Democrats hope to gain control of Congress by harnessing what polls show to be voters’ dissatisfaction with both Capitol Hill and President Donald Trump.
Dr. Rob Davidson, an emergency physician from western Michigan, had never considered running for Congress. Then came February 2017. The 46-year-old Democrat found himself at a local town-hall meeting going toe-to-toe with Rep. Bill Huizenga, his Republican congressman of the previous six years.
"I told him about my patients," Davidson recalled. "I see, every shift, some impact of not having adequate health care, not having dental insurance or a doctor at all."
His comments triggered cheers from the audience but didn't seem to register with Huizenga, a vocal Obamacare critic. And that got Davidson thinking.
"I've always been very upset … about patients who can't get health care," he said. But it never inspired him to act. Until this June, that is, when the political novice joined what is now at least eight other Democratic physicians running in races across the country as first-time candidates for Congress.
Democrats hope to gain control of Congress by harnessing what polls show to be voters' dissatisfaction with both Capitol Hill and President Donald Trump. The president maintains Republican support but registers low approval ratings among Americans overall, according to news organization FiveThirtyEight. Democrats also see promise in candidates such as Davidson, a left-leaning physician who may have a special advantage: firsthand health system experience.
Of the Democratic doctors running for office, all but one are seeking House seats. In addition to the nine newcomers, there are two incumbents up for re-election. Each candidate is campaigning hard on the need to reform the health care system.
And they present a stark contrast to Congress' current physician makeup.
Twelve of the 14 doctors now in Congress are Republicans. Three are senators. Half of the 14 practice in high-paying specialties such as orthopedic surgery, urology and anesthesiology.
By contrast, these stumping Democratic physicians hail predominantly from specialties such as emergency medicine, pediatrics and internal medicine, though one is a radiologist. They're fighting to represent a mix of rural, urban and suburban districts.
"Electing Democratic doctors would certainly change the face of medicine in Congress, and perhaps lend more credence in that body to more liberal health care policies," said Dr. Matthew Goldenberg, a psychiatrist at Yale School of Medicine who has researched political behavior and advocacy among doctors.
Physicians once trended Republican. The infusion of female and minority doctors, experts said, has changed this. Now, more than 50 percent of party-affiliated doctors are Democrats, and the medical establishment has — following Republican efforts to undo Obamacare — emerged as a staunch defender of the law.
Indeed, many doctor-candidates point to the GOP's repeal-and-replace efforts as their motivation.
"It's at a boiling point for many of these physicians," said Jim Duffett, executive director of the left-leaning Doctors for America, which supports universal health care.
While health care consistently emerges as a top issue, Democrats are more likely to rank it No. 1. For independents and Republicans, though, it's neck and neck with the economy — and some political analysts question how effective it will be in flipping conservative districts.
"Democrat voters blame Republicans for the problems with health care right now. Republicans blame Democrats. Independents say, 'A pox on both your houses,'" argued Jim McLaughlin, a Republican pollster working on several 2018 races who has previously worked with Trump. "They're making a big mistake thinking they can run on [health care]."
That said, doctors can be effective messengers, especially in their communities.
Research suggests Americans hold their own physicians in high regard.
"Voters listen carefully to what physicians have to say about health policy," said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina. "In a district that's not so one-sided red or blue, there's no question that the white coat confers prestige. It's something physician candidates can speak to with authority."
Davidson, for instance, supports a "Medicare-for-all"-style overhaul, an approach that involves expanding the federal insurance program for seniors and disabled people to all Americans. If elected, he said, he intends to join Democrats' burgeoning support for a single-payer system, in which the government runs the sole health insurance program, guaranteeing universal coverage. He did not have a primary challenge and is running against Huizenga, the Republican incumbent, in the general election for Michigan's 2nd Congressional District.
Or there's Dr. Kyle Horton, an internist running in the North Carolina 7th District. She supports expanding Medicare, by lowering the eligibility age from 65 to 50. She also supports a "public option" health insurance plan sold by the government.
Dr. Hiral Tipirneni, an emergency physician in Arizona's 8th Congressional District, asserts all Americans should be able to buy in to Medicare.
Physicians can have an advantage on other controversial topics, by casting them as public health issues, said Howard Rosenthal, a political scientist at New York University.
Davidson's campaign, for instance, posts videos on Facebook in which he talks about topics such as health care access and gun violence. One — filmed after an overnight ER shift — has gotten 41,000 views so far.
Also spurring physicians: concerns about abortion access.
Dr. Cathleen London, a Maine doctor, launched her campaign against four-term incumbent GOP Sen. Susan Collins for the 2020 election. She said she had been considering a run, but the upcoming vote for a justice to replace Anthony Kennedy on the Supreme Court — which could have sweeping implications for reproductive health law — pushed her to declare.
"Doctors are really frustrated with Washington, frustrated with the lack of listening to us," London said.
Many of these Democrats face steep climbs.
Of races featuring newcomer physicians, the Cook Political Report, which analyzes elections, rates only Arizona's 2nd Congressional District as leaning Democratic, and the doctor in that race is just one of seven candidates in the primary. The outcome for Washington's 8th District, where Dr. Kim Schrier, a pediatrician, is a candidate, is considered a toss-up and a Democratic pickup target.
Tipirneni is the only non-incumbent doctor to have a fundraising advantage so far, according to data from Open Secrets, a nonpartisan, nonprofit project tracking campaign-finance records.
Regardless of electoral results, many observers say the potential implications are sizable — even if few doctors go to Washington.
"They are planting a flag, and they're going to be raising some important issues — not just health care, but health care is going to be front and center," said Duffett, from Doctors for America. "That will help change the political debate and political landscape."
McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs.
There are many lawmakers who made their names in health care, seeking to usher through historic changes to a broken system.
John McCain was not one of them.
And yet, the six-term senator from Arizona and decorated military veteran leaves behind his own health care legacy, seemingly driven less by his interest in health care policy than his disdain for bullies trampling the "little guy."
He was not always successful. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990, most of the health initiatives he undertook failed after running afoul of traditional Republican priorities. His prescriptions often involved more government regulation and increased taxes.
In 2008, as the Republican nominee for president, he ran on a health care platform that dumbfounded many in his party who worried it would raise taxes on top of overhauling the U.S. tradition of workplace insurance.
Many will remember McCain as the incidental savior of the Affordable Care Act, whose late-night thumbs-down vote halted his party's most promising effort to overturn a major Democratic achievement — the signature achievement, in fact, of the Democrat who beat him to become president. It was a vote that earned him regular — and biting — admonishments from President Donald Trump.
McCain died Saturday, following a battle with brain cancer. He was 81. Coincidentally, his Senate colleague and good friend Ted Kennedy died on the same date, Aug. 25, nine years ago, succumbing to the same type of rare brain tumor.
Whether indulging in conspiracy theories or wishful thinking, some have attributed McCain's vote on the ACA in July 2017 to a change of heart shortly after his terminal cancer diagnosis.
But McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system's ballooning costs.
His prey were the sort of boogeymen that made for compelling campaign ads in a career stacked with campaigns. But McCain was "always for the little guy," said Douglas Holtz-Eakin, the chief domestic policy adviser on McCain's 2008 presidential campaign.
"John's idea of empathy is saying to you, 'I'll punch the bully for you,'" he said in an interview before McCain's death.
McCain's distaste for President Barack Obama's health care law was no secret. While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace the law with something better.
After Republicans spent months bickering amongst themselves about what was better, McCain was disappointed in the option presented to senators hours before their vote: hobble the ACA and trust that a handful of lawmakers would be able to craft an alternative behind closed doors, despite failing to accomplish that very thing after years of trying.
What bothered McCain more, though, was his party's strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory.
In his 2018 memoirs, "The Restless Wave," McCain said even Obama called to express gratitude for McCain's vote against the Republican repeal bill.
"I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare," McCain wrote. "That had not been my goal."
Better known for his work on campaign finance reform and the military, McCain did have a hand in one landmark health bill — the Americans with Disabilities Act of 1990, the country's first comprehensive civil rights law that addressed the needs of those with disabilities. An early co-sponsor of the legislation, he championed the rights of the disabled, speaking of the service members and civilians he met in his travels who had become disabled during military conflict.
McCain himself had limited use of his arms due to injuries inflicted while he was a prisoner of war in Vietnam, though he was quicker to talk about the troubles of others than his own when advocating policy.
Yet two of his biggest bills on health care ended in defeat.
In 1998, McCain introduced a sweeping bill that would regulate the tobacco industry and increase taxes on cigarettes, hoping to discourage teenagers from smoking and raise money for research and related health care costs. It faltered under opposition from his fellow Republicans.
McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients' bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies, said Sonya Elling, who served as a health care aide in McCain's office for about a decade. But he came around.
"It was the human, the personal aspect of it, basically," said Elling, now senior director of federal affairs at Eli Lilly. "It was providing him some of the real stories about how people were being hurt and some of the barriers that existed for people in the current system."
The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed.
McCain's health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate's Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans' care measures he undertook.
It was McCain's relationship with Kennedy that stood out, inspiring eerie comparisons when McCain was diagnosed last year with glioblastoma — a form of brain cancer — shortly before his vote saved the Affordable Care Act.
That same aggressive brain cancer killed Kennedy in 2009, months before the passage of the law that helped realize his work to secure better access for Americans to health care.
"I had strenuously opposed it, but I was very sorry that Ted had not lived to see his long crusade come to a successful end," McCain wrote in his 2018 book.
While some of his biggest health care measures failed, the experiences helped burnish McCain's résumé for his 2000 and 2008 presidential campaigns.
In 2007, trailing other favored Republicans, such as former New York City mayor Rudy Giuliani in early polling and fundraising, McCain asked his advisers to craft a health care proposal, said Holtz-Eakin. It was an unusual move for a Republican presidential primary.
The result was a remarkable plan that would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued employer-provided plans were driving up costs, as well as keeping salaries lower.
The plan was controversial, triggering "a total freakout" when McCain gained more prominence and scrutiny, Holtz-Eakin said. But McCain stood by it.
"He might not have been a health guy, but he knew how important that was," he said. "And he was relentless about getting it done."
Not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.
New York University's School of Medicine is learning that no good deed goes unpunished.
The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018.
NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place.
"A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt," Dr. Robert Grossman, the dean of the medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans.
The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt.
"As I start rank ordering the various charities I want to give to, the people who can pay for medical school in cash aren't at the top of my list," said Craig Garthwaite, a health economist at Northwestern University's Kellogg School of Management.
"If you had to find some cause to put tons of money behind, this strikes me as an odd one," said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University.
Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000.
But it is less clear how much of an impact that debt has on students' choice of medical specialty. The AAMC's data suggests debt does not play as big a role in specialty selection as some analysts claim.
If debt were a huge factor, one would expect that doctors who owed the most would choose the highest-paying specialties. But that's not the case.
"Debt doesn't vary much across the specialties," said Julie Fresne, AAMC's director of student financial services and debt management.
Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. "No one [who chooses a higher-paying job] says they did it because they want two Teslas," he said. "They say they have all this debt."
Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. "Doctors in general do just fine," he said. "The idea we should pity physicians or worry about them strikes me as odd."
Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted for pediatrics, calling it a "garbageman" specialty.
There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers.
Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master's degree.
This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings.
In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia's program is based on students' financial need.
The programs are funded, in whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU.
Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all "is not the most target-efficient way to reach that goal."
Ashley Summers said she got an unpleasant surprise in February when she tried to pick up a prescription for her rheumatoid arthritis: Her pharmacy said her insurance had been canceled, even though her premiums were paid.
Summers called Blue Shield of California and got her policy reinstated — then she said it happened again in March and this time, the lapse in coverage dragged on for three months.
Without insurance to cover her medications and doctor visits, her arthritis and fibromyalgia worsened to the point that she could barely walk, she said. In June, she said, the state granted her permission to switch to another insurer.
"This entire mess has been so incredibly stressful," said Summers, 49, a personal assistant in Los Angeles who had paid $593 a month in premiums. For Blue Shield just to pull the plug like this is infuriating."
Around the state, consumers with individual Blue Shield policies, like Summers, say they have been subject to sudden, erroneous cancellations, especially in recent months, forcing them to go without heart medicine, skip vaccinations for their children and pay hundreds of dollars out-of-pocket for other medical care. On social media, customers have described frantic attempts to get their coverage reinstated.
@BlueShieldCA Blueshield keeps failing to process my auto-pay and then canceling me. Sure feels like they don’t like insuring me. Asked on Facebook and many people are having this problem. How about you?
Oh yay, it’s been another 6 months or so of paying in full for insurance and again @BlueShieldCA randomly retroactively cancels our coverage 🎉 cc @CoveredCA this has been happening for nearly 5 years now.
Blue Shield has acknowledged failures in enrollment and billing for some customers who purchased individual policies since 2014, both inside and outside the Covered California exchange. The company declined to specify how many customers were affected. The problems don't appear to involve people with employer coverage or enrolled in government health programs.
In a June 22 lawsuit, the San Francisco insurer blamed many of these problems on an outside contractor it had hired in preparation for the launch of the Affordable Care Act in 2014. In a countersuit, the contractor, HealthPlan Services, denied the allegations and accused Blue Shield of sharing inaccurate customer data.
In a statement, Blue Shield said: "The roll out of the Affordable Care Act was hard on the entire health care system. Our vendor failed to provide the support it promised and we spent millions of dollars to mitigate the impacts to our members."
On Friday, Summers sued Blue Shield in Los Angeles County Superior Court, alleging breach of contract and seeking class-action status on behalf of other customers. The insurer couldn't be reached for comment about the complaint.
Scott Glovsky, a Pasadena, Calif., attorney representing Summers, said Blue Shield has known about these problems for years. "Blue Shield is taking people's hard-earned dollars and then abandoning them when they're sick," he said.
Tina Hoover, 47, a horse trainer in Sherman Oaks, Calif., said Blue Shield canceled her policy twice in two months, even though she'd been paying her premiums faithfully for years.
Blue Shield denied more than $1,000 in doctor visits, saying she'd been terminated. After four calls, inconsistent responses, non-responses and a pointed comment by her husband on Twitter, she finally got her insurance back, she said.
"It was frightening that Blue Shield could be so disorganized on something so important like my health care," said Hoover, who pays $858 a month in premiums and has been a policyholder with the insurer for 15 years.
All health insurers face complaints, from improper denials of care to annoying customer service. But some experts say these persistent breakdowns in customer service at Blue Shield represent a black eye for California's third-largest health insurer, which has 460,000 customers on the Covered California exchange and 3.8 million enrollees overall.
"I've never seen anything on this scale for such basic insurance operations," said Paula Wade, an industry analyst at Decision Resources Group in Nashville, Tenn. "Honest to goodness, if you can't take people's money and credit their account — that's incredibly simple."
Here's me calling @BlueShieldCA AGAIN so I can renew my heart meds after they managed to screw up my automatic payments & never notified me until they cancelled my policy. How hard is to TAKE MY DAMN MONEY?
@BlueShieldCA I’ve been trying to add my infant son to my policy since 5/21. I’ve paid his premiums and no one on your staff can explain to me why he still has no coverage. His shots are now delayed and noone on the phone seems to know what’s happening. Completely unacceptable.
I rarely tweet, but @BlueShieldCA has the absolute worst customer service. They accidentally terminated my insurance, and apologized for the error. After losing approx. 13 hours of work time on the phone, still no solution. What the heck??
Across its plans last year, Blue Shield had the highest complaint rate per 10,000 enrollees among the eight largest health insurers statewide, according to the California Department of Managed Health Care. Blue Shield had 7.43 complaints per 10,000 enrollees, followed by Anthem Blue Cross (5.83), UnitedHealthcare (4.72) and Kaiser Permanente (4.6). (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
For its individual market plans, Blue Shield chose to outsource sign-ups, billing and payment processing to HealthPlan Services, a major contractor for insurers industrywide. In its breach-of-contract lawsuit against the contractor, Blue Shield said it needed outside help to handle the dramatic overhaul of the individual market in 2014 under the ACA.
By June 2014, Blue Shield said it had formed a team of people "whose sole job was to address the failures in HPS' services to ensure that Blue Shield's customers' interests were not impacted," according to the lawsuit.
But the glitches persisted, and Blue Shield said in its lawsuit that it has lost tens of millions of dollars due to the contractor's "egregious" failures on billing, refunds and related matters.
HealthPlan Services' "data was ever-changing, inconsistent and flat-out incorrect," Blue Shield said in the 15-page complaint in San Francisco federal court.
In a statement to California Healthline, HealthPlan Services called Blue Shield's claims "baseless" and said it has a "successful track record of providing quality services to its clients and their members."
But in court papers, Blue Shield said the problems went beyond the sudden cancellations.
For instance, about 14,000 Blue Shield customers experienced "multiple attempted charges on their bank accounts" over one weekend, according to the insurance company's lawsuit. About half the time, Blue Shield alleged, its contractor proposed refunds or credits that were excessive or had no basis at all. One time, a $27,000 refund went to the wrong customer, according to the lawsuit.
In April 2017, Blue Shield said, it initiated termination of the vendor's contract.
In an Aug. 13 counterclaim, HealthPlan Services said "Blue Shield's highly unusual data maintenance and transmission methods and business processes resulted in customer-facing errors that were directly attributable to Blue Shield's conduct."
In a statement, Blue Shield countered that "HPS' allegations are unfounded and we look forward to responding to them in the legal proceedings."
Meantime, San Francisco resident Burcu Sivrikaya, 32, said she found out late last month that Blue Shield had canceled her coverage — effective May 1. She spent hours on the phone talking to seven different company representatives trying to get her policy reinstated, only to be told it would take 30 days, she said. "Are they using pen and paper? Why does it take 30 days? It's insane."
Now Sivrikaya, a social media manager, is trying to get Blue Shield to refund the $1,179 she said she paid in premiums for the three months the company withdrew coverage.
The Department of Managed Health Care fined Blue Shield and a subsidiary $557,500 last year for improper cancellations and a variety of customer grievance violations. Blue Shield is contesting some of those allegations and penalties, according to the state.
Blue Shield noted that it performed well on certain categories in the state data, such as an extremely low complaint rate among medical providers.
The company also said its customer satisfaction score improved in a recent consumer survey by Forrester Research, increasing by nearly 2 percentage points to 63.6 out of 100. Forrester still labeled Blue Shield's performance as "poor," putting it in ninth place out of 17 health insurers that were rated this year.
The doctor most responsible for turning the sunshine supplement into a billion-dollar juggernaut has received hundreds of thousands of dollars from the vitamin D industry, according to government records and interviews.
Dr. Michael Holick's enthusiasm for vitamin D can be fairly described as extreme.
The Boston University endocrinologist, who perhaps more than anyone else is responsible for creating a billion-dollar vitamin D sales and testing juggernaut, elevates his own levels of the stuff with supplements and fortified milk. When he bikes outdoors, he won't put sunscreen on his limbs. He has written book-length odes to vitamin D, and has warned in multiple scholarly articles about a "vitamin D deficiency pandemic" that explains disease and suboptimal health across the world.
His fixation is so intense that it extends to the dinosaurs. What if the real problem with that asteroid 65 million years ago wasn't a lack of food, but the weak bones that follow a lack of sunlight? "I sometimes wonder," Holick has written, "did the dinosaurs die of rickets and osteomalacia?"
Holick's role in drafting national vitamin D guidelines, and the embrace of his message by mainstream doctors and wellness gurus alike, have helped push supplement sales to $936 million in 2017. That's a ninefold increase over the previous decade. Lab tests for vitamin D deficiency have spiked, too: Doctors ordered more than 10 million for Medicare patients in 2016, up 547 percent since 2007, at a cost of $365 million.
But few of the Americans swept up in the vitamin D craze are likely aware that the industry has sent a lot of money Holick's way. A Kaiser Health News investigation found that he has used his prominent position in the medical community to promote practices that financially benefit corporations that have given him hundreds of thousands of dollars — including drugmakers, the indoor-tanning industry and one of the country's largest commercial labs.
In an interview, Holick acknowledged he has worked as a consultant to Quest Diagnostics, which performs vitamin D tests, since 1979. Holick, 72, said that industry funding "doesn't influence me in terms of talking about the health benefits of vitamin D."
There is no question that the hormone is important. Without enough of it, bones can become thin, brittle and misshapen, causing a condition called rickets in children and osteomalacia in adults. The issue is how much vitamin D is healthy, and what level constitutes deficiency.
Holick's crucial role in shaping that debate occurred in 2011. Late the previous year, the prestigious National Academy of Medicine (then known as the Institute of Medicine), a group of independent scientific experts, issued a comprehensive, 1,132-page report on vitamin D deficiency. It concluded that the vast majority of Americans get plenty of the hormone through diet and sunlight, and advised doctors to test only patients at high risk of vitamin D-related disorders, such as osteoporosis.
A few months later, in June 2011, Holick oversaw the publication of a report that took a starkly different view. The paper, in the peer-reviewed Journal of Clinical Endocrinology & Metabolism, was on behalf of the Endocrine Society, the field's foremost professional group, whose guidelines are widely used by hospitals, physicians and commercial labs nationwide, including Quest. The society adopted Holick's position that "vitamin D deficiency is very common in all age groups" and advocated a huge expansion of vitamin D testing, targeting more than half the United States population, including those who are black, Hispanic or obese — groups that tend to have lower vitamin D levels than others.
The recommendations were a financial windfall for the vitamin D industry. By advocating such widespread testing, the Endocrine Society directed more business to Quest and other commercial labs. Vitamin D tests are now the fifth-most-common lab test covered by Medicare.
The guidelines benefited the vitamin D industry in another important way. Unlike the National Academy, which concluded that patients have sufficient vitamin D when their blood levels are at or above 20 nanograms per milliliter, the Endocrine Society said vitamin D levels need to be much higher — at least 30 nanograms per milliliter. Many commercial labs, including Quest and LabCorp, adopted the higher standard.
Yet there's no evidence that people with the higher level are any healthier than those with the lower level, said Dr. Clifford Rosen, a senior scientist at the Maine Medical Center Research Institute and co-author of the National Academy report. Using the Endocrine Society's higher standard creates the appearance of an epidemic, he said, because it labels 80 percent of Americans as having inadequate vitamin D.
"We see people being tested all the time and being treated based on a lot of wishful thinking, that you can take a supplement to be healthier," Rosen said.
Patients with low vitamin D levels are often prescribed supplements and instructed to get checked again in a few months, said Dr. Alex Krist, a family physician and vice chairman of the U.S. Preventive Services Task Force, an expert panel that issues health advice. Many physicians then repeat the test once a year. For labs, "it's in their financial interest" to label patients with low vitamin D levels, Krist said.
In a 2010 book, "The Vitamin D Solution," Holick gave readers tips to encourage them to get their blood tested. For readers worried about potential out-of-pocket costs for vitamin D tests — they range from $40 to $225 — Holick listed the precise reimbursement codes that doctors should use when requesting insurance coverage. "If they use the wrong coding when submitting the claim to the insurance company, they won't get reimbursed and you will wind up having to pay for the test," Holick wrote.
Holick acknowledged financial ties with Quest and other companies in the financial disclosure statement published with the Endocrine Society guidelines. In an interview, he said that working for Quest for four decades — he is currently paid $1,000 a month — hasn't affected his medical advice. "I don't get any additional money if they sell one test or 1 billion," Holick said.
A Quest spokeswoman, Wendy Bost, said the company seeks the advice of a number of expert consultants. "We feel strongly that being able to work with the top experts in the field, whether it's vitamin D or another area, translates to better quality and better information, both for our patients and physicians," Bost said.
Since 2011, Holick's advocacy has been embraced by the wellness-industrial complex. Gwyneth Paltrow's website, Goop, cites his writing. Dr. Mehmet Oz has described vitamin D as "the No. 1 thing you need more of," telling his audience that it can help them avoid heart disease, depression, weight gain, memory loss and cancer. And Oprah Winfrey's website tells readers that "knowing your vitamin D levels might save your life." Mainstream doctors have pushed the hormone, including Dr. Walter Willett, a widely respected professor at Harvard Medical School.
Today, seven years after the dueling academic findings, the leaders of the National Academy report are struggling to be heard above the clamor for more sunshine pills.
"There isn't a 'pandemic,'" A. Catharine Ross, a professor at Penn State and chair of the committee that wrote the report, said in an interview. "There isn't a widespread problem."
Ties To Drugmakers And Tanning Salons
In "The Vitamin D Solution," Holick describes his promotion of vitamin D as a lonely crusade. "Drug companies can sell fear," he writes, "but they can't sell sunlight, so there's no promotion of the sun's health benefits."
Yet Holick also has extensive financial ties to the pharmaceutical industry. He received nearly $163,000 from 2013 to 2017 from pharmaceutical companies, according to Medicare's Open Payments database, which tracks payments from drug and device manufacturers. The companies paying him included Sanofi-Aventis, which markets vitamin D supplements; Shire, which makes drugs for hormonal disorders that are given with vitamin D; Amgen, which makes an osteoporosis treatment; and Roche Diagnostics and Quidel Corp., which both make vitamin D tests.
The database includes only payments made since 2013, but Holick's record of being compensated by drug companies started before that. In his 2010 book, he describes visiting South Africa to give "talks for a pharmaceutical company," whose president and chief executive were in the audience.
Holick's ties to the tanning industry also have drawn scrutiny. Although Holick said he doesn't advocate tanning, he has described tanning beds as a "recommended source" of vitamin D "when used in moderation."
Holick has acknowledged accepting research money from the UV Foundation — a nonprofit arm of the now-defunct Indoor Tanning Association — which gave $150,000 to Boston University from 2004 to 2006, earmarked for Holick's research. The International Agency for Research on Cancer classified tanning beds as carcinogenic in 2009.
In 2004, the tanning-industry associations led Dr. Barbara Gilchrest, who then was head of Boston University's dermatology department, to ask Holick to resign from the department. He did so, but remains a professor at the medical school's department of endocrinology, diabetes and nutrition and weight management.
In "The Vitamin D Solution," Holick wrote that he was "forced" to give up his position due to his "stalwart support of sensible sun exposure." He added, "Shame on me for challenging one of the dogmas of dermatology."
Although Holick's website lists him as a member of the American Academy of Dermatology, an academy spokeswoman, Amanda Jacobs, said he was not a current member.
Dr. Christopher McCartney, chairman of the Endocrine Society's clinical guidelines subcommittee, said the society has put in place stricter policies on conflict of interest since its vitamin D guidelines were released. The society's current policies would not allow the chairman of the guideline-writing committee to have financial conflicts.
A Miracle Pill Loses Its Luster
Enthusiasm for vitamin D among medical experts has dimmed in recent years, as rigorous clinical trials have failed to confirm the benefits suggested by early, preliminary studies. A string of trials found no evidence that vitamin D reduces the risk of cancer, heart disease or falls in the elderly. And most scientists say there isn't enough evidence to know if vitamin D can prevent chronic diseases that aren't related to bones.
Although the amount of vitamin D in a typical daily supplement is generally considered safe, it is possible to take too much. In 2015, an article in the American Journal of Medicine linked blood levels as low as 50 nanograms per milliliter with an increased risk of death.
Some researchers say vitamin D may never have been the miracle pill that it appeared to be. Sick people who stay indoors tend to have low vitamin D levels; their poor health is likely the cause of their low vitamin D levels, not the other way around, said Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women's Hospital in Boston. Only really rigorous studies, which randomly assign some patients to take vitamin D and others to take placebos, can provide definitive answers about vitamin D and health. Manson is leading one such study, involving 26,000 adults, expected to be published in November.
A number of insurers and health experts have begun to view widespread vitamin D testing as unnecessary and expensive. In 2014, the U.S. Preventive Services Task Force said there wasn't enough evidence to recommend for or against routine vitamin D screening. In April, the task force explicitly recommended that older adults outside of nursing homes avoid taking vitamin D supplements to prevent falls.
In 2015, Excellus BlueCross BlueShield published an analysis highlighting the overuse of vitamin D tests. In 2014, the insurer spent $33 million on 641,000 vitamin D tests. "That's an astronomical amount of money," said Dr. Richard Lockwood, Excellus' vice president and chief medical officer for utilization management. More than 40 percent of Excellus patients tested had no medical reason to be screened.
In spite of Excellus' efforts to rein in the tests, vitamin D usage has remained high, Lockwood said. "It's very hard to change habits," he said, adding: "The medical community is not much different than the rest of the world, and we get into fads."
The science-based treatment methods for neonatal abstinence syndrome, involve keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities.
Dr. Jodi Jackson has worked for years to address infant mortality in Kansas. Often, that means she treats newborns in a high-tech neonatal intensive care unit with sophisticated equipment whirring and beeping. And that is exactly the wrong place for an infant like Lili.
Lili's mother, Victoria, used heroin for the first two-thirds of her pregnancy and hated herself for it.
"When you are in withdrawal, you feel your baby that's in withdrawal too," said Victoria, recalling sensations during her pregnancy. (Kaiser Health News is using her first name only because she has used illegal drugs.) "You feel your baby uncomfortable inside of you, and you know that. And then you use and then the baby's not [uncomfortable], and that's a really awful, vulgar thought, but it's true. That's how it is. It's terrible."
Though Victoria went into recovery before giving birth, Lili was born dependent on the methadone Victoria took to treat her opioid addiction. Treatment for infants like Lili has evolved, Jackson said.
"What happened 10, 15 years ago, is [drug-dependent] babies were immediately removed from the mom, and they were put in an ICU warmer with bright lights with nobody holding them," said Jackson, who is a neonatologist at Children's Mercy Hospital in Kansas City, Mo. "Of course, they are going to be upset about that! And so the risk of withdrawal is much higher."
Jackson now leads a statewide effort to get hospitals in Kansas to use the science-based treatment methods for neonatal abstinence syndrome, as the condition is formally known. The symptoms include high-pitched screams, clenched muscles and trouble sleeping. The treatment involves keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities to ease the baby's symptoms until she can be weaned off of them.
It's estimated that around 2 percent of infants are now born drug-dependent. In areas gripped by the opioid crisis, the rate is even higher.
The low-tech, high-touch treatment approach that Lili received in the first weeks of her life is one that health experts encourage hospitals everywhere to adopt as they grapple with increasing numbers of infants born with drug dependencies.
In many parts of the state, Jackson said, she's starting from scratch.
"Many hospitals have no standard of practice. No standard approach," Jackson said.
But improving outcomes for opioid-dependent babies will probably take more than just educating hospital staff.
Dr. Elisha Wachman, who is a neonatalogist at Boston Medical Center and teaches pediatrics at Boston University, said that providing this kind of care is a big adjustment for many hospitals.
"It really depends on the capacity of the hospital and where they house the babies for monitoring," Wachman said. "Some of them don't have room for the mothers to stay with the babies."
Compounding the problem, the matter of exactly what are the "best practices" is far from settled.
For example, new research suggests that methadone may be a better recovery drug for newborns than morphine, which Wachman said is most often used, even though doctors are still unsure about morphine's long-term effects.
"There are very few high-quality clinical trials that have been done in this population of infants," Wachman said. "If you can imagine, this is an incredibly difficult population to study. To do a randomized, controlled trial, for instance, of opiates and neonates is incredibly challenging."
Jackson acknowledged the challenges, but she said establishing consistent practices based on what doctors do know is an important first step toward getting answers.
Victoria said she did everything she could to help newborn Lili get healthy in the hospital, with no idea whether they'd be together in the long term.
"I was trying not to be connected with her, because, I thought, they're probably going to take her," Victoria said. "I haven't been clean that long. So I was trying to not, like, be in love with her. But I was so in love with her." Lili is her fourth child.
Victoria has continued to show state officials that she is committed to staying off drugs. She has been allowed to raise Lili at Amethyst Place, a recovery home in Kansas City.
Lili is now a 16-month-old girl who shares her mother's blond hair, bright eyes and big smile. Despite her difficult start in life, the toddler is in good health, and her mom has been drug-free for a more than a year and a half.
In a campaign motivated by a muddy mix of health care and business, smaller hospitals and the medical device industry are arguing that the TAVR technique should be more widely deployed.
BALTIMORE — When Medicare in 2011 agreed to pay for a revolutionary procedure to replace leaky heart valves by snaking a synthetic replacement up through blood vessels, the goal was to offer relief to the tens of thousands of patients too frail to endure open-heart surgery, the gold standard.
To help ensure good results, federal officials limited Medicare payment only to hospitals that serve large numbers of cardiac patients.
The strategy worked. In the past seven years, more than 135,000 mostly elderly patients have undergone transcatheter aortic valve replacement, known as TAVR. And TAVR's in-hospital mortality rate has dropped by two-thirds, to 1.5 percent.
Now, in a campaign motivated by a muddy mix of health care and business, smaller hospitals and the medical device industry are arguing that the technique should be more widely deployed. They note only about half of the nearly 1,100 hospitals offering surgical valve replacement can do TAVR. And they say current limitations discriminate against minorities and people in rural areas, forcing patients to undergo a riskier and significantly more invasive treatment — or miss getting a new valve altogether.
Hospitals that already have a TAVR franchise are fighting to stifle new competitors, saying programs that don't do enough procedures would not provide high-quality care.
At stake is the care of thousands of patients. Half of the more than 250,000 Americans estimated each year to develop severe aortic valve stenosis — narrowing of the valve that regulates the flow of blood from the heart to the largest artery of the body — die within two years. Getting an artificial heart valve lowers that death rate to as low as 17 percent, studies show.
Also at stake is the $45,000 Medicare pays hospitals for each TAVR case — excluding the doctor's fee. While hospitals typically make only a small profit on the procedure — partly because the device costs more than $30,000 — they benefit because each TAVR patient typically needs other cardiac services and tests that can boost the hospital's bottom line.
In addition, offering TAVR carries a cachet that helps recruit and retain top specialists, who bring in more patients.
At a Medicare advisory committee hearing in Baltimore on July 25, both sides of the debate emphasized how they were seeking to help patients. But the economics of TAVR was ever-present given the horde of medical device and hospital officials and industry analysts in the audience.
The committee split on the issue, although a majority of members backed the continued use of volume requirements. The Centers for Medicare & Medicaid Services is expected to decide later this year whether to change its patient volume minimum for TAVR.
Dr. Jason Felger, a heart surgeon who wants his community hospital in San Angelo, Texas, to offer the procedure, said behind the fight over TAVR is protecting profit and revenue. He refers patients to hospitals more than three hours away for the procedure or, if they aren't willing to travel, they risk their lives to undergo the conventional operation.
Hospitals that offer TAVR, he said, aren't willing to give up the referrals they now rely on from other hospitals.
"It's all about the money," he said.
Improving A Hospital's Reputation
Unlike open-heart surgery, in which the chest is cracked open to remove the unhealthy valve, TAVR involves threading a catheter tipped with a replacement valve through a blood vessel to the heart. Doctors then implant the new valve. The old valve remains but is pushed aside, and the new one takes over its work.
With this less invasive valve procedure, people can get out of the hospital within two or three days and get back to daily activities much sooner than with open-heart surgery, which typically has a six-week recovery time.
TAVR has been approved by the Food and Drug Administration for people who cannot have open-heart surgery or for whom it would be risky. These include the elderly and frail and people with complications such as kidney and lung disease. But TAVR use has expanded among younger, and less sick, patients in recent years. Within the next year, the FDA is likely to approve the procedure for all patients needing a new aortic valve, industry analysts say.
TAVR does carry risks, including stroke. Patients may also need a pacemaker after the procedure to regulate heart rhythm.
TAVR involves threading a catheter tipped with a replacement valve through a blood vessel to the heart. Doctors then implant the new valve.
The large majority of patients getting TAVR are 65 and over. The importance of Medicare's blessing goes beyond its payments, since private insurers typically follow Medicare standards. Physicians seeking to expand use of TAVR point out that Medicare has no volume requirements for other major cardiac procedures.
The two largest TAVR medical device companies are divided on the issue. Edwards Lifesciences Corp. of Irvine, Calif., supports eliminating the minimum-patient requirements, while Minneapolis-based Medtronic favors keeping the status quo. The Advanced Medical Technology Association, or AdvaMed, an industry trade group, also supports the change.
About 50,000 patients are expected to have TAVR this year, and those numbers are forecast to double by 2020, according to American College of Cardiology and other major heart groups.
When Michael Vigil, 50, needed TAVR in May, he drove more than three hours from his home in eastern Wyoming to a hospital in Denver. Before the procedure, the oil-drilling contractor was constantly tired and out of breath — even after mundane chores at home. Vigil's aortic valve had been damaged from radiation treatments for non-Hodgkin lymphoma decades before.
Vigil was sent home a day after the TAVR procedure. He was back at work the following week.
He said he felt more energized almost immediately after having the procedure.
"It's worked so well, my wife wishes they dialed it back a little," Vigil said.
Donnette Smith, president of the patient advocacy group Mended Hearts, said many patients don't have good access to the procedure.
"Patients do not know of this option unless they walk through the right door of the right hospital," said Smith of Huntsville, Ala. She had heart valve surgery in 1988.
Mended Hearts receives funding from device makers.
'Experience Matters'
To gain Medicare approval for TAVR programs, hospitals have to perform annually 50 open-heart valve repairs, 400 angioplasties and 1,000 cardiac catheterizations — a procedure in which medical teams use skills similar to those needed for TAVR.
Doctors at larger hospitals say procedure volume is a good predictor for success. The American College of Cardiology and the Society of Thoracic Surgeons recommend hospitals be able to do at least 50 TAVRs each year within two years of startup. More than three-quarters of the 582 hospitals authorized by Medicare for TAVR meet that standard.
"Whether it's playing the violin or performing heart surgery, experience matters," said Dr. Thoralf Sundt, chief of cardiac surgery at Massachusetts General Hospital.
Dr. Ashish Pershad, an interventional cardiologist who performs TAVR at Banner Medical Center in Phoenix, agreed that there are access issues. But he said it's not because of a lack of programs. Rather, he said, surgeons too often don't refer patients for it because they make more money from doing the open-heart surgical valve replacement.
"Patients are missing out on this procedure because they are not being referred, and primary care doctors lack knowledge about it," he said.
Expanding Treatment Options
Doctors seeking a Medicare rule to widen access say there is little evidence hospitals that perform more TAVRs have lower mortality rates. As long as they can show low mortality and complications, they believe their hospitals should be able to offer the service.
"Our intention is not to lower the quality of outcomes by expanding to 'low volume' centers; but to provide excellent care to a larger population of patients," Felger and his colleagues at Shannon Medical Center in San Angelo, Texas, wrote to the CMS advisory group.
Last year, Felger said, he sent a dozen patients to hospitals in Austin or Dallas for TAVR, while eight other patients opted for the open-heart surgery.
"I have patients tell me they would rather have the surgical procedure at their local hospital than traveling to another city," he said. "They tell me 'Let's do this; if I die, I die.'"
The sales pitch was 'simply not true' and 'a smoking gun,' said one physician at the Johns Hopkins Bloomberg School of Public Health Center for Drug Safety and Effectiveness.
Two decades ago, Purdue Pharma produced thousands of brochures and videos that urged patients with chronic pain to ask their physicians for opioids such as OxyContin, arguing that concerns over addiction and other dangers from the drugs were overblown, company records reveal.
Kaiser Health News earlier this year posted a cache of Purdue marketing documents that show how the pharmaceutical company sought to boost sales of the prescription painkiller, starting in the mid-1990s.
Purdue turned the records over to the Florida attorney general's office in 2002 during its investigation of the company. Additional Purdue documents from the Florida investigation detail how the company targeted patients and allayed addiction worries.
"Fear should not stand in the way of relief of your pain," a pivotal marketing brochure said.
Purdue said it handed out thousands of copies of the brochure, which emphasized consumer power in treating pain, as well as a videotape. "The single most important thing for you to remember is that you are the authority on your pain. Nobody else feels it for you so nobody else can describe how much it hurts, or when it feels better," the pamphlet states.
More than 1,500 pending civil lawsuits, filed mostly by state and local governments, allege that deceptive marketing claims helped fuel a national epidemic of opioid addiction and thousands of overdose deaths.
This week, the New York attorney general's office filed another suit that accuses Purdue of operating a "public nuisance" in it sales tactics and marketing of opioids. Like many others, the suit demands compensation for addiction treatment costs and other problems. Purdue and other drugmakers have denied all allegations.
President Donald Trump said Thursday he wants the federal government to sue drugmakers in response to the addiction epidemic.
The Purdue brochure from the late 1990s spurred recent criticism from drug safety experts. Dr. G. Caleb Alexander, a physician at the Center for Drug Safety and Effectiveness at Johns Hopkins Bloomberg School of Public Health, said the sales pitch was "simply not true" and called it "a smoking gun."
"We have learned the hard way that many patients develop opioid [addiction] when using these medicines as prescribed," he said.
Alexander said other drugmakers also appealed to patients hoping to influence their doctors — a tactic that was relatively new in the late 1990s. But Alexander said he was "shocked" to hear that Purdue did so with OxyContin, given the risks posed by long-term use of the morphine-like narcotic.
"These drugs [opioids] are in a class of their own when it comes to the harms that they have caused," Alexander said.
The internal Purdue documents, dating from 1996 to 2002, show that the company began marketing OxyContin to doctors in late 1995 for treating moderate to severe cancer pain. With modest sales of $49.4 million in 1996, Purdue posted a loss of $452,000 on the drug. In 1997, sales reached $146.5 million for a pretax profit of $16.5 million, the company records show.
In 1998, as Purdue hawked OxyContin for conditions such as arthritis and back pain, it decided to "increase communications" with patients, company records show.
The goal: "convince patients and their families to actively pursue effective pain treatment. The importance of the patient assessing their own pain and communicating the status to the health care giver will be stressed."
Purdue's six-page pamphlet for patients, provided to the Florida attorney general, was titled "OxyContin: A Guide to Your New Pain Medicine." "Your health care team is there to help, but they need your help, too," the pamphlet says. It says OxyContin is for treating "pain like yours that is moderate to severe and lasting for more than a few days."
To patients or family members worried about addiction, Purdue's pamphlet said: "Drug addiction means using a drug to get 'high' rather than to relieve pain. You are taking opioid pain medication for medical purposes. The medical purposes are clear and the effects are beneficial, not harmful."
Asked to comment this week, Purdue spokesman Robert Josephson said the company "discontinued the use of this piece many years ago."
Dr. Michael Barnett, a physician and assistant professor at the Harvard T.H. Chan School of Public Health, said that some of Purdue's early marketing claims may have seemed reasonable to many doctors 20 years ago.
But he faulted the medical profession for not demanding scientific evidence that opioids were in fact safe and prudent for widespread use.
"I think a lot of physicians are coming to the realization that a lot of what we were taught about pain management was pure conjecture," he said. "I feel foolish for believing it."
In hindsight, he said, Purdue's sales tactics seem "almost a satire of an unscrupulous corporation that really has no interest in understanding the implications and complications of people using their drugs."
Dr. Art Van Zee, a physician in southwestern Virginia who was among the first to recognize the ravages of OxyContin misuse, said that some people who became addicted were drug abusers.
But he added: "There clearly are people that I've taken care of who took it as directed orally and became opioid-addicted."
Purdue also paid a New York City production company to shoot a videotape called "From One Pain Patient to Another," featuring testimonials by seven patients from the Raleigh, N.C., area under the care of pain doctor Alan Spanos. Filming took place at the patients' homes, places of work and other area locations on July 17, 1997, according to the documents.
Purdue did not pay the patients, though Spanos received $3,400 as a "physician spokesman" on that video and another, the company records state. Contacted recently by phone, Spanos would not comment. In the documents, Purdue said that the patients "participated willingly, wishing to speak out regarding the importance to them of being able to receive effective therapy for their chronic pain."
Between January 1998 and June 2001, Purdue distributed 16,000 copies of the video to doctors, who showed them to selected patients.
The video did not mention OxyContin directly, but the Food and Drug Administration did balk at a claim in the video that fewer than 1 percent of people taking opioids became addicted. The FDA said that claim was not substantiated, according to a December 2003 General Accountability Office audit.
Purdue destroyed remaining copies of the video in July 2001, including 4,434 Spanish-language versions, according to the company records.
By then, annual OxyContin sales had topped $1 billion as Purdue pushed to "attach an emotional aspect to non-cancer pain so physicians treat it more seriously and aggressively," according to the company's marketing reports.
Asked about the video, Purdue spokesman Josephson said the drugmaker has not made that claim — regarding 1 percent addiction — "in more than 15 years."
Purdue submitted the marketing records to the Florida attorney general's office during its investigation of the company. The state settled the case in 2002 when Purdue agreed to pay $2 million to help set up an electronic prescription-tracking program.
Florida officials released the records to two Florida newspapers in 2003 after Purdue lost a court battle to keep them confidential. KHN posted some of those documents earlier this year for readers to review on its website.
With their 24/7 lighting, heating and water needs, they use up to five times more energy than a fancy hotel.
Executives at some systems view their facilities like hotel managers, adding amenities, upscale new lobbies and larger parking garages in an effort to attract patients and increase revenue. But some hospitals are revamping with a different goal in mind: becoming more energy-efficient, which can also boost the bottom line.
"We're saving $1 [million] to $3 million a year in hard cash," said Jeff Thompson, the former CEO of Gundersen Health System in La Crosse, Wis., the first hospital system in the U.S. to produce more energy than it consumed back in 2014. As an added benefit, he said, "we're polluting a lot less."
The health care sector — one of the nation's largest industries — is responsible for nearly 10 percent of all greenhouse gas emissions — hundreds of millions of tons worth of carbon each year. Hospitals make up more than one-third of those emissions, according to a paper by researchers at Northeastern University and Yale.
Increasingly, though, health systems are paying attention:
Gundersen Health System in Wisconsin employs wind, wood chips, landfill-produced methane gas — and even cow manure — to generate power, reporting more than a 95 percent drop in its emissions of carbon monoxide, particulate matter and mercury from 2008 to 2016.
Boston Medical Center analyzed its hospital for duplicative and underused space, then downsized while increasing patient capacity. Among other changes, it now has a gas-fired 2-megawatt cogeneration plant that traps and reuses heat, saving money and emissions, while supplying 41 percent of the hospital's needs and acting as a backup for essential services if the municipal power grid goes out.
Theda Clark Medical Center in Wisconsin is saving nearly $800,000 a year — 30 percent of its energy costs — after making changes that included retrofitting lights, insulating pipes, taking the lights out of vending machines and turning off air exchangers in parts of its building after hours.
Kaiser Permanente aims to be "carbon-neutral" by 2020, mainly by incorporating solar energy at up to 100 of its hospitals and other facilities. One already in use — at its Richmond (Calif.) Medical Center — is credited with reducing electric bills by about $140,000 a year. (Kaiser Health News is not affiliated with Kaiser Permanente.)
While the environmental benefits are important, "what I've seen over the years is cost reductions are the prime motivator," said Patrick Kallerman, research manager at the Bay Area Council Economic Institute, which released a report this spring outlining ways the hospital industry can help states such as California reach environmental goals by becoming more efficient.
Some of its recommendations are simple: replacing old lighting and windows. Others are more complex: powering down heating and cooling in areas not being used and updating ventilation standards first set back in Florence Nightingale's day. Such tight standards "might not be necessary," Kallerman said. Loosening them could help save money and energy.
When Bob Biggio was hired in 2011 to oversee Boston Medical Center's facilities, hospital leaders were about to launch a broad redesign. Yet the hospital was also facing serious financial struggles. He put the move on hold while analyzing how the hospital was using its existing space, looking for unused or duplicative areas.
"My first impression with data I had gathered was our campus was about 400,000 square feet bigger than it needed to be, said Biggio. "A square foot you never have to build is most efficient of all."
The new design is smaller but more efficient, handling 20 percent higher patient volume and eliminating the need for ambulance transportation between far-flung areas of the campus. It also cut power consumption by 42 percent from a 2011 baseline.
While the hospital sunk a lot of money into the renovation, the center was able to sell off some of its land to help offset the costs, leading to about a five-year return on investment, Biggio said.
"We are a safety-net hospital with a large Medicaid population," he said. "So this is the last place people expect to see the type of investments and progress we've made."
But how to sell that in the C-suite?
The environmental argument wasn't how Thompson convinced executives at Gundersen.
"At no point did I mention climate change or polar bears," said Thompson.
Instead, he focused on the organization's mission to improve health — and the potential cost savings.
"There are multiple examples — at Gundersen and other places — where, if we're thoughtful, we can improve the local economy, lower the cost of health care and decrease the pollution that is making people sick," he said.
But hospitals' energy efficiency efforts vary, with only about 10 percent attempting changes as dramatic as those done at Gundersen, estimated Alex Thorpe, a hospital energy expert at Optum Advisory Services, a consulting firm owned by UnitedHealth Group.
"About 50 percent are in the middle," he added, perhaps because these investments are weighed against other capital needs.
"If you have a well-known doctor that wants a new cutting-edge piece of equipment, then it can be hard to make the business case [for investing in alternative energy]," said Thorpe.
Of the more than 5,000 hospitals in the country, about 1,100 are members of Practice Greenhealth, a nonprofit that promotes environmental stewardship. Fewer than 300 hospitals qualify as Energy Star facilities, an Environmental Protection Agency program that recognizes buildings that rank in the top quartile for energy conservation among their peers.
Greenhealth estimates its members average about a million dollars a year in savings, but it all depends what steps they take.
There are modest savings from such things as reducing the heating and air conditioning in operating rooms during hours they are not in use, with median annual cost savings of $45,398, a report from the group notes. Other energy reduction efforts net another median $53,599 in annual savings, while swapping older lighting for new LED bulbs in operating rooms saves another $3,329.
Individually, those savings are not even rounding errors in most hospitals' total expenses, which are measured in the millions of dollars.
Still, within facility expenses, energy use accounts for 51 percent of spending, so even modest cuts are "significant," said Kara Brooks, sustainability program manager for the American Society for Healthcare Engineering.
Ultimately, that may affect what hospitals charge insurers and patients.
"If hospitals can lower peak demand through energy efficiency efforts, that will directly impact their pricing," said Thorpe.
Even as the Trump administration has blocked other provisions of the ACA and pushed Congress to repeal the law, it has encouraged states to establish reinsurance programs and seek federal funding.
When Tracy Deis decided in 2016 to transition from a full-time job to part-time contract work, the loss of her employer's health insurance was not a major worry because she knew she could get coverage through the marketplace set up by the Affordable Care Act.
But price was a big concern.
"The ACA made it possible to make the switch in my life," said Deis, 48, who lives in Minneapolis. But she quickly added, "I was really worried about the cost."
Her anxiety was understandable. In Minnesota, the average cost of insurance in the state-run exchange soared 57 percent in 2017, after a 40 percent rise in 2016.
Amid a public outcry, the legislature last year took several steps to stabilize its individual insurance marketplace.
Among those moves, lawmakers launched a "reinsurance" program. The program helps pay the costs insurers incur for people with high medical bills. In turn, the companies — knowing that these "outlier" expenses will be covered — can lower premiums. Alaska had launched a similar program in 2016.
The Alaska and Minnesota models have now become touchstones for other states eager to prevent startling premium increases in the individual insurance marketplace.
Critically, much of the money comes from the federal government. A provision in the ACA allows states to experiment with their marketplaces as long as they honor ACA requirements and don't cost the federal government more money. (Federal reinsurance funding for high-cost patients reduces premium subsidies, which are fully paid by the federal government.)
Notably, even as the Trump administration has blocked other provisions of the ACA and pushed Congress to repeal the law, it has encouraged states to establish reinsurance programs and seek federal funding.
In Alaska, lawmakers used only state funds to cut an anticipated 43 percent premium increase to 7 percent in 2017. As the program continued in 2018 with $58 million in federal funds, the lone insurer in the state, Premera Blue Cross Blue Shield, lowered premiums by an average 22.4 percent. And on Aug. 2, Premera announced it had asked the state if it could reduce premiums by an average 3.9 percent in 2019.
Alaska's program, unlike other states', covers all the costs for people with 33 high-cost conditions. In 2017, about half of all expenses for enrollees in the exchange were for people with one or more of those conditions.
"We have unique issues here," said Jim Grazko, president of Premera Blue Cross Blue Shield of Alaska. "Without the reinsurance program, things would be untenable in the individual market."
The federal Department of Health and Human Services approved Minnesota's waiver request for a 2018 reinsurance program, with $131 million in funding. The program covers medical bills between $50,000 and $250,000 for marketplace customers.
It worked. Premium rates declined by 13 percent in 2018 compared with 2017 and are projected to drop again in 2019 by 5 to 8 percent, according to Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans.
That was good news for Deis. Her monthly premium this year is $317, down from $355 in 2017. She's in a plan that includes the doctors she wanted and is happy with her coverage, although it has a deductible of $7,050.
"I wouldn't mind if my premiums came down again for 2019," she said. "Every little bit helps."
Pushing Premiums Down
Oregon also launched a federally approved reinsurance program in 2018. And last month, the Trump administration notified Wisconsin and Maine that their requests for reinsurance program funding had been approved.
Four other states — Idaho, Louisiana, Maryland and New Jersey — are seeking federal approval for reinsurance programs enacted this year. All hope to have plans in place for 2019.
Eric Cioppa, Maine's insurance commissioner, estimates his state's reinsurance program will reduce premiums in 2019 by an average 9 percent compared to what they would have been without the program.
"Reinsurance is possibly the best proven mechanism to restrain premium increases and keep health insurance affordable," said Trish Riley, executive director of the National Academy for State Health Policy in Portland, Maine. "The biggest plus is that it's a tool with support across the political spectrum."
That includes some deep conservatives, such as Wisconsin Gov. Scott Walker, a Republican and longtime critic of Obamacare. He strongly supports the reinsurance program and touts it on the campaign trail as he seeks a third term.
Wisconsin's program establishes a $200 million fund — $166 million of it federal money — to pay about 50 percent of the costs for individuals with medical expenses between $50,000 and $200,000.
The state's insurance department estimates the program will yield premiums in 2019 that will be 11 percent lower on average than they would have been without reinsurance. Premiums rose 44 percent in 2018, leading 25,000 people to drop coverage.
For Amy Brooks, of Madison, Wis., the initiative is especially timely. Brooks, 48, who pays $150 a month for subsidized coverage in an ACA plan because her job didn't come with insurance, was diagnosed in April with a benign brain tumor that required surgery.
She lost her job after the diagnosis and said having insurance coverage "takes a gigantic weight off my shoulder. I would have gone bankrupt. … Anything that keeps the costs down is a huge help because I could need this coverage for some time."
No Panacea
Insurance analysts say that state-based reinsurance programs are a potent mechanism to lower premiums, but not a panacea.
The programs don't address underlying medical costs, for example. And if money for the programs is not sustained — or increased — over time, reinsurance can yield a one-time decline in premiums over a year or two.
"That initial decrease is meaningful, to be sure," said Matthew Fiedler, a health policy researcher at the Brookings Institution in Washington, D.C. "But other steps are needed to help stabilize the exchanges." That could include more money for reinsurance as time goes on, he said.
The every-state-for-itself approach also frustrates insurers and consumer advocates.
"A sustained federal approach would be much preferable and what we'd like to see," said Kris Haltmeyer, vice president for legislative and regulatory policy at the Blue Cross Blue Shield Association, which represents 36 Blues plans nationwide.
After Republicans in Congress failed to repeal and replace the ACA in 2017, Sens. Patty Murray (D-Wash.) and Lamar Alexander (R-Tenn.) launched a bipartisan effort to stabilize the ACA marketplaces. A prominent part of their plan was a $30 billion reinsurance pool — $10 billion a year.
The effort failed in March amid discord over an unrelated abortion measure in the bill.