KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

A Big Hearing For 'Medicare-For-All' — In A Small Room

KFF Health News, May 1, 2019

The hearing was a swap House Speaker Nancy Pelosi made to left-leaning members of her caucus when she courted them to support her candidacy for speaker.

This article was first published on Tuesday, April 20, 2019 in Kaiser Health News.

By Julie Rovner

The first congressional hearing on a "Medicare-for-all" bill in at least a decade took place Tuesday, but without the usual phalanx of T-shirted supporters — or even the presidential candidates — who have been pushing the bill.

That's because the hearing took place not at one of three major committees that oversee health policy in the House, but in the ornate — and comparatively miniature — hearing room of the House Rules Committee.

That panel's primary role is to set the terms for House floor debates, and its hearing room can seat about 50 people in the audience, compared with hundreds in the larger rooms of the Capitol complex's office buildings. Also, members of the public cannot easily access the room on the third floor of the Capitol as they can the House office buildings across the street.

That arrangement was no accident — the Rules Committee is often called the "Speaker's Committee" because it is so closely aligned with the speaker's goals and is more heavily populated with members of the majority party than the usual committee breakdowns. House Speaker Nancy Pelosi has said repeatedly she does not want to push Medicare-for-all — a plan popular among progressive Democrats to move the country to government health care system — while Republicans control the Senate and the White House.

So, this hearing was the fulfillment of a promise she made to some of the more left-leaning members of her caucus when she courted them to support her candidacy for speaker. Another hearing, this one by the House Budget Committee — also not among the committees that would normally handle major health legislation, is expected to follow soon.

Those usual panels — Ways and Means, Energy and Commerce, and Education and Labor — are busy working on health legislation, including bills to address prescription drug prices and "surprise" medical bills, but not currently on a Medicare-for-all bill.

Rep. Michael Burgess (R-Texas) pointed out that anomaly. "I don't want to say this hearing isn't normal, but normally, health care policy would come … through the authorizing committees," he said in a gibe to the House Democratic leadership. Burgess is also a member of one of those committees: Energy and Commerce.

Pelosi did make a cameo at the Rules hearing, escorting activist Ady Barkan, who has the neurodegenerative disease amyotrophic lateral sclerosis, or ALS, and was the star witness for the proponents of Medicare-for-all. Barkan, an outspoken critic of Republicans' efforts to repeal and replace the Affordable Care Act in 2017, testified Tuesday by computer-generated voice, since his disease has progressed to the point he can no longer speak easily.

Still, despite the unusual venue, backers of universal health care hope the hearing marks the beginning of a journey to a new national health system.

"This is a historic moment," Rules Chairman Jim McGovern (D-Mass.) said, surveying the standing-room-only crowd. "I don't think we can squeeze anyone else in here." McGovern said he is a strong supporter of the Medicare-for-all bill introduced by Reps. Pramila Jayapal (D-Calif.) and Debbie Dingell (D-Mich.), which has more than 100 co-sponsors.

For all the political machinations and sometimes overheated rhetoric about a major overhaul of the U.S. health system, the hearing itself was remarkably unremarkable — with witnesses both for and against the idea of the federal government providing health coverage to all Americans calmly discussing the pros and cons.

"The ugly truth is this: Healthcare is not treated as a human right in the United States of America," Barkan told the committee. "This fact is outrageous. And it is far past time that we change it."

Republicans were also eager to talk about Medicare-for-all — so they could bash it.

"This bill is an extraordinary bill," said Rep. Tom Cole (R-Okla.), the panel's ranking member. "It would completely change America's healthcare system. And not for the better."

And while the most enthusiastic backers of the bill were not in the hearing room, they were not far away.

More than 300 members of the California Nurses Association/National Nurses United, one of the unions that has been pushing Medicare-for-all for years, watched the hearing from an overflow room in the Cannon House Office Building and visited offices to try to gin up support, said co-President Malinda Markowitz.

Markowitz said she was optimistic about the path forward for the measure. "We're going to continue to go to legislators that aren't supporting this and let them know we're not letting them off the hook," she said.

Republicans want the debate to continue in Congress, too. They hope they can stoke fear of a government takeover of health care that will work to their advantage in the next election.

The top Republicans on the House Ways and Means Committee on Tuesday wrote to Chairman Richard Neal (D-Mass.) urging him to schedule a hearing on the bill. "A public accounting of H.R. 1384 is necessary to inform the working families and seniors we represent to the risks of their health coverage under this proposal," said ranking Republican on the full committee, Rep. Kevin Brady (Texas), and the health subcommittee, Rep. Devin Nunes (Calif.).

That is apparently fine with Neal. In a brief interview Tuesday, he said his committee "likely would" hold a hearing in the current Congress. "I think we should have a full-throttle debate" about Medicare-for-all, he said.

Julie Rovner: jrovner@kff.org, @jrovner

Will Ties To A Catholic Hospital System Tie Doctors' Hands?

KFF Health News, April 29, 2019

Dignity Health, like other Catholic chains, is bound by ethical and religious directives from the United States Conference of Catholic Bishops.

This article was first published on Monday, April 29,2019 in Kaiser Health News.

By Jenny Gold

SAN FRANCISCO — As Catholic healthcare systems across the country expand, the University of California's flagship San Francisco hospital has become the latest arena for an emotional debate: Should the famously progressive medical center increase its treatment space by joining forces with a Catholic-run system that restricts care according to religious doctrine?

At issue is a proposal that UCSF Medical Center affiliate with Dignity Health, a massive Catholic healthcare system that, like other Catholic chains, is bound by ethical and religious directives from the United States Conference of Catholic Bishops.

Among other prohibitions on services, Dignity hospitals ban abortions unless the mother's life is at risk, in vitro fertilization and physician-assisted death.

Twenty-four of Dignity's 39 hospitals prohibit contraception services and gender-confirming care for transgender people, such as hormone therapy and surgical procedures.

The affiliation would not keep UCSF from performing such procedures at its own medical center and outpatient clinics, and both entities would remain independent. UC doctors with practicing privileges at Dignity would be free to discuss all treatment options and could refer patients to other facilities when necessary.

But they would have to abide by Dignity's care restrictions while practicing at Dignity hospitals.

For opponents of the plan, the issue boils down to a clear-cut principle: How can a public hospital that has been a leader in women's healthcare and medical services for the gay and transgender community partner with a private system that not only denies such services but also casts them as immoral?

"It feels really concerning to me that our university that has been a fierce advocate for women's health and LGBTQ health would be affiliating with a corporation that doesn't support those values and restricts care," said Dr. Jody Steinauer, who directs UCSF's Bixby Center for Global Reproductive Health.

The two systems already have a relationship among several departments, including neurology, cardiology and adolescent psychology. This new affiliation would formalize the collaboration at Dignity's four Bay Area hospitals and could expand services to departments including cancer care and cardiology, which would be staffed by UCSF physicians.

The proposal has sharply split faculty and medical staff at UCSF, who are airing their differences in impassioned letters and heated public forums. Participants on both sides include national figures renowned in their specialty fields.

Supporters of a closer alliance with Dignity say it's an easy way to add capacity to a public healthcare system that is strapped for bed space and turning away more than 800 patients a year. They also note that Dignity is California's largest private provider for patients with Medi-Cal, the state-federal insurance program for the poor.

"So much healthcare is being delivered in this country by faith-based organizations. For us to not participate with them seems like a missed opportunity," Mark Laret, president and CEO of UCSF Health, told a December meeting of the UC Board of Regents, which must decide the issue.

The agreement could include a new labor and delivery unit based at Dignity's St. Francis Memorial Hospital, which would be staffed by non-UCSF obstetricians. That would let Dignity absorb more patients with low-risk pregnancies, leaving UCSF time and space to deal with more complex cases, said Dr. Dana Gossett, a UCSF obstetrician-gynecologist who has been part of the negotiations with Dignity.

"I feel a little like women's health has been portrayed as a casualty of this negotiating," said Gossett. "But as someone who works in labor and delivery and is in the trenches every day, I see it differently. I see the damages our capacity problems have on women right now because we haven't expanded our capacity enough to meet the need."

Of particular concern to opponents of the affiliation are two recent lawsuits against Dignity filed by the American Civil Liberties Union. In one case, a woman was denied a tubal ligation following a cesarean section delivery at a Dignity facility in Redding, Calif. In another, a transgender man was denied a hysterectomy after a Dignity facility in Sacramento learned the procedure was part of his plan to align his gender identity and body.

In March, Steinauer, the head of the Bixby Center, joined more than 1,500 UCSF faculty members, residents, students and alumni in signing a letter opposing the affiliation. "Our affiliation with [Dignity] not only compromises the safety and quality of our patient care, but also threatens the integrity of our reputation as a provider of evidence-based care in an inclusive environment free of bias and discrimination," they wrote.

UCSF is hardly the first public hospital to wrestle with the question of Catholic health care.

Catholic hospital systems now oversee 1 in 6 acute care hospital beds in the U.S., according to MergerWatch, a nonprofit group that tracks hospital consolidation. And the number of hospitals that are Catholic-owned or -affiliated increased by 22% from 2001 to 2016.

Earlier this year, Dignity Health joined forces with another system called Catholic Health Initiatives in a merger approved by both the California Department of Justice and the Vatican. The resulting $29 billion system, CommonSpirit Health, has 119 acute care hospitals and is now the largest nonprofit hospital system in the country, according to MergerWatch.

As health systems across the country scramble to merge and affiliate to gain market share, Catholic health systems have become an appealing partner for some secular hospitals, even when values diverge. In a highly consolidated region like Northern California, partnership options are limited.

The University of Michigan is affiliated with two Catholic systems: Trinity Health and Ascension. The University of Washington affiliated with the Catholic nonprofit PeaceHealth in 2013.

Entanglements between secular and Catholic hospitals have presented problems, said Lois Uttley, who runs MergerWatch. During a trial affiliation between secular Sierra Vista Regional Health Center and the Catholic Carondelet Health Network, both in Arizona, obstetricians initially were told they could perform tubal ligations, only to be told later they needed to stop. The partnership was dissolved.

The UCSF administration said a formal affiliation is necessary to expand services and increase revenue. Dignity is already an important part of UCSF's Canopy Health, a network of doctors and hospitals that can earn bonuses for delivering medical care more efficiently under a program created by the Affordable Care Act. Canopy Health aims to provide care for upwards of 200,000 patients within a few years.

The details of the arrangement are being worked out, but under discussion is the possibility that UCSF will get a financial stake in the affiliated Dignity hospitals, according to UCSF administrators.

The arrangement would provide "a revenue flow to support some of our money-losing programs," UCSF's Laret told the UC Regents this month. "There really is not a good alternative from our standpoint," he added. "If we have to disengage from our partnership with Dignity, forget UCSF, I think that it's catastrophic for the health care delivery system in San Francisco."

Dignity, meanwhile, would benefit from the inflow of patients at hospitals that often operate under capacity.

UCSF has promised workarounds to avoid potential conflicts where Dignity's hospitals prohibit services. Patients would be informed upfront about which services are not provided at Dignity facilities, for example, so they could choose to go to their preferred hospital. No UCSF staff would be asked to provide obstetric or reproductive services at Catholic facilities. And if patients at a Dignity hospital needed a prohibited service, they could be transferred to UCSF.

In an emailed statement, Dr. Todd Strumwasser, a Dignity Health senior vice president, wrote that "physicians practicing at Dignity Health hospitals may discuss all treatment options with patients" and "facilitate access" to another site when a Dignity hospital does not provide a certain service. "In a situation in which a pregnant woman's life is in danger, life-saving procedures that may result in termination of the pregnancy will be performed."

Such policies, however, are subject to changes by the bishops who set the rules at Catholic hospitals, said Lori Freedman, a UCSF professor who studies reproductive health care at Catholic hospitals.

"We don't know what the future really looks like," Freedman said. "Sometimes workarounds don't stick around."

Jenny Gold: jgold@kff.org, @JennyAGold

Hospitals Chafe Under Medicare's New Payment Rule For Off-Campus Clinics

KFF Health News, April 26, 2019

With its new policy, Medicare is saying that an off-campus office is an off-campus office, regardless of whether it's owned by a hospital, a group of doctors or a solo practitioner.

This article was first published on Friday, April 26, 2019, in Kaiser Health News.

By Carmen Heredia Rodriguez

Eric Lewis' plans for expansion have derailed.

As chief executive officer of Olympic Medical Center, he oversees efforts to provide care to roughly 75,000 people in Clallam County, in the isolated, rural northwestern corner of Washington state.

Last year, Lewis planned to build a primary care clinic in Sequim, a town about 17 miles from the medical center's main campus in Port Angeles.

But those plans were put aside, Lewis said, because of a change in federal reimbursements this year. Medicare has opted to pay hospitals with outpatient facilities that are "off campus" a lower rate, equivalent to what it pays independent doctors for clinic visits.

Over the past decade, hospitals have been rapidly building outpatient clinics or purchasing existing independent ones. It was a lucrative business strategy because such clinics could charge higher rates, on the premise that they were part of a hospital.

With its new policy, Medicare is essentially saying that an off-campus office is an off-campus office, regardless of whether it's owned by a hospital, a group of doctors or a solo practitioner.

Making that statement will save Medicare — and possibly patients — money. The federal insurer bore the brunt of its members' extra charges, but beneficiaries sometimes picked up part of that expense through deductibles and copayments. Patients with commercial insurance often were blindsided by high bills — going to what seemed to be a normal primary care clinic, only to discover they were charged a hospital facility fee, for example.

Health policy experts said the new policy represents an important step in rationalizing payments. The new policy — part of a strategy called "site-neutral" payment — has its roots in the Obama administration and was part of the Bipartisan Budget Act of 2015.

"You don't care about where [your treatment is] happening. You care that it's a safe and inexpensive procedure," said Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management. "And the facility fee just adds to the cost with very little added value."

The new payment structure may hurt some hospitals financially, he and other experts acknowledged. But making reimbursements more uniform across providers facilitates competition and may lead commercial insurance to follow suit — which could translate to more savings.

The policy's two-part phase-in cut Medicare payments for clinic visits to outpatient departments by 30% this year, according to the rule finalized in November. By 2020, the rate will be cut another 30%.

The Centers for Medicare & Medicaid Services (CMS) estimates the change will save the federal government $380 million this year and patients an average of $7 every time they visit a hospital-owned clinic because their copayments will be lower. Clinic visits are the most commonly charged service for hospital outpatient care in Medicare.

It could also cut down on consolidation in the industry, experts said, by closing the loophole that created incentives for hospitals to purchase independent physician practices and charge higher rates for services at taxpayers' expense.

The American Hospital Association filed a lawsuit in December alleging that CMS overstepped its authority when setting the new reimbursement schedule. Olympic Medical Center is among the named plaintiffs.

The hospital association claims that the new rule infringes on a precedent Congress set with the 2015 budget law. That legislation standardized Medicare payments for clinic visits to physicians' offices and new hospital outpatient facilities, but allowed most hospital-affiliated departments that existed at that time to continue receiving a higher rate, according to a comment letter from the Medicare Payment Advisory Commission. The group is a nonpartisan agency that advises Congress.

The differential for site-based payments was designed originally to help hospitals offset the higher costs they incur for maintaining the staff and equipment to handle a wide variety of treatments, said Christopher Whaley, an associate policy researcher at the research organization Rand Corp.

But that relief became an incentive for hospitals to buy independent practices, said Dr. Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School. Hospitals could charge higher prices for services performed in newly acquired clinics. Mehrotra said the new CMS rule could be a way to slow down the trend.

"This isn't going to fully put the brakes on it," he said, "but it could be one push on the brakes here to kind of push that consolidation down."

Some experts have urged the government to expand the number of services covered by the site-neutral policy, including paying hospitals' on-site clinics a rate equivalent to what independent doctors receive.

Hospitals acknowledged the change implemented by CMS could lead to savings in the health care system, but they say it comes at the cost of patient access. In Washington state, Lewis anticipates a loss of $1.6 million for his hospital. The lack of a clinic in Sequim means ailing patients there will not be able to get care close to their homes, he said.

"If you're well-to-do financially, these aren't big problems," Lewis added. "But I think the poorest, elderly, sickest of our society will pay the price of this policy."

Said Melinda Hatton, general counsel for the hospital association: "I think access trumps a couple extra dollars in copays every single time."

On the other hand, many independent physicians support the change. Marni Jameson Carey, executive director of the Association of Independent Doctors, echoed the experts' hope that the rule will curb consolidation. According to a report by the consulting firm Avalere Health, the number of hospital-owned physician practices more than doubled, from 35,700 to 80,000, between July 2012 and January 2018. Hospitals own more than 31% of all physician practices, the researchers said.

Jameson Carey said these mergers can also cause problems for the local economy. When a nonprofit hospital acquires an independent clinic, it effectively removes a tax-paying business from the area. That's because nonprofit hospitals are exempt from paying certain federal, state and local taxes in exchange for providing community benefits.

"So not only do they [hospitals] get the facility fee," Jameson Carey said, but also, "they don't have to pay taxes."

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

Pain Clinics' Doctors Needlessly Tested Hundreds Of Urine Samples, Court Records Show

KFF Health News, April 25, 2019

Once among the largest pain management groups in the Southeast, CPS crumbled amid financial woes and a criminal investigation that ensnared its former CEO.

This article was first published on Wednesday, April 24, 2019, in Kaiser Health News.

By Fred Schulte

A Tennessee-based chain of pain clinics that abruptly shut down last summer faces five whistleblower lawsuits accusing it of defrauding Medicare and other health insurers by billing for hundreds of unnecessary urine drug tests and other dubious health services, newly unsealed court records show.

The federal suits target Tennessee-based Comprehensive Pain Specialists, also known as Anesthesia Services Associates, PLLC, and several of its physician owners. At its peak, CPS ran 60 pain clinics in 12 states, according to the suits, as well as a lucrative urine-testing lab in Brentwood, Tenn. CPS closed with no warning in July, leaving patients in several states distressed and scrambling to find a new source of narcotic pain medicines.

In federal court filings unsealed in Nashville this week, federal prosecutors said they would take over the urine-testing allegations and sue several CPS owners, including co-founding anesthesiologists Peter Kroll and Steven Dickerson. Dickerson is a Republican state senator representing Nashville.

Kroll could not be reached for comment Wednesday. Dickerson did not respond to an email or a phone message left at his legislative office.

It is not clear whether the whistleblowers, who include former CPS doctors and other employees, would pursue several allegations against the company that the federal government declined to join in. CPS, in an unrelated court filing in December, said the company had terminated all of its employees and that debts "greatly exceed its assets."

Once among the largest pain management groups in the Southeast, CPS crumbled amid financial woes that included nearly a dozen civil suits alleging unpaid debts, and a criminal investigation that ensnared its former chief executive, John Davis. Davis, 41, was convicted this month in federal court in Nashville on health care fraud charges. He is to be sentenced later this year.

CPS was the subject of a November 2017 investigation by Kaiser Health News that scrutinized its Medicare billings for urine drug tests. Medicare paid the company at least $11 million for urine screenings and related tests in 2014, when five of CPS' medical professionals stood among the nation's top such Medicare billers. One nurse practitioner working at a CPS clinic in Cleveland, Tenn., generated $1.1 million in urine-test billings that year, according to Medicare records analyzed by KHN.

Kroll, who also served as CPS' medical director, said at the time that the tests were justified for patient safety and to reduce chances the pills might be sold on the black market. Kroll billed Medicare $1.8 million for urine tests in 2015, the KHN analysis of Medicare billing records found.

Kroll in an interview with KHN at the time said that he and fellow anesthesiologist Dickerson came up with the idea for the pain clinics over a cup of coffee at a Nashville Starbucks in 2005.

One of the whistleblower suits alleging unnecessary urine tests was first filed under seal in 2016 by Suzanne Alt, a doctor who worked in the company's pain clinics in Troy, Mo., and Keokuk, Iowa, from May 2014 to March 2015. She alleged CPS doctors were "strongly encouraged to order full-panel urine drug screens on each patient, every time, despite the patient's history, compliance and risk."

She also said that the company's electronic medical records "made it extremely difficult to order anything less than the full panel." Alt said she was told the Tennessee lab did about 600 of these screens daily. Another whistleblower said he toured the lab with CPS executives and observed an "overpowering and unpleasant smell of urine." In response, a CPS executive said, "To me, it smells like money," according to the suit.

"They were making a killing," said Birmingham, Ala., attorney Don McKenna, who represents Alt in the case.

Another of the whistleblowers, former CPS anesthesiologist Cynthia Niendorff, alleged that the company billed Medicare about $754 for each additional urine test, even though earlier results had come back negative. She said CPS grossed approximately $6 million per month from the urine-testing lab and said about 20% of this amount was suspect, according to the suit.

Mary Butner, a former insurance specialist for CPS in Gallatin, Tenn., alleged that CPS charged some patients $1,500 for a drug test to measure blood levels of medication and $400 for a drug test designed to detect illegal drugs — charges that the suit called "grossly inflated and disproportional to the actual costs." She also alleged that CPS would fill prescriptions for patients whose drug tests detected the presence of illegal drugs, or showed that they were not taking their medication as directed.

Butner also accused medical director Kroll of approving prescriptions for back braces when it was "clearly medically unnecessary," including some people who had injuries to a knee or elbow.

Fred Schulte: fschulte@kff.org, @fredschulte

Association Insurance Pushes On Despite Court Ruling

KFF Health News, April 25, 2019

A federal judge in March invalidated large chunks of the law that created association health plans. But many of the plans are still operating and waiting to see if the Trump Administration appeals the ruling.

This article was first published on Thursday, April 25, 2019, in Kaiser Health News.

By Julie Appleby

When the Trump administration in June issued rules making it easier for small employers to band together to buy health insurance, "we started looking immediately," recalled Scott Lyon, a top executive at the Small Business Association of Michigan.

Although he offered traditional small-group health insurance to his association's employees and members, Lyon liked adding a new option for both: potentially less expensive coverage through an association health plan, which doesn't have to meet all the rules of the Affordable Care Act.

Now, a few months in, "we've got 400 companies and a couple of thousand workers signed up," said Lyon last week.

Nationally, an estimated 30,000 people are in such association health plans, a type of health insurance seeing a nascent resurgence following an initial drop-off after the ACA took effect in 2014.

Most of the new enrollees joined through groups like Lyon's or local chambers of commerce, farm bureaus or agriculture-based cooperatives. Such groups see the plans not only as a way to offer insurance, but also as an enticement to boost membership.

In the first legal test, however, U.S. District Judge John Bates at the end of March sided with 11 states and the District of Columbia challenging the law. He invalidated a large chunk of those June rules, saying the administration issued them as an "end-run around the Affordable Care Act."

So what now?

Unless the government seeks — which it has yet to do — and is granted a stay of the judge's order, "plans formed under the vacated sections of the rule are illegal," said Timothy Jost, an emeritus health law professor from Washington and Lee University.

Still, that won't mean anything for existing plans if the states or federal regulators choose not to enforce the ruling, Jost said.

And that could cause more confusion in the marketplace.

While the states that brought the challenge are expected to enforce the ruling, some other states support broader access to association health plans, said Christopher Condeluci, an attorney who represents several such plans, including the one formed by Lyon's group.

"These plans are not an end run around the ACA," said Condeluci.

Association health plans already established under the administration's rules cover "virtually" all the federal law's essential health benefits, he said, with the exception of dental and vision care for children.

Local chamber of commerce plans are mainly continuing business as usual while watching to see if the government will appeal, said Katie Mahoney, vice president of health policy at the U.S. Chamber of Commerce.

A few, including a plan offered through the Las Vegas chamber, may limit new enrollment for sole proprietors, she said, as the judge sharply questioned whether they qualified as "employers" under federal laws.

Sole proprietors are generally individuals who own and operate their own businesses without any employees.

Bates wrote that, in the regulation, the Department of Labor "stretches the definition of employer" beyond what federal law allows. The rule was designed to increase access to plans that "avoid the most stringent requirements" of the ACA.

The opinion by Bates, who was appointed by President George W. Bush, is widely expected to be appealed, although the government has not yet done so.

The decision affects one pillar of a broader effort by the Trump administration to expand access to less expensive health insurance. Association plans have long been a favorite of Republicans, existing before the ACA. Supporters say they are one way to pool groups of businesses together to get better premium rates.

Still, some plans faced problems in the past, including bankruptcy or complaints that they misled consumers by not fully informing them about what is covered.

After the ACA took effect, enrollment fell, partly because many small businesses were buying new ACA plans and many existing association plans had to comply with ACA rules for small-group coverage anyway. People who ran their own businesses and had no employees qualified only for coverage through the ACA's individual market.

But the Trump administration in June broadened the definition of those eligible to buy insurance through employer-based associations to include sole proprietors and also made it easier to form associations to offer coverage.

In addition, the changes allowed more association plans to be classified as large-employer coverage, which exempts them from some of the ACA's requirements. For example, association plans don't have to include all 10 of the ACA's "essential" health benefits, such as mental health care and prescription drug coverage.

Also, unlike ACA plans, association insurers can set premium rates based on an employer's industry, as well as taking into account the age range and gender makeup of their workforce.

In other words, association plans can charge less for companies with workforces that are generally younger and male in occupations that involve mainly desk work than for firms with mostly older workers or companies doing riskier work, such as cutting down trees or roofing.

Still, such plans must abide by other ACA provisions, including accepting people with preexisting medical conditions.

Critics, including the states that sued, say the new rules and other administration-backed changes will weaken the market for ACA plans by drawing out younger and healthier people. The states also argued that the new rules would be costly for them to administer, alleging they would have to devote more resources to preventing consumer fraud.

In Michigan, Lyon said the association his group formed, called Transcend, offers coverage to small employers and sole proprietors that is just as generous as large-group plans. It is a fully insured plan through the state's Blue Cross Blue Shield carrier that covers a broad array of benefits, except children's dental and vision.

"One thing we don't want to do is sell a bag of air to our members," said Lyon.

While some new members have reported large savings by enrolling, Lyon said association plans are not necessarily less expensive than small-group coverage. It all depends on the demographic and occupational makeup of the small business, he said.

"Our best estimate was association health plans would be the right solution for 30 to 35% of the small-group world," said Lyon. "It all has to come together. Age matters. Gender matters. It's so specific to each company."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Liver Illness Strikes Latino Children Like A 'Silent Tsunami'

KFF Health News, April 19, 2019

About 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher.

This Kaiser Health News article was first published on Friday, April 19, 2019 in California Healthline

By Rob Waters

Saira Diaz uses her fingers to count the establishments selling fast food and sweets near the South Los Angeles home she shares with her parents and 13-year-old son. "There's one, two, three, four, five fast-food restaurants," she says. "And a little mom and pop store that sells snacks and sodas and candy."

In that low-income, predominantly Latino neighborhood, it's pretty hard for a kid to avoid sugar. Last year, doctors at St. John's Well Child and Family Center, a nonprofit community clinic seven blocks away, became alarmed by the rising weight of Diaz's son, Adrian Mejia. They persuaded him to join an intervention study run by the University of Southern California and Children's Hospital Los Angeles (CHLA) that weans participants off sugar in an effort to reduce the rate of obesity and diabetes among children.

It also targets a third condition fewer people have heard of: fatty liver disease.

Linked both to genetics and diets high in sugar and fat, "fatty liver disease is ripping through the Latino community like a silent tsunami and especially affecting children," said Dr. Rohit Kohli, chief of gastroenterology, hepatology and nutrition at CHLA.

Recent research shows about 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher. One large study in Dallas found that 45% of Latinos had fatty livers.

The illness, diagnosed when more than 5% of the liver's weight is fat, does not cause serious problems in most people. But it can progress to a more severe condition called nonalcoholic steatohepatitis, or NASH, which is linked to cirrhosis, liver cancer and liver failure. This progressive form of fatty liver disease is the fastest-growing cause of liver transplants in young adults.

The USC-CHLA study is led by Michael Goran, director of the Diabetes and Obesity Program at CHLA, who last year made an alarming discovery: Sugar from sweetened beverages can be passed in breast milk from mothers to their babies, potentially predisposing infants to obesity and fatty livers.

Called HEROES, for Healthy Eating Through Reduction of Excess Sugar, his program is designed to help children like Adrian, who used to drink four or more sugary drinks a day, shed unhealthy habits that can lead to fatty liver and other diseases.

Fatty liver disease is gaining more attention in the medical community as lawmakers ratchet up pressure to discourage the consumption of sugar-laden drinks. Legislators in Sacramento are mulling proposals to impose a statewide soda tax, put warning labels on sugary drinks and bar beverage companies from offering discount coupons on sweetened drinks.

"I support sugar taxes and warning labels as a way to discourage consumption, but I don't think that alone will do the trick," Goran said. "We also need public health strategies that limit marketing of sugary beverages, snacks and cereals to infants and children."

William Dermody, a spokesman for the American Beverage Association said: "We understand that we have a role to play in helping Americans manage consumption of added sugars, which is why we are creating more drinks with less or no sugar."

In 2016, 45 deaths in Los Angeles County were attributed to fatty liver disease. But that's a "gross underestimate," because by the time people with the illness die, they often have cirrhosis, and that's what appears on the death certificate, said Dr. Paul Simon, chief science officer at the L.A. County Department of Public Health.

Still, Simon said, it was striking that 53% of the 2016 deaths attributed to fatty liver disease were among Latinos — nearly double their proportion of total deaths in the county.

Medical researchers consider fatty liver disease a manifestation of something called metabolic syndrome — a cluster of conditions that include excess belly fat and elevated blood pressure, blood sugar and cholesterol that can increase the risk of heart disease, stroke and diabetes.

Until 2006, few doctors knew that children could get fatty liver disease. That year Dr. Jeffrey Schwimmer, a professor of pediatrics at the University of California-San Diego, reviewed the autopsies of 742 children and teenagers, ages 2 to 19, who had died in car crashes or from other causes, and he found that 13% of them had fatty liver disease. Among obese kids, 38% had fatty livers.

After Schwimmer's study was released, Goran began using MRIs to diagnose fatty liver in living children.

A 2008 study by another group of researchers nudged Goran further. It showed that a variant of a gene called PNPLA3 significantly increased the risk of the disease. About half of Latinos have one copy of that high-risk gene, and a quarter have two copies, according to Goran.

He began a new study, which showed that among children as young as 8, those who had two copies of the risky gene and consumed high amounts of sugar had three times as much fat in their livers as kids with no copy of the gene. Now, in the USC-CHLA study, he is testing whether reduced consumption of sugar decreases the fatty liver risk in children who have the PNPLA3 gene variant.

At the start of the study, he tests kids to see if they have the PNPLA3 gene, uses an MRI to measure their liver fat and catalogs their sugar intake. A dietitian on his team educates the family about the impact of sugar. Then, after four months, they measure liver fat again to assess the impact of the intervention. Goran expects to have results from the study in about a year.

More recently, Goran has been investigating the transmission of sugar from mothers to their babies. He showed last year that in nursing mothers who drank beverages sweetened with high-fructose corn syrup — the primary sweetener in standard formulations of Coca-Cola, Pepsi and other sodas — the fructose level in their breast milk rose and stayed elevated for several hours, ensuring that the baby ingested it.

This early exposure to sugar could be contributing to obesity, diabetes and fatty livers, based on previous research that showed fructose can enhance the fat storage capacity of cells, Goran said.

At Torrance Memorial Medical Center, Dr. Karl Fukunaga meets with a patient, Margarita Marrou, a retired medical clerk originally from Peru. She was diagnosed several years ago with a severe form of fatty liver disease and has cut down her sugar consumption and lost weight. (Rob Waters for KHN)

In neighborhoods like South Los Angeles, where Saira Diaz and Adrian Mejia live, a lack of full-service markets and fresh produce makes it harder to eat healthily. "Access to unhealthy food options — which are usually cheaper — is very high in this city," Derek Steele, director of health equity programs at the Social Justice Learning Institute in Inglewood, Calif., told Kaiser Health News.

The institute has started farmers markets, helped convert two corner stores into markets with healthier food options and created 109 community gardens on public and private lands in South L.A. and neighboring Inglewood, which has 125 liquor and convenience stores and 150 fast-food outlets.

At Torrance Memorial Medical Center, 10 miles down the road, Dr. Karl Fukunaga, a gastroenterologist with Digestive Care Consultants, said he and his colleagues are seeing so many patients with fatty liver disease that they plan to start a clinic to address it. He urges his patients to avoid sugar and cut down on carbohydrates.

Adrian Mejia and his mother received similar advice from a dietitian in the HEROES program. Adrian gave up sugary beverages, and his liver fat dropped 43%. Two months ago, he joined a soccer league.

"Before, I weighed a lot and it was hard to run," he said. "If I kept going at the pace I was going, probably later in my life I would be like my [diabetic] grandma. I don't want that to happen."

This KHN story first published on California Healthline, a service of the California Healthcare Foundation.

As Syphilis Invades Rural America, A Fraying Health Safety Net Is Failing To Stop It

KFF Health News, April 18, 2019

Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views.

This article was first published on Thursday, April 18, 2019 in Kaiser Health News.

By Lauren Weber

When Karolyn Schrage first heard about the "dominoes gang" in the health clinic she runs in Joplin, Mo., she assumed it had to do with pizza.

Turns out it was a group of men in their 60s and 70s who held a standing game night — which included sex with one another. They showed up at her clinic infected with syphilis.

That has become Schrage's new normal. Pregnant women, young men and teens are all part of the rapidly growing number of syphilis patients coming to the Choices Medical Services clinic in the rural southwestern corner of the state. She can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.

Public health officials say rural counties across the Midwest and West are becoming the new battleground. While syphilis is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges. Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex.

In Missouri, the total number of syphilis patients has more than quadrupled since 2012 — jumping from 425 to 1,896 cases last year — according to a Kaiser Health News analysis of new state health data. Almost half of those are outside the major population centers and typical STD hot spots of Kansas City, St. Louis and its adjacent county. Syphilis cases surged at least eightfold during that period in the rest of the state.

At Choices Medical Services, Schrage has watched the caseload grow from five cases to 32 in the first quarter of 2019 alone compared with the same period last year. "I've not seen anything like it in my history of doing sexual healthcare," she said.

Back in 1999, the Centers for Disease Control and Prevention had a plan to eradicate the sexually transmitted disease that totaled over 35,000 cases nationwide that year. While syphilis can cause permanent neurological damage, blindness or even death, it is both treatable and curable. By focusing on the epicenters clustered primarily throughout the South, California and in major urban areas, the plan seemed within reach.

Instead, U.S. cases topped 101,500 in 2017 and are continuing to rise along with other sexually transmitted diseases. Syphilis is back in part because of increasing drug use, but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public health infrastructure.

"It really is astounding to me that in the modern Western world we are dealing with the epidemic that was almost eradicated," said Schrage.

Grappling With The Jump

Craig Highfill, who directs Missouri's field prevention efforts for the Bureau of HIV, STD and Hepatitis, has horror stories about how syphilis can be misunderstood.

"Oh, no, honey, only hookers get syphilis," he said one rural doctor told a patient who asked if she had the STD after spotting a lesion.

In small towns, younger patients fear that their local doctor — who may also be their Sunday school teacher or basketball coach — may call their parents. Others don't want to risk the receptionist at their doctor's office gossiping about their diagnosis.

Some men haven't told family members they're having sex with other men. And still more have no idea their partner may have cheated on them — and their doctors don't want to ask, according to Highfill.

It's even hard to expect providers who haven't seen a case of syphilis in their lifetime to automatically recognize the hallmarks of what is often called the "great imitator," Highfill said. Syphilis can manifest differently among patients, but frequently shows up for a few weeks as lesions or rashes — often dismissed by doctors who aren't expecting to see the disease.

Since 2000, the current syphilis epidemic was most prevalent among men having sex with men. Starting in 2013, public health officials began seeing an alarming jump in the number of women contracting syphilis, which is particularly disturbing considering the deadly effects of congenital syphilis — when the disease is passed from a pregnant woman to her fetus. That can cause miscarriage, stillbirth or birth deformities.

Among those rising numbers of women contracting syphilis and the men who were their partners, self-reported use of methamphetamines, heroin or other intravenous drugs continues to grow, according to the CDC. Public health officials suggest that increased drug use — which can result in a pattern of risky sex or trading sex for drugs — worsens the outbreaks.

That perilous trend is playing out particularly in rural Missouri, argues Dr. Hilary Reno, an assistant professor of medicine at Washington University School of Medicine in St. Louis who is researching syphilis transmission and drug use in the state. Tracking cases from 2015 through June 2018, she found that more than half of patients outside of the major metropolitan areas of Kansas City and St. Louis reported using drugs.

Less Money, More Problems

Federal funding for STD prevention has stayed relatively flat since 2003, with $157.3 million allocated for fiscal year 2018. But that amounts to a nearly 40% decrease in purchasing power over that time, according to the National Coalition of STD Directors.

In Missouri, CDC annual funding has been cut by over $354,000 from 2012 to 2018 — a 17% decrease even as the number of cases quadrupled, Highfill said.

Iowa, too, has seen its STD funding cut by $82,000 over the past decade, according to Iowa Department of Health's STD program manager George Walton.

"It is very difficult to get ahead of an epidemic when case counts are steadily — sometimes rapidly — increasing and your resources are at best stagnant," Walton said. "It just becomes overwhelming."

Highfill bemoaned that legislatures in Texas, Oregon and New York have all allocated state money to raise awareness or provide transportation to local clinics. Missouri has not allocated anything.

A New Playing Field

In the digital age, fighting syphilis is much harder for public health responders, said Rebekah Horowitz, a senior program analyst on HIV, STDs and viral hepatitis at the National Association of County and City Health Officials.

The increased use of anonymous apps gives people greater access to more sexual partners, she said. Tracking down those partners is now much harder than camping out at the local bar in town.

"We can't get inside of Grindr and do our traditional public health efforts," she said.

That's not to say Highfill's department hasn't tried. It has engineered a series of educational ads on Instagram, Grindr and Facebook displaying messages such as "Knowledge looks good on you."

Highfill would love to do more — if Missouri had the money.

Public health clinics nationwide have also had to limit hours, reduce screening and increase fees that can reach $400. And some run by health departments across the country have been forced to close — at least 21 in 2012 alone, according to CDC data.

In Missouri, restrictions on Planned Parenthood's Medicaid reimbursements that were passed last year in the legislature, and are again under debate, mean the nonprofit organization cannot be reimbursed for STD treatment for some patients.

That is another crack in the already failing public health infrastructure, said Reno, the Washington University professor who also serves as the medical director of the St. Louis County Sexual Health Clinic.

"We have a system that's not even treading water," she said. "We are the ship that is listing to the side."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Workplace Wellness Programs Barely Move The Needle, Study Finds

KFF Health News, April 17, 2019

Workers in the wellness programs self-reported healthier behavior, but saw no differences in health measures, such as improved blood sugar, how much they spent on healthcare, or how often they missed work.

This article was first published on Tuesday, April 16, 2019 by Kaiser Health News.

By Julie Appleby

Workplace wellness programs have become an $8 billion industry in the U.S. But a study published Tuesday in JAMA found they don't cut costs for employers, reduce absenteeism or improve workers' health.

Most large employers offer some type of wellness program — with growth fueled by incentives in the federal Affordable Care Act.

A host of studies over the years have provided conflicting results about how well they work, with some showing savings and health improvements while others say the efforts fall short.

Many studies, however, faced a number of limitations, such as failing to have a comparison group, or figuring out whether people who sign up for such wellness programs are somehow healthier or more motivated than those who do not.

Now researchers from the University of Chicago and Harvard may have overcome these obstacles with one of the first large-scale studies that is peer-reviewed and employs a more sophisticated trial design.

They randomly assigned 20 BJ's Wholesale Club outlets to offer a wellness program to all employees, then compared results with 140 stores that did not.

The big-box retailer employed nearly 33,000 workers across all 160 clubs during the test.

After 18 months, it turned out that yes, workers participating in the wellness programs self-reported healthier behavior, such as exercising more or managing their weight better than those not enrolled.

But the efforts did not result in differences in health measures, such as improved blood sugar or glucose levels; how much employers spent on health care; or how often employees missed work, their job performance or how long they stuck around in their jobs.

"The optimistic interpretation is there is no way we can get improvements in health or more efficient spending if we don't' first have changes in health behavior," said one study author, Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago. (Dr. Zirui Song, an assistant professor of health policy and medicine at Harvard Medical School, was its co-author.)

"But if employers are offering these programs in hopes that health spending and absenteeism will go down, this study should give them pause," Baicker said.

The study comes amid widespread interest in wellness programs.

The Kaiser Family Foundation's annual survey of employers found that 53% of small firms and 82% of large firms offer a program in at least one of these areas: smoking cessation, weight management and behavioral or lifestyle change. (Kaiser Health News is an editorially independent program of the foundation.)

Some programs are simple, offering gift cards or other small incentives to fill out a health risk assessment, take a lunch-and-learn class or join a gym or walking group. Others are far more invasive, asking employees to report on a variety of health-related questions and roll up their sleeves for blood tests.

A few employers tie financial incentives to workers actually lowering risk factors, such as high blood pressure or cholesterol — or making concerted efforts to participate in programs that might help them do so over time.

The Affordable Care Act allowed employers to offer financial incentives worth up to 30% of the cost of health insurance, leading some employers to offer what could be hundreds or even thousands of dollars off workers' deductibles or premiums to get them to participate. That led to court challenges about whether those programs are truly voluntary.

In the study reported in JAMA, the incentives were modest. Participants got small-dollar gift cards for taking wellness courses on topics such as nutrition, exercise, disease management and stress control. Total potential incentives averaged $250. About 35% of eligible employees at the 20 participating sites completed at least one module.

Results from those workers — including attendance and tenure data, their self-reported health assessment and results from lab blood tests — were specifically compared with similar reports from 20 primary comparison sites where workers were not offered the wellness gift cards and classes. Overall employment and health spending data from all worksites were included in the study.

Wellness program vendors said details matter when considering whether efforts will be successful.

Jim Pshock, founder and CEO of Bravo Wellness, said the incentives offered to BJ's workers might not have been large enough to spur the kinds of big changes needed to affect health outcomes.

Amounts of "of less than $400 generally incentivize things people were going to do anyway. It's simply too small to get them to do things they weren't already excited about," he said.

An accompanying editorial in JAMA noted that "traditional, broad-based programs like the one analyzed by Song and Baicker may lack the necessary intensity, duration, and focus on particular employee segments to generate significant effects over a short time horizon."

In other words, don't give up entirely on wellness efforts, but consider "more targeted approaches" that focus on specific workers with higher risks or on "health behaviors [that] may yield larger health and economic benefits," the editorial suggested.

It could be, the study acknowledges, that 18 months isn't enough time to track such savings. So, Baicker and Song also plan to publish three-year results once they are finalized.

Still, similar findings were recently reported in another randomized control trial conducted at the University of Illinois, where individuals were randomly selected to be offered wellness programs.

In one interesting point, that study found that wellness-program participants were likely already healthier and more motivated, "thus a primary benefit of these programs to employers may be their potential to attract and retain healthy workers with low medical spending."

Everyone involved in studying or conducting wellness agrees on one thing: Changing behavior — and getting people motivated to participate at all — can be difficult.

Steven Aldana, CEO of WellSteps, a wellness program vendor, said that for the efforts to be successful they must cut across many areas, from the food served in company cafeterias to including spouses or significant others to help people quit smoking, eat better or exercise more.

"Behavior is more complicated than simply taking a few wellness modules," said Aldana. "It's a lifestyle matrix or pattern you have to adopt."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

How to Fight 'Scary' Superbugs? Cooperation—And A Special Soap

KFF Health News, April 12, 2019

A novel approach recognizes that superbugs don't remain isolated in one hospital or nursing home but move quickly through a community.

This article was first published on Friday, April 12, 2019 in Kaiser Health News.

By Anna Gorman

Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government's Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don't remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC's office on healthcare-acquired infection research.

"No healthcare facility is an island," Jernigan said. "We all are in this complicated network."

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC.

People in hospitals are vulnerable to these bugs, and people in nursing homes are particularly vulnerable. Up to 15% of hospital patients and 65% of nursing home residents harbor drug-resistant organisms, though not all of them will develop an infection, said Dr. Susan Huang, who specializes in infectious diseases at the University of California-Irvine.

"Superbugs are scary and they are unabated," Huang said. "They don't go away."

Some of the most common bacteria in 'healthcare facilities are methicillin-resistant Staphylococcus aureus, or MRSA, and carbapenem-resistant Enterobacteriaceae, or CRE, often called "nightmare bacteria." E. coli and Klebsiella pneumoniae are two common germs that can fall into this category when they become resistant to last-resort antibiotics known as carbapenems. CRE bacteria cause an estimated 600 deaths each year, according to the CDC.

CREs have "basically spread widely" among healthcare facilities in the Chicago region, said Dr. Michael Lin, an infectious-diseases specialist at Rush University Medical Center, who is heading the CDC-funded effort there. "If MRSA is a superbug, this is the extreme — the super superbug."

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and healthcare workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes.

In Chicago, researchers are working with 14 nursing homes and long-term acute care hospitals, where staff are screening people for the CRE bacteria at admission and bathing them daily with chlorhexidine.

The Chicago project, which started in 2017 and ends in September, includes a campaign to promote handwashing and increased communication among hospitals about which patients carry the drug-resistant organisms.

The infection-control work was new to many nursing homes, which don't have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County healthcare Agency. "We don't have an infinite amount of time," he said. "Taking a chance to try to make a difference in CRE's trajectory now is really important."

The CDC-funded project in California is based in Orange County, where 36 hospitals and nursing homes are using the antiseptic wash along with an iodine-based nose swab. The goal is to prevent new people from getting drug-resistant bacteria and keep the ones who already have the bacteria on their skin or elsewhere from developing infections, said Huang, who is leading the project.

Huang kicked off the project by studying how patients move among different hospitals and nursing homes in Orange County, and discovered they do so far more than imagined. That prompted a key question: "What can we do to not just protect our patients but to protect them when they start to move all over the place?" she recalled.

Her previous research showed that patients with the MRSA bacteria who used chlorhexidine for bathing and as a mouthwash, and swabbed their noses with a nasal antibiotic, could reduce their risk of developing a MRSA infection by 30%. But all the patients in that study, published in February in the New England Journal of Medicine, already had been discharged from hospitals.

Now the goal is to target patients still in hospitals or nursing homes and extend the work to CRE. The traditional hospitals participating in the new project are focusing on patients in intensive care units and those who already carried drug-resistant bacteria, while the nursing homes and the long-term acute care hospitals perform the cleaning — also called "decolonizing" — on every resident.

One recent morning at Coventry Court Health Center, a nursing home in Anaheim, Calif., 94-year-old Neva Shinkle sat patiently in her wheelchair. Licensed vocational nurse Joana Bartolome swabbed her nose and asked if she remembered what it did.

"It kills germs," Shinkle responded.

"That's right — it protects you from infection."

In a nearby room, senior project coordinator Raveena Singh from UC-Irvine talked with Caridad Coca, 71, who had recently arrived at the facility. She explained that Coca would bathe with the chlorhexidine rather than regular soap. "If you have some kind of open wound or cut, it helps protect you from getting an infection," Singh said. "And we are not just protecting you, one person. We protect everybody in the nursing home."

Coca said she had a cousin who had spent months in the hospital after getting MRSA. "Luckily, I've never had it," she said.

Coventry Court administrator Shaun Dahl said he was eager to participate because people were arriving at the nursing home carrying MRSA or other bugs. "They were sick there and they are sick here," Dahl said.

Results from the Chicago project are pending. Preliminary results of the Orange County project, which ends in May, show that it seems to be working, Huang said. After 18 months, researchers saw a 25% decline in drug-resistant organisms in nursing home residents, 34% in patients of long-term acute care hospitals and 9% in traditional hospital patients. The most dramatic drops were in CRE, though the number of patients with that type of bacteria was smaller.

The preliminary data also shows a promising ripple effect in facilities that aren't part of the effort, a sign that the project may be starting to make a difference in the county, said Zahn of the Orange County Healthcare Agency.

"In our community, we have seen an increase in antimicrobial-resistant infections," he said. "This offers an opportunity to intervene and bend the curve in the right direction."

This KHN story first published on California Healthline, a service of the California 'healthcare Foundation.

As Sanders Officially Revives Medicare-for-All, Plan B For Democrats Gains Traction

KFF Health News, April 11, 2019

Many presidential hopefuls, even official co-sponsors of Sanders' Medicare-for-All proposal, are at the same time edging toward a more incremental approach, called 'Medicare for America.'

This article was published by Kaiser Health News on April 11, 2019.

By Shefali Luthra, Kaiser Health News

As Democratic presidential primary candidates try to walk a political tightrope between the party's progressive and center-left wings, they face increasing pressure to outline the details of their health reform proposals.

On Wednesday, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a "Medicare-for-all" bill, the idea that fueled his 2016 presidential run.

As with its previous iterations, Sanders' latest bill would establish a national single-payer "Medicare" system with vastly expanded benefits, prohibit private plans from competing with Medicare and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).

Already, it has an impressive list of Senate cosponsors — including Sanders' rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.) and Elizabeth Warren (D-Mass.).

But many of the candidates — even official Medicare-for-all co-sponsors — are at the same time edging toward a more incremental approach, called "Medicare for America." Proponents argue it could deliver better health care to Americans while avoiding political, budgetary and legal objections.

It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.

During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 to join Medicare, or allowing people younger than 65 to buy into it if they choose (the "public option"). Many aren't eager to face the industry opposition that a full-on Medicare expansion would surely trigger.

From the consumer perspective, sweeping reform poses a risk. Despite Medicare's popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.

That tension is pushing a number of candidates toward an emerging option called "Medicare for America." The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro (Conn.) and Rep. Jan Schakowsky (Ill.). It hasn't been reintroduced in the new Congress.

This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some costs out-of-pocket. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program's beneficiaries currently, and which would be outlawed under Medicare-for-all.

"Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack," said Celinda Lake, a Democratic pollster. "A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about."

Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O'Rourke, who launched his own 2020 bid in mid-March. Other candidates — including Warren, Gillibrand and Pete Buttigieg, the mayor of South Bend, Ind. — have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.

Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.

Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar, a Minnesota Democrat running in the primary's moderate lane, may not suffice.

"The ACA is popular at the 50 percent level, but it's not energetic. It doesn't get people who really like it," Blendon said. "What they're looking for is something that is exciting but isn't threatening."

Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.

Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).

The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare's expansion, though critics on the left worry it would mean some people would still be unable to afford care.

This also tracks with recent polling which suggests that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.

Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.

For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the Buttigieg, Gillibrand and Warren campaigns all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other candidates in the race — Harris, Klobuchar, Booker, former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee — similarly declined to comment.

Reading between the lines, though, their promises to achieve universal health care by expanding Medicare — while retaining private insurance — leaves them few options besides something like Medicare for America, argued one of its main architects.

"There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you're going to have to do the kinds of things" spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.

Still, though, it has prompted objections from both the left and the right.

On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household's income.) Those critics also say the plan's accommodations to private insurance limit the government's ability to negotiate lower prices.

Conservatives repeat many of the arguments levied against Medicare-for-all — too expensive, too disruptive.

Hospitals, insurance, drugmakers and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.

Said David Blumenthal of the Commonwealth Fund: "The fact of expanded Medicare will be the focus of attacks."

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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