liver transplant ad. "We want to spend our money wisely, and need information about the quality and cost of health care services. Health care advertising — which purports to offer that information and fill that need for consumers — really doesn't."
Last year, hospitals nationwide spent more than $450 million on advertising overall, according to figures from Kantar Media, a firm that monitors ad spending. That comes on the heels of a surge between 2011 and 2015, during which time hospitals and health systems upped their ad spending by 41 percent, according to figures published by Advertising Age, which tracks marketing trends. By 2015, hospital ad spending accounted for close to a quarter of all health care-related advertising, according to the Advertising Age report.
The UPMC ad is just one flavor. New York City's Hospital for Special Surgery, an orthopedic hospital, launched its own national campaign this year — a minute-long spot featuring jaunty electronic music and people of all ages dancing, jogging and doing yoga and gymnastics. "How you move," the text asserts, "is why we're here."
John Englehart, the hospital's chief marketing officer, said the campaign is meant to introduce potential patients to HSS from around the country, but he said it should be viewed with other informational materials, such as independent rankings. He wouldn't comment on how much the hospital has spent on its ad, though iSpot places its value at about $325,000.
A nationally broadcast ad for Yale New Haven Hospital, in Connecticut, shows a cancer survivor at a bicycle race telling viewers the hospital "did give me my life back." That spot had a far shorter campaign life, and iSpot estimates its value around $11,000. The hospital did not provide comment, despite multiple requests.
Until now, hospital-to-patient marketing has stayed out of the spotlight, as politicians are focused on high drug costs and warn they will crack down on advertising by the pharmaceutical industry. (Pharma ads make up the bulk of paid health care marketing, though hospitals constitute the majority of health care spending.)
Unlike prescription drugs, whose commercials require special approval from the federal Food and Drug Administration, ads for hospitals and health systems are regulated by the Federal Trade Commission, which oversees the marketing of consumer goods.
Or as Schenker put it, "We're treating them the same way we treat ads for cars and cereal." But when it comes to health care versus other commodities, "it's not as easy to figure out if we've made a good choice," she said.
Direct marketing from hospitals and health care centers is by no means a new phenomenon. Billboards and TV ads for spinal surgery and cancer treatments date back years.
But "there's more money in hospitals' coffers these days to [market services] more. And why not?" said Robert Berenson, a health care expert at the Urban Institute, a think tank in Washington, D.C.
An ad like UPMC's highlighting its live-donor liver transplant program signals prestige.
It caters to patients from around the country and even abroad who are often wealthier, or out-of-network, or covered by higher-paying private insurance, noted Paul Ginsburg, a health economist at the University of Southern California. All are more profitable audiences. (UPMC said it has provided live transplants to patients of all stripes, including those covered by Medicaid, which insures low-income people and pays hospitals less.)
Gerard Anderson, a Johns Hopkins health policy professor and expert on health care pricing, said the ad also can communicate to local consumers that, if they sign up with UPMC — as opposed to a competing hospital — they're more likely to get better care.
"You're differentiating yourself from everyone else by saying, 'I can do this very sophisticated thing that no one else can do. Therefore, sign up with me,'" Anderson said.
Or as Berenson put it: "There are not that many people with liver transplants. There's some halo effect. They're trying to get people to recognize the name and go for other services."
But there is no evidence to suggest that excelling in one particular, complex procedure tracks with providing good care overall.
UPMC casts its campaign as an outreach effort meant to inform people who need liver transplants of a potentially lifesaving option. It is not meant to imply anything further, hospital representatives said. "This is truly an awareness educational campaign," said Dean Walters, UPMC's chief marketing officer. He said 14,000 people in the United States need a liver transplant, and that number grows every year. "This is about making sure consumers are aware of this option."
Walters would not disclose how much UPMC has spent on this particular campaign, though he acknowledged the hospital has made a "financial commitment" to promoting this service. According to Kantar, the marketing firm, UPMC spent more than $4 million on advertising in the first six months of 2018.
Englehart said HSS' ad is meant to dispel any illusion that the hospital is catering to wealthy patients only — though he also said their campaign is meant to enhance HSS' reputation both nationally and internationally.
Many health economists suggested the payoff can extend well beyond tapping into the market of potential American or foreign patients. A campaign like this one helps hospitals gain negotiating power in their ongoing struggle with insurers over reimbursement rates.
A hospital that successfully brands itself as excellent or prestigious — even in one procedure or specialty — can leverage that identity when bargaining with insurers.
"They want Hospital A in their network even more, which means Hospital A can extract more from insurers — mainly in the form of higher prices," said Martin Gaynor, a health care economist at Carnegie Mellon University and former head of the FTC's Bureau of Economics.
If patients return to Dr. Crystal Bowe soon after taking medication for a sexually transmitted infection, she usually knows the reason: Their partners have re-infected them.
"While you tell people not to have sex until both folks are treated, they just don't wait," she said. "So they are passing the infection back and forth."
That's when Bowe, who practices on both sides of the North and South Carolina border, does something doctors are often reluctant to do: She prescribes the partners antibiotics without meeting them.
Federal health officials have recommended this practice, known as expedited partner therapy, for chlamydia and gonorrhea since 2006. It allows doctors to prescribe medication to their patients' partners without examining them. The idea is to prevent the kind of reinfections described by Bowe — and stop the transmission of STDs to others.
However, many physicians aren't taking the federal government's advice because of entrenched ethical and legal concerns.
"Health care providers have a long tradition of being hesitant to prescribe to people they haven't seen," said Edward Hook, professor at the University of Alabama's medical school in Birmingham. "There is a certain skepticism."
A nationwide surge of sexually transmitted diseases in recent years, however, has created a sense of urgency for doctors to embrace the practice. STD rates have hit an all-time high, according to the Centers for Diseases Control and Prevention. In 2017, the rate of reported gonorrhea cases increased nearly 19 percent from a year earlier to 555,608. The rate of chlamydia cases rose almost 7 percent to 1.7 million.
"STDs are everywhere," said Dr. Cornelius Jamison, a lecturer at the University of Michigan Medical School. "We have to figure out how to … prevent the spread of these infections. And it's necessary to be able to treat multiple people at once."
A majority of states allow expedited partner therapy. Two states — South Carolina and Kentucky — prohibit it, and six others plus Puerto Rico lack clear guidance for physicians.
A 2014 study showed that patients were as much as 29 percent less likely to be re-infected when their physicians prescribed medication to their partners. The study also showed that partners who got those prescriptions were more likely to take the drugs than ones who were simply referred to a doctor.
Yet only about half of providers reported ever having prescribed drugs to the partners of patients with chlamydia, and only 10 percent said they always did so, according to a different study. Chlamydia rates were higher in states with no law explicitly allowing partner prescriptions, research published earlier this year showed.
Because of increasing antibiotic resistance to gonorrhea, the CDC no longer recommends oral antibiotics alone for the infection. But if patients' partners can't go in for the recommended treatment, which includes an injection, the CDC said that oral antibiotics by themselves are better than no treatment at all.
"Increasing resistance plus increasing disease rates is a recipe for disaster," said David Harvey, executive director of the National Coalition of STD Directors. The partner treatment is important for "combating the rising rates of gonorrhea in the U.S. before it's too late."
The CDC recommendations are primarily for heterosexual partners because there is less data on the effectiveness of partner treatment in men who sleep with men, and because of concern about HIV risk.
Bowe said that even though she writes STD prescriptions for her patients' partners, she still worries about possible drug allergies or side effects.
"I don't know their medical conditions," she said. "I may contribute to a problem down the road that I'm going to be held liable for."
In many cases, doctors and patients simply do not know about partner therapy. Ulysses Rico, who lives in Coachella, Calif., said he contracted gonorrhea several years ago and was treated by his doctor. He didn't know at the time that he could have requested medicine for his girlfriend. She was reluctant to go to her doctor and instead got the required antibiotics through a friend who worked at a hospital.
"It would have been so much easier to handle the situation for both of us at the [same] moment," Rico said.
Several medical associations support partner treatment. But they acknowledge the ethical issues, saying it should be used only if the partners are unable or unwilling to come in for care.
Federal officials are trying to raise awareness of the practice by training doctors and other medical professionals, said Laura Bachmann, chief medical officer of the CDC's office of STD prevention. The agency posts a map with details about the practice in each state.
Over the past several years, advocates have won battles state-by-state to get partner treatment approved, but implementation is challenging and varies widely, said Harvey, whose National Coalition of STD Directors is a member organization that works to eliminate sexually transmitted diseases.
The fact that some states don't allow it, or haven't set clear guidelines for physicians, also creates confusion — and disparities across state lines.
The Planned Parenthood affiliate that serves Indiana and Kentucky sees this firsthand, said clinical services director Emilie Theis. In Indiana, providers can legally write prescriptions for their patients' partners, but they are prohibited from doing so in Kentucky, even though the clinics are only a short drive apart, she noted. A similar dynamic is at play along the South Carolina-North Carolina border, where Bowe practices.
California started allowing partner treatment for chlamydia in 2001 and for gonorrhea in 2007. The state gives medication to certain safety-net clinics, a program it expanded three years ago. However, "it has been an incredibly difficult sell" because many medical providers think "it's a little bit outside of the traditional practice of medicine," said Heidi Bauer, chief of the STD control branch of California's public health department.
At APLA Health, which runs several health clinics in the Los Angeles area, nurse practitioner Karla Taborga occasionally gives antibiotics to patients for their partners. But she tries to get the partners into the clinic first, because she worries they might also be at risk for other sexually transmitted infections.
"If we are just treating for chlamydia, we could be missing gonorrhea, syphilis or, God forbid, HIV," Taborga said. But if prescribing the drugs without seeing the patients is the only way to treat them, she said, "it's better than nothing."
Edith Torres, a Los Angeles resident, said she pressured her then-husband to go to the doctor after he gave her chlamydia several years ago: She refused to have sex with him until he did. Torres said she wanted him to hear directly from the doctor about the risks of STDs and how they are transmitted.
If he had taken the medication without a doctor visit, he wouldn't have learned those things, she said. "I was scared, and I didn't want to get it again."
A ballot initiative that would have continued funding Montana's Medicaid expansion beyond June 2019 has failed. But advocates say they'll continue to push for money to keep the expansion going after that financial sunset.
A ballot initiative that would have continued funding Montana's Medicaid expansion beyond June 2019 has failed. But advocates say they'll continue to push for money to keep the expansion going after that financial sunset.
"We now turn our attention to the legislature to maintain Montana's bipartisan Medicaid expansion and protect those enrolled from harmful restrictions that would take away health insurance coverage," said a concession statement Wednesday from Chris Laslovich, campaign manager with the advocacy group Healthy Montana, which supported the measure.
Most of the money in favor of I-185 came from the Montana Hospital Association. "I'm definitely disappointed that big money can have such an outsized influence on our political process," said Dr. Jason Cohen, chief medical officer of North Valley Hospital in Whitefish.
The ballot measure would have tacked an additional $2-per-pack tax on cigarettes. It would have also taxed other tobacco products, as well as electronic cigarettes, which aren't currently taxed in Montana.
Part of the expected $74 million in additional tax revenue would have funded continuation of Medicaid expansion in Montana.
Unless state lawmakers vote to continue funding the Medicaid expansion, it's set to expire in June 2019. If that happens, Montana would become the first state to undo a Medicaid expansion made under the Affordable Care Act.
In September, Gov. Steve Bullock, a Democrat, told the Montana Association of Counties that if the Medicaid initiative failed, "we're going to be in for a tough [2019 legislative] session. Because if you thought cuts from last special session were difficult, I think you should brace, unfortunately, for even more."
Republican State Rep. Nancy Ballance, who opposed I-185, disagrees with Bullock's position. "I think one of the mistakes that was made continually with I-185 was the belief that there were only two options: If it failed, Medicaid expansion would go away; if it passed, Medicaid expansion would continue forever as it was."
Ballance, who didn't receive money to campaign against the initiative, said Medicaid expansion in Montana can be tweaked without resorting to a sweeping new tax on tobacco products.
"No one was willing to talk about a middle-ground solution where Medicaid expansion is adjusted to correct some of the things that we saw as issues or deficiencies in that program," she said. "I think now is the time to roll up our sleeves and come up with a solution that takes both sides into consideration."
Ballance said conservatives in the legislature want recipients of expansion benefits to face a tougher work requirement and means testing, so those with low incomes who also have significant assets like real estate won't qualify.
In any event, Ballance said she suspects that if the initiative had passed, it would have immediately faced a court challenge.
North Valley Hospital's Cohen said he hopes Montana will pass a tobacco tax hike someday. "We all know how devastating tobacco is to our families, our friends and our communities," Cohen said. "And I think we also all know how important having insurance coverage is, and so I think people are dedicated to fighting this battle and winning it."
Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday's election. Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate.
Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday's election.
Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate. Three deep-red states passed ballot measures expanding their programs and two other states elected governors who have said they will accept expansion bills from their legislatures.
Supporters were so excited by the victories they said they will start planning for more voter referendums in 2020.
Medicaid proponents also were celebrating the Democrats' takeover of the House, which would impede any Republican efforts to repeal the ACA and make major cuts to the federal-state health insurance program for low-income people.
"Tuesday was huge for the Medicaid program," said Katherine Howitt, associate director of policy at Community Catalyst, a Boston-based advocacy group. "The overall message is that the electorate does not see this as a Democrat or GOP issue but as an issue of basic fairness, access to care and pocketbook issue. Medicaid is working and is something Americans want to protect."
But health experts caution that GOP opposition won't fade away.
David Jones, an assistant professor in the Department of Health Law, Policy and Management at Boston University, said ballot organizers now have a blueprint on how to expand Medicaid in states that have resisted. "I see this as a turning point in ACA politics," he said. Still, he added‚ "it's not inevitable."
Medicaid is the largest government health program, insuring at least 73 million low-income Americans. Half of them are children. To date, 32 states and the District of Columbia have expanded it under the ACA. Before that law, Medicaid was generally limited to children, sometimes their parents, pregnant women and people with disabilities.
The ACA encouraged states to open the program to all Americans earning up to 138 percent of the poverty level ($16,753 for an individual in 2018). The federal government is paying the bulk of the cost: 94 percent this year, but gradually dropping to 90 percent in 2020. States pay the rest.
GOP opposition has left about 4.2 million low-income Americans without coverage in various states.
"It's not over until it's over is the story of Medicaid expansion and the Affordable Care Act as the politics never ends and the opportunity for obstruction never ends," said Jones. "But the trend overall has been to increasing implementation and increasing coverage."
Montana Fails To Endorse Funding
Two years after President Donald Trump carried Idaho, Nebraska and Utah by double-digit margins with a message that included repeal of the ACA, voters in those states approved the ballot referendums Tuesday. Together, the states have about 300,000 uninsured adults who would be eligible for the program.
In addition, Democrats secured the governor's offices in Kansas and Maine, which will increase the likelihood those states pursue expansion. Legislatures in both states have previously voted to expand, only to have GOP governors block the bills. Maine voters also passed a referendum in 2017 endorsing expansion, but Republican Gov. Paul LePage again refused to accept it.
Current and incoming Republican governors in Utah and Idaho said they wouldn't block implementation of the effort if voters approved it. Nebraska Gov. Pete Ricketts said Wednesday he would follow the will of the voters but would not support paying for it with a tax increase.
It wasn't a clean sweep, however, for Medicaid on Tuesday.
In preliminary results, a ballot issue to fund Montana's Medicaid expansion — which is already in place and slated to expire next July — was failing. Tobacco companies had mounted a campaign to stop the measure, which would have partially financed the expansion with taxes on tobacco products.
The Montana legislature and the Democratic governor are expected to address the issue in the session that starts in January. No state has reversed its Medicaid expansion, even though GOP governors in Kansas and Arkansas have threatened to do so.
Nearly 100,000 Montana residents have received Medicaid since its expansion, twice as many as expected.
Nancy Ballance, the Republican chairwoman of the Montana House Appropriations Committee who opposed the bill that expanded Medicaid in 2015, said she is confident the state legislature will extend the program past July. But she expects the legislature to put some limits on the program, such as adding an asset test and work requirements.
"There are some people in the state who may not have disabilities but need some help to access coverage," she said. "I think we can pass something without people having a gap in coverage. … That will be a priority."
"It was never our intent to simply sunset the expansion and have it go away," she said. Rather, the legislature put the sunset provision in to revisit the provision to make any changes.
Chris Jacobs, a conservative health policy analyst in Washington, D.C., said the Montana results showed that when voters are given a choice of having to pay for Medicaid expansion through a new tax they were not willing to go along.
But in Utah, voters did agree to fund their state plan by adding 0.15 percent to the state's sales tax, just over a penny for a $10 purchase.
Fernando Wilson, acting director of the Center for Health Policy at the University of Nebraska Medical Center, said the vote on the state's ballot question indicated many people wanted to help 80,000 uninsured Nebraskans gain coverage.
"I think it showed there was a clear need for it," he said. The legislature likely won't block the expansion, Wilson said, though it may try to add a conservative twist such as adding premiums or other steps.
Sheila Burke, a lecturer in health policy at Harvard Kennedy School, said voters approved Medicaid expansion not just because it would help improve health coverage for their residents but to help stabilize their hospitals, particularly those in rural areas. Hospitals have said this step helps their bottom lines because it cuts down on uninsured patients and uncompensated care.
"The broad population does see the value of Medicaid," she said. "They saw it as a loss by their states not to accept the federal funds," she said.
Despite the victories, Burke said, advocates should not assume other states such as Florida, Texas and Tennessee will follow suit.
"I don't see a radical shift, but it moves us closer," she said.
'Fertile Ground' For More Referendums
If advocates press for more referendums, Florida might be a tempting target. More than 700,000 adults there could become eligible, but the campaign would likely also be very costly.
Jonathan Schleifer, executive director of The Fairness Project, which financed the ballot initiatives in Maine in 2017 and the four states this year, refused to say which states would be targeted next.
The group is funded by the Service Employees International Union-United Healthcare Workers West, a California health care workers union.
"The GOP has been bashing the ACA for nearly a decade, and voters in the reddest states in the country just rejected that message," Schleifer said. "It's a repudiation and a tectonic shift in health care in this country."
"There is fertile ground" for more such ballot votes, said Topher Spiro, vice president for health policy at Center for American Progress, a liberal think tank. "It is clear that public opinion is on the side of Medicaid expansion and the election results merely confirm that."
"This will build momentum for expansion in other states," he added.
The election results also could have consequences on efforts by states to implement work requirements for Medicaid enrollees.
New Hampshire and Michigan — which expanded the program but recently won federal approval to add controversial work requirements — could revisit that additional mandate as a result of Democrats winning control over both houses of the legislature in New Hampshire and the governor's office in Michigan.
Voters said healthcare, particularly preserving protections for people with preexisting conditions, was their top issue. But healthcare remained more important to Democrats than to Republicans.
Health care proved important but apparently not pivotal in the 2018 midterm elections on Tuesday as voters gave Democrats control of the U.S. House, left Republicans in charge in the Senate and appeared to order an expansion of Medicaid in at least three states long controlled by Republicans.
In taking over the House, Democrats are unlikely to be able to advance many initiatives when it comes to health policy, given the GOP's control of the Senate and White House. But they will be able to deliver an effective veto to Republican efforts to repeal the Affordable Care Act, convert the Medicaid health care system for low-income people into a block grant program and make major changes to Medicare.
One likely development is an expansion of Medicaid in several of the 18 states that had so far not offered coverage made available by the Affordable Care Act. Early returns showed voters in Utah, Nebraska and Idaho easily approving ballot measures calling for expansion.
In Montana, voters are deciding if the existing expansion should be continued and the state's expenses covered by raising tobacco taxes. In preliminary results, opponents outnumbered supporters but key counties were not expected to release their tallies until Wednesday.
Medicaid might also be expanded in Kansas, where Democratic gubernatorial candidate Laura Kelly defeated GOP Secretary of State Kris Kobach. The Kansas legislature had previously passed Medicaid expansion, but it was vetoed in 2017 by former GOP Gov. Sam Brownback. Kobach had not supported the ACA expansion.
And in Maine, where voters approved Medicaid expansion in 2017 but GOP Gov. Paul LePage refused to implement it, Democrat Janet Mills was victorious. She has promised to follow the voters' wishes. LePage was not running.
In exit polling, as in many earlier surveys in 2018, voters said that health care, particularly preserving protections for people with preexisting conditions, was their top issue. But health care remained more important to Democrats than to Republicans.
Those who urged Democrats to emphasize health care this year took credit for the congressional successes. "The race for the House was a referendum on the Republican war on health care. You know it, I know it, and the Republican incumbents who shamefully tried to cover up their real record on health care and lost their seats know it," said Brad Woodhouse of the advocacy group Protect Our Care.
But the issue was not enough to save some of the Senate Democrats in states won by President Donald Trump in 2016. Sen. Claire McCaskill (D-Mo.) was defeated by GOP Attorney General Josh Hawley, who is a plaintiff in a key lawsuit seeking to declare the Affordable Care Act unconstitutional. Sens. Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.), who also campaigned hard on health care, were defeated.
Nonetheless, Sen. Joe Manchin (D-W.Va.) beat Republican Patrick Morrisey, the state's attorney general who is also a plaintiff in the lawsuit seeking to upend the ACA.
Rep. Nancy Pelosi (D-Calif.), the leader of the House Democrats who would be first in line to take over as speaker, told supporters gathered in Washington for a victory celebration that her caucus would make health care a key legislative issue.
"It's about stopping the GOP and [Senate Majority Leader] Mitch McConnell's assault on Medicare, Medicaid and the Affordable Care Act and the health care of 130 million Americans living with preexisting medical conditions," she said. She pledged that Democrats would take "very, very strong legislative action" to lower the cost of prescription drugs.
Among the many new faces in the House is at least one with some significant experience in health policy. Former Health and Human Services Secretary Donna Shalala, who ran the department for all eight years of the Clinton administration, won an open seat in Florida.
The tobacco tax initiative has become the most expensive ballot measure race in Montana history, drawing $17 million in opposition funding from tobacco companies in a state with fewer than 200,000 smokers.
Montana legislators expanded Medicaid by a very close vote in 2015. They passed the measure with an expiration date: It would sunset in 2019, and all who went onto the rolls would lose coverage unless lawmakers voted to reapprove it.
Fearing legislators might not renew funding for Medicaid's expanded rolls, Montana's hospitals and health advocacy groups came up with a ballot measure to keep it going — and to pay for it with a tobacco tax hike.
If ballot initiative I-185 passes Tuesday, it will mean an additional $2-per-pack tax on cigarettes and levy a tax on e-cigarettes, which are currently not taxed in Montana.
The tobacco tax initiative has become the most expensive ballot measure race in Montana history — drawing more than $17 million in opposition funding from tobacco companies alone — in a state with fewer than 200,000 smokers.
Amanda Cahill works for the American Heart Association and is a spokeswoman for Healthy Montana, the coalition backing the measure. She said coalition members knew big tobacco would fight back.
"We poked the bear, that's for sure," Cahill said. "And it's not because we were all around the table saying, 'Hey, we want to have a huge fight and go through trauma the next several months.' It's because it's the right thing to do."
Most of the $17 million has come from cigarette maker Altria. According to records from the National Institute on Money in Politics, that's more money than Altria has spent on any state proposition nationwide since the center started keeping track in 2004.
Meanwhile, backers of I-185 have spent close to $8 million on the initiative, with most of the money coming from the Montana Hospital Association.
"What we want to do is — No. 1 — stop Big Tobacco's hold on Montana," Cahill said. Also, she continued, it's imperative that the nearly 100,000 people in Montana who have gotten Medicaid under the expansion will be able to keep their health care.
Cahill said I-185 will allocate plenty of money to cover the expansion, though some lawmakers say the state can't afford the expansion even with higher taxes.
Nancy Ballance, a Republican representative in the Montana state Legislature, opposes the measure.
"In general I am not in favor of what we like to refer to as 'sin taxes,' " Ballance said. "Those are taxes that someone determines should be [levied] so that you change people's behavior."
Ballance also isn't in favor of ballot initiatives that, she said, try to go around what she sees as core functions of the Legislature: deciding how much revenue the state needs, for example, or where it should come from, or how it should be spent.
"An initiative like this for a very large policy with a very large price tag — the Legislature is responsible for studying that," Ballance said. "And they do so over a long period of time, to understand what all the consequences are — intended and otherwise."
Most citizens, she said, don't have the time or expertise to develop that sort of in-depth understanding of a complicated issue.
Montana's initiative to keep Medicaid's expansion going would be a "double whammy" for tobacco companies, said Ben Miller, the chief strategy officer for the nonprofit Well Being Trust.
"People who are covered are more likely to not smoke than people who are uninsured," said Miller, who has studied tobacco tax policies for years. He notes research showing that people with lower incomes are more likely than those with higher incomes to smoke; and if they're uninsured, they're less likely to quit.
Federal law requires Medicaid to offer beneficiaries access to medical help to quit smoking.
Plus, Miller added, every time cigarette taxes go up — thereby increasing the price per pack — that typically leads to a decrease in the number of people smoking.
And that, he said, works against a tobacco company's business model, "which is, 'you need to smoke so we can make money.' "
Ballance agrees that tobacco companies likely see ballot initiatives like I-185 as threats to their core business. But, she said, "for anybody who wants to continue smoking, or is significantly addicted, the cost is not going to prohibit them from smoking."
MODESTO, Calif. — Betsy Foster and Doug Dillon are devotees of Josh Harder. The Democratic upstart is attempting to topple Republican incumbent Jeff Denham in this conflicted, semi-rural district that is home to conservative agricultural interests, a growing Latino population and liberal San Francisco Bay Area refugees.
To Foster's and Dillon's delight, Harder supports a "Medicare-for-all" health care system that would cover all Americans.
Foster, a 54-year-old campaign volunteer from Berkeley, believes Medicare-for-all is similar to what's offered in Canada, where the government provides health insurance to everybody.
Dillon, a 57-year-old almond farmer from Modesto, says Foster's description sounds like a single-payer system.
"It all means many different things to many different people," Foster said from behind a volunteer table inside the warehouse Harder uses as his campaign headquarters. "It's all so complicated."
Across the country, catchphrases such as "Medicare-for-all," "single-payer," "public option" and "universal health care" are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.
Republicans, including President Donald Trump, describe such proposals as "socialist" schemes that will cost taxpayers too much. They say their party is committed to providing affordable and accessible health insurance, which includes coverage for preexisting conditions, but with less government involvement.
Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as "quick answers without a lot of detail," said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.
"It's quite understandable people don't understand the terms," Anderson added.
For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.
But Sanders' labels are misleading, health experts agree, because Medicare isn't actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.
What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn't participate.
In other words: single-payer, with the federal government at the helm.
Absent federal action, Democratic gubernatorial candidates Gavin Newsom in California, Jay Gonzales in Massachusetts and Andrew Gillum in Florida are pushing for state-run single-payer.
To complicate matters, some Democrats are simply calling for universal coverage, a vague philosophical idea subject to interpretation. Universal health care could mean a single-payer system, Medicare-for-all or building upon what exists today — a combination of public and private programs in which everyone has access to health care.
Others call for a "public option," a government plan open to everyone, including Democratic House candidates Antonio Delgado in New York and Cindy Axne in Iowa. Delgado wants the public option to be Medicare, but Axne proposes Medicare or Medicaid.
Are you confused yet?
Sacramento-area voter Sarah Grace, who describes herself as politically independent, said the dialogue is over her head.
"I was a health care professional for so long, and I don't even know," said Grace, 42, who worked as a paramedic for 16 years and now owns a holistic healing business. "That's telling."
In fact, most voters approached for this article declined to be interviewed, saying they didn't understand the issue. "I just don't know enough," Paul Her of Sacramento said candidly.
"You get all this conflicting information," said Her, 32, a medical instrument technician who was touring the state Capitol with two uncles visiting from Thailand. "Half the time, I'm just confused."
The confusion is all the more striking in a state where the expansion of coverage has dominated the political debate on and off for more than a decade. Although the issue clearly resonates with voters, the details of what might be done about it remain fuzzy.
A late-October poll by the Public Policy Institute of California shows the majority of Californians, nearly 60 percent, believe it is the responsibility of the federal government to make sure all Americans have health coverage. Other state and national surveys reveal that health care is one of the top concerns on voters' minds this midterm election.
Democrats have seized on the issue, pounding GOP incumbents for voting last year to repeal the Affordable Care Act and attempting to water down protections for people with preexisting medical conditions in the process. A Texas lawsuit brought by 18 Republican state attorneys general and two GOP governors could decimate protections for preexisting conditions under the ACA — or kill the law itself.
Republicans say the current health care system is broken, and they have criticized the rising premiums that have hit many Americans under the ACA.
Whether the Democratic focus on health care translates into votes remains to be seen in the party's drive to flip 23 seats to gain control of the House.
The Denham-Harder race is one of the most watched in the country, rated too close to call by most political analysts. Harder has aired blistering ads against Denham for his vote last year against the ACA, and he sought to distinguish himself from the incumbent by calling for Medicare-for-all — an issue he hopes will play well in a district where an estimated 146,000 people would lose coverage if the 2010 health law is overturned.
Yet Harder is not clinging to the Medicare-for-all label and said Democrats may need to talk more broadly about getting everyone health care coverage.
"I think there's a spectrum of options that we can talk about," Harder said. "I think the reality is we've got to keep all options open as we're thinking towards what the next 50 years of American health care should look like."
To some voters, what politicians call their plans is irrelevant. They just want reasonably priced coverage for everyone.
Sitting with his newspaper on the porch of a local coffee shop in Modesto, John Byron said he wants private health insurance companies out of the picture.
The 73-year-old retired grandfather said he has seen too many families struggle with their medical bills and believes a government-run system is the only way.
"I think it's the most effective and affordable," he said.
Linda Wahler of Santa Cruz, who drove to this Central Valley city to knock on doors for the Harder campaign, also thinks the government should play a larger role in providing coverage.
But unlike Byron, Wahler, 68, wants politicians to minimize confusion by better defining their health care pitches.
"I think we could use some more education in what it all means," she said.