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An Ice Rink To Fight Opioid Crisis: Drug-Free Fun vs. Misuse of Settlement Cash

A Kentucky county nestled in the heart of Appalachia, where the opioid crisis has wreaked devastation for decades, spent $15,000 of its opioid settlement money on an ice rink.

That amount wasn’t enough to solve the county’s troubles, but it could have bought 333 kits of Narcan, a medication that can reverse opioid overdoses. Instead, people are left wondering how a skating rink addresses addiction or fulfills the settlement money’s purpose of remediating the harms of opioids.

Like other local jurisdictions nationwide, Carter County is set to receive a windfall of more than $1 million over the next decade-plus from companies that sold prescription painkillers and were accused of fueling the overdose crisis.

County officials and proponents of the rink say offering youths drug-free fun like skating is an appropriate use of the money. They provided free entry for students who completed the Drug Abuse Resistance Education (D.A.R.E.) curriculum, recovery program participants, and foster families.

But for Brittany Herrington, who grew up in the region and became addicted to painkillers that were flooding the community in the early 2000s, the spending decision is “heartbreaking.”

“How is ice-skating going to teach [kids] how to navigate recovery, how to address these issues within their home, how to understand the disease of addiction?” said Herrington, who is now in long-term recovery and works for a community mental health center, as well as a regional coalition to address substance use.

She and other local advocates agreed that kids deserve enriching activities, but they said the community has more pressing needs that the settlement money was intended to cover.

Carter County’s drug overdose death rate consistently surpasses state and national averages. From 2018 to 2021, when overdose deaths were spiking across the country, the rate was 2.5 times as high in Carter County, according to the research organization NORC.

Other communities have used similar amounts of settlement funding to train community health workers to help people with addiction, and to buy a car to drive people in recovery to job interviews and doctors’ appointments.

Local advocates say $15,000 could have expanded innovative projects already operating in northeastern Kentucky, like First Day Forward, which helps people leaving jail, many of whom have a substance use disorder, and the second-chance employment program at the University of Kentucky’s St. Claire health system, which hires people in recovery to work in the system and pays for them to attend college or a certification program.

“We’ve got these amazing programs that we know are effective,” Herrington said. “And we’re putting an ice-skating rink in. That’s insane to me.”

A yearlong investigation by KFF Health News, along with researchers at the Johns Hopkins University Bloomberg School of Public Health and the national nonprofit Shatterproof, found many jurisdictions spent settlement funds on items and services with tenuous, if any, connections to addiction. Oregon City, Oregon, spent about $30,000 on screening first responders for heart disease. Flint, Michigan, bought a nearly $10,000 sign for a community service center building , and Robeson County, North Carolina, paid about $10,000 for a toy robot ambulance.

Although most of the settlement agreements come with national guidelines explaining the money should be spent on treatment, recovery, and prevention efforts, there is little oversight and the guidelines are open to interpretation.

A Kentucky law lists more than two dozen suggested uses of the funds, including providing addiction treatment in jail and educating the public about opioid disposal. But it is plagued by a similar lack of oversight and broad interpretability.

Chris Huddle and Harley Rayburn, both of whom are elected Carter County magistrates who help administer the county government, told KFF Health News they were confident the ice rink was an allowable, appropriate use of settlement funds because of reassurances from Reneé Parsons, executive director of the Business Cultivation Foundation. The foundation aims to alleviate poverty and related issues, such as addiction, through economic development in northeastern Kentucky.

The Carter County Times reported that Parsons has helped at least nine local organizations apply for settlement dollars. County meeting minutes show she brought the skating rink proposal to county leaders on behalf of the city of Grayson’s tourism commission, asking the county to cover about a quarter of the project’s cost.

In an email, Parsons told KFF Health News that the rink — which was built in downtown Grayson last year and hosted fundraisers for youth clubs and sports teams during the holiday season — serves to “promote family connection and healing” while “laying the groundwork for a year-round hockey program.”

“Without investments in prevention, recovery, and economic development, we risk perpetuating the cycle of addiction in future generations,” she added.

She said the rink, as well as an $80,000 investment of opioid settlement funds to expand music and theater programs at a community center, fit with the principles of the Icelandic prevention model, “which has been unofficially accepted in our region.”

That model is a collaborative community-based approach to preventing substance use that has been highly effective at reducing teenage alcohol use in Iceland over the past 20 years. Instead of expecting children to “just say no,” it focuses on creating an environment where young people can thrive without drugs.

Part of this effort can involve creating fun activities like music classes, theatrical shows, and even ice-skating. But the intervention also requires building a coalition of parents, school staffers, faith leaders, public health workers, researchers, and others, and conducting rigorous data collection, including annual student surveys.

About 120 miles west of Carter County, another Kentucky county has for the past several years been implementing the Icelandic model. Franklin County’s Just Say Yes program includes more than a dozen collaborating organizations and an in-depth annual youth survey. The project began with support from the Centers for Disease Control and Prevention and has also received opioid settlement dollars from the state.

Parsons did not respond to specific questions about whether Carter County has taken the full complement of steps at the core of the Icelandic model.

If it hasn’t, it can’t expect to get the same results, said Jennifer Carroll, a researcher who studies substance use and wrote a national guide on investing settlement funds in youth-focused prevention.

“Pulling apart different elements, at best, is usually going to waste your money and, at worst, can be counterproductive or even harmful,” she said.

At least one Carter County magistrate has come to regret spending settlement funds on the skating rink.

Millard Cordle told KFF Health News that, after seeing the rink operate over the holidays, he felt it was “a mistake.” Although younger children seemed to enjoy it, older kids didn’t engage as much, nor did it benefit rural parts of the county, he said. In the future, he’d rather see settlement money help get drugs off the street and offer people treatment or job training.

“We all learn as we go along,” he said. “I know there’s not an easy solution. But I think this money can help make a dent.”

As of 2024, Carter County had received more than $630,000 in opioid settlement funds and was set to receive more than $1.5 million over the coming decade, according to online records from the court-appointed settlement administrator.

It’s not clear how much of that money has been spent, beyond the $15,000 for the ice rink and $80,000 for the community arts center.

It’s also uncertain who, if anyone, has the power to determine whether the rink was an allowable use of the money or whether the county would face repercussions.

Kentucky’s Opioid Abatement Advisory Commission, which controls half the state’s opioid settlement funds and serves as a leading voice on this money, declined to comment.

Cities and counties are required to submit quarterly certifications to the commission, promising that their spending is in line with state guidelines. However, the reports provide no detail about how the money is used, leaving the commission with little actionable insight.

At a January meeting, commission members voted to create a reporting system for local governments that would provide more detailed information, potentially opening the door to greater oversight.

That would be a welcome change, said John Bowman, a person in recovery in northeastern Kentucky, who called the money Carter County spent on the ice ink “a waste.”

Bowman works on criminal justice reform with the national nonprofit Dream.org and encounters people with substance use disorders daily, as they struggle to find treatment, a safe place to live, and transportation. Some have to drive over an hour to the doctor, he said — if they have a car.

He hopes local leaders will use settlement funds to address problems like those in the future.

“Let’s use this money for what it’s for,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Covid ‘Contrarians’ Are in Power. We Still Haven’t Hashed Out Whether They Were Right.

In October, Stanford University professor Jay Bhattacharya hosted a conference on the lessons of covid-19 in order “to do better in the next pandemic.” He invited scholars, journalists, and policy wonks who, like him, have criticized the U.S. management of the crisis as overly draconian.

Bhattacharya also invited public health authorities who had considered his alternative approach reckless. None of them showed up.

Now, the “contrarians” are seizing the reins: President Donald Trump has nominated Bhattacharya to lead the National Institutes of Health and Johns Hopkins University surgeon Marty Makary to run the Food and Drug Administration. Yet the polarized disagreements about what worked and what didn’t in the fight against the biggest public health disaster in modern times have yet to be aired in a nonpartisan setting — and it seems unlikely they ever will be.

“The whole covid discussion turned into culture war dialogue, with one side saying, ‘I believe in the economy and liberty,’ and the other saying, ‘I believe in science and saving people’s lives,’” said Philip Zelikow, a scholar and former diplomat based at Stanford’s Hoover Institution.

Frances Lee, a Princeton University political scientist, has a book coming out that calls for a national inquiry to determine the lockdown and mandate approaches that were most effective.

“This is an open question that needs to be confronted,” she said. “Why not look back?”

For now, even with the threat of an H5N1 bird flu pandemic on the horizon, and some other plague waiting in the wings of a bat or goose in a far-flung corner of the world, U.S. public health officials face ebbing public trust as well as a disruptive new health administration led by skeptics of established medicine. On Feb. 7, the Trump administration announced devastating NIH budget cuts, although a judge put them on hold three days later.

Zelikow led the 34-member Covid Crisis Group, funded by four private foundations in 2021, whose work was intended to inform an independent inquiry along the lines of the 9/11 Commission, which Zelikow headed.

The covid group published a book detailing its findings, after Congress and the Biden administration abandoned initiatives to create a commission.

That was a shame, said Jennifer Nuzzo, director of the Pandemic Center at the Brown University School of Public Health, because “while there are some real ideological battles over covid, there’s also lots of stuff that potentially could be fixed related to government efficiency and policy.”

Bhattacharya, Makary, and others in 2023 called for a larger study of the pandemic. It’s not known whether the Trump administration would support one, Lee said.

The new CIA director, John Ratcliffe, however, has reopened the Wuhan lab leak theory, an issue that Republicans have used to try to cast blame on Anthony Fauci, an infectious disease expert and a top covid adviser to both the first Trump and Biden administrations. Sen. Ron Johnson (R-Wis.), the new head of the Senate’s Permanent Subcommittee on Investigations, says he’ll investigate what he described as a cover-up of covid vaccine safety problems.

Bhattacharya declined to respond to questions for this article. Makary did not respond to requests for comment.

Stanford epidemiologist John Ioannidis said his colleague Bhattacharya has an opportunity to advance understanding of the pandemic.

“Until now it has been mostly a war on impressions and media, kind of mobilizing the troops. That’s not really how science should be done,” Ioannidis said. “We need to move forward with some calm reflection, with no retaliation.”

Mistakes Were Made

In October 2020, Bhattacharya co-authored the “Great Barrington Declaration” with Trump White House support. It called for people to ignore covid and go about their business while protecting the old and vulnerable — without specifics about how.

Bhattacharya and Makary championed the policies of Sweden, which did not impose a harsh lockdown but emerged with a death rate far lower than that of the United States. The Swedes had advantages including lower poverty rates, greater access to health care, and high levels of social trust. For instance, by April 2022, 87% of Swedes ages 12 and over were vaccinated against covid — without mandates. The U.S. figure, for adults over 18, was 76% at the time.

After Bhattacharya’s earlier research was rebuffed by most of the public health establishment, he “curdled into a theological position that the risk wasn’t that severe and the economic costs were so high that we had to roll the dice, or segregate the elderly — which you cannot do,” Zelikow said.

Ten experts interviewed for this article largely agreed that the health establishment lost public trust after bungling the initial handling of the pandemic. Existing pandemic plans were faulty or ignored. Shortages of protective gear and inadequate testing rendered containment of the virus impossible. As time wore on, government scientists failed to emphasize that their recommendations would change as new data came in.

“We totally blew it,” former NIH Director Francis Collins said, in a discussion sponsored by Braver Angels, a group that promotes dialogue among political opponents. Though he blamed disinformation about vaccines for many deaths, he also wished public health officials had said “we don’t know” more often.

Collins said he didn’t pay enough attention to the socioeconomic impact of lockdowns. “You attach infinite value to stopping the disease and saving a life,” he said. “You attach zero value to whether this actually totally disrupts people’s lives, ruins the economy, and has many kids kept out of school in a way that they never quite recover from.”

While Fauci and other public health officials did express worries about collateral damage from mandates, U.S. measures were stricter than in much of the world. That’s left unresolved issues, such as how long schools should have been shuttered, whether mask mandates worked, and whether the public was misled about the efficacy of vaccines.

At the same time, U.S. officials failed to communicate clearly that vaccines prevented most deaths and hospitalizations. An estimated 232,000 unvaccinated Americans died from covid during the first 15 months in which shots were freely available.

Experiences with HIV control taught public health officials not to moralize about behavior, to focus on harm reduction, and to use the least restrictive methods possible, Nuzzo said. Yet politicization led to shaming of people who wouldn’t mask or refused vaccination.

Harm reduction was top of mind for infectious disease doctor Monica Gandhi when she defied lockdown orders by keeping open Ward 86, the clinic she runs for 2,600 HIV patients at Zuckerberg San Francisco General Hospital. Her patients — many poor or homeless — had to be treated in person to keep their HIV in check, she said.

In general, the lockdowns hurt low-income people most, she said. The wealthy “were happy to be shut down, and the poor struggled and struggled.” Gandhi’s two children attended a private school that quickly reopened, she said. Yet she recalled how a medical assistant burst into tears when asked how her family was doing.

“My 8-year-old is at home, on Zoom, all by himself,” the woman told Gandhi. “I have to work and he doesn’t know how to learn that way. There’s no one to give him food.”

Despite strictures, including school closures that were longer than in most European countries, the U.S.’ death rate from covid was the highest in the world, except for Bulgaria, according to an Ioannidis study of countries with reliable data.

Part of the blame lies with the first Trump administration, which “more or less just said, ‘You states manage this crisis,’” Zelikow said. “They went through a lot of somersaults. They did a lot of feckless things and then they basically just gave up,” he said. Pandemic deaths peaked in the four months after the November 2020 election that Trump lost.

Ioannidis, a critic of lockdowns, said the United States was doomed to a bad outcome in any case because of vulnerabilities in the population including poverty, inequality, lack of health care access, poorly protected nursing homes, high rates of obesity, and low levels of trust.

But the disappearance of viral diseases such as respiratory syncytial virus and flu in late 2020 showed how much worse it could have been without lockdowns, said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, who has noted that, while children were the least vulnerable to covid, it killed 1,700 of them by April 2023. More than a million American children had had long covid as of 2022, according to a new Centers for Disease Control and Prevention study.

Consensus Never Arrived

After arising by accidental passage from bats and other animals to humans (or, alternatively, from a Chinese lab accident), the coronavirus was uncannily adept at frustrating containment efforts — and aggravating political tensions. Its ability to infect up to 50% of people asymptomatically, infection outcomes ranging from sniffles to death, waning immunity after infection and vaccination, and the shifting health impact of new variants meant “the deck was stacked against public health,” said biology professor Joshua Weitz of the University of Maryland.

In the end, teams formed along political lines. Conservatives attacked governors for depriving them of liberty, and Trump’s erroneous ramblings about curing the disease with bleach and ultraviolet light inspired intolerance on the left.

“If anyone else was president we would have had a better result,” Gandhi said. “But if Trump said the sky was blue, then goddamn it, the infection disease doctors disagreed.”

The right and left don’t even agree on the correct questions to ask about the pandemic, said Josh Sharfstein, a vice dean of the Bloomberg School of Public Health at Johns Hopkins University.

“Everyone knew that 9/11 was a terrorist attack,” he said. “But what the pandemic was and represents — there’s so much disagreement still.”

“We let children down, we let poor people down,” Ioannidis said in closing remarks at the Stanford conference. “We let our future down.”

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Republicans Are Eyeing Cuts to Medicaid. What’s Medicaid, Again?

In January, during a congressional hearing on his way to becoming secretary of the Department of Health and Human Services, Robert F. Kennedy Jr. got basic details wrong about Medicaid — a program he now oversees.

He said that Medicaid is fully funded by the federal government (it’s not) and that many enrollees are unsatisfied with high out-of-pocket costs (enrollees pay limited, if any, out-of-pocket costs).

Medicaid is complex. The $880 billion-a-year state-federal program offers health coverage to millions of disabled and low-income Americans. The program covers different services for different people in different parts of the country — and enrollees may interact with private insurance companies without “Medicaid” in their names, leaving some unaware that they’re on the program at all.

Although President Donald Trump promised to “love and cherish” Medicaid, Republicans in Congress last week announced federal budget proposals that could dramatically curtail the program. As that debate begins, here is what you need to know about Medicaid.

What is Medicaid, and how is it different from Medicare?

Medicaid and Medicare were created by the same legislation — an addition to the Social Security Act — that was signed into law by President Lyndon B. Johnson in 1965.

Medicaid is a government health insurance program for people with low incomes and adults and children with disabilities.

Medicare, by contrast, generally covers those 65 or older.

For older Americans with low incomes, Medicaid covers out-of-pocket costs for Medicare. Such people are commonly called “dual eligibles,” because they qualify for both programs.

Who is on Medicaid?

More than 79 million people receive services from Medicaid or the closely related Children’s Health Insurance Program. That represents about 20% of the total population of the United States. Most enrollees qualify because of low incomes.

About 40% of all children in the country are covered by Medicaid or CHIP, created in 1997. Both pay for services such as routine checkups, vaccinations, and hospital stays. Medicaid also covers pregnant people before and after they give birth and pays for more than 40% of all births.

Medicaid also covers people with disabilities or complex medical needs and helps them afford services that allow them to live independently in community settings, outside of institutions such as nursing homes and state-run hospitals.

The program serves a diverse cross section of the country. About 40% of people under 65 who use Medicaid are white, 30% are Hispanic, 19% are Black, and 1% are Indigenous people.

Federal Medicaid dollars cannot be used to cover immigrants who are in the U.S. without legal permission, though some states, as well as Washington, D.C., have used their own funds to extend Medicaid coverage to such individuals. California was the first state to do so.

What are the income qualifications?

Eligibility generally depends on whether a person is low income, and states have different ways of defining that. For a four-adult household without dependent children, the current national median coverage level is $44,367.

The Affordable Care Act, often called Obamacare, which passed in 2010, allowed more people to qualify for Medicaid on the basis of income. This is what is known as “Medicaid expansion.”

The law offered states a sizable incentive to add more people to their programs: The federal government would pitch in more money per enrollee to help cover them.

The intention behind the expansion was to close gaps in health insurance programs for the millions of Americans who don’t get coverage through an employer. Medicaid would cover people with extremely low incomes, and as their incomes rose, they could move to subsidized health plans sold through the Affordable Care Act’s exchanges.

In 2012, the U.S. Supreme Court said the decision of whether to expand the program would be left up to individual states. Today, 40 states and the District of Columbia — led by Democrats and Republicans alike — have opted in.

In the 10 states that haven’t expanded Medicaid to more low-income adults, the median earnings qualification level is $5,947 a year for a single-person household in 2025. Those who make more are not eligible.

Adults in those states who make too much for Medicaid can also make too little to qualify for help buying plans on the Affordable Care Act exchanges, leaving some unable to afford coverage. An estimated 1.5 million fall into this coverage gap.

Where does the money to pay for it come from?

The federal government pays most of the cost of Medicaid by matching a portion of what states spend.

Currently, the federal government matches at least 50% of state spending and offers states more money for some services and enrollees — for instance, for children and pregnant women.

Less wealthy states — determined by considering residents’ per capita incomes — receive a higher match, translating to a higher percentage of federal dollars. In Mississippi, for instance, the federal government picks up 77% of the cost of Medicaid.

States also receive a 90% match from the federal government for enrollees eligible for Medicaid under the ACA’s expansion.

There is no limit on how much states can spend on the program, and hundreds of billions of federal dollars flow into states each year. In 2023, states spent about 15% of their own budgets on Medicaid.

What does that money pay for?

Federal law requires all state Medicaid programs to cover certain services, including emergency medical transportation, X-rays and lab work, family planning, and medication-assisted treatment for people with opioid use disorder. The program also covers many nursing and home health services, though federal law allows those benefits to be clawed back after an enrollee’s death.

Beyond that, states have the flexibility to choose the services their Medicaid programs cover. All states cover prescription drugs, and most cover eyeglasses, some dental care, and physical therapy.

Medicaid covers more mental health and long-term care services than any other type of insurance, public or private.

What is Medicaid called in my state?

Medicaid programs can go by many different names, even within the same state, in part because most states use private insurance companies to run them. This can be confusing for consumers who may not realize they are actually enrolled in Medicaid.

In New York, for instance, Medicaid plans are offered by major companies, such as Anthem Blue Cross Blue Shield and UnitedHealthcare — and some you may not have heard of, such as Amida Care and MetroPlusHealth. In Wisconsin, enrollees may be in BadgerCare Plus; in Connecticut, Husky Health; in Texas, STAR; and in California, Medi-Cal.

How does Medicaid affect hospitals and doctors in my state?

Medicaid generally pays health care providers such as doctors and hospitals less money for services than Medicare or private insurance does. But it can be more money than they’d get caring for people who are uninsured — and without Medicaid, many more Americans would be uninsured.

Like states, providers and hospitals have come to rely on this money and express concerns that even phasing it out over time would require major adjustments.

What’s going to happen to Medicaid?

It’s not clear. Republicans in Washington are again pushing for major changes, which could take the form of cuts to federal funding. That could reduce the number of people who qualify, the services available, or both. A similar push focused on repealing and replacing Obamacare in 2017, during Trump’s first term, was unsuccessful.

Perhaps one of the biggest obstacles to changing Medicaid is its popularity: 77% of Americans — and majorities of Democrats, independents, and Republicans — view the program favorably.

At the heart of it all are key questions about the role of government in people’s health: How big should the U.S. medical insurance safety net be? Who deserves government assistance? And how will enrollees, states, providers, and the health care system at large absorb major changes to Medicaid, even if a rollout were staggered?

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Iowa Medicaid Sends $4M Bills to Two Families Grieving Deaths of Loved Ones With Disabilities

Collection agents for the state of Iowa have sent letters seeking millions of dollars from the estates of at least two people with disabilities who died after spending most of their lives in a state institution.

The amounts represent what Medicaid spent covering the residents’ care when they lived at the Glenwood Resource Center, a state-run facility that closed last summer.

The bills are extraordinary examples of a practice called Medicaid estate recovery. Federal law requires states to try to collect money after some types of Medicaid recipients die. The point is to encourage people to use their own resources before relying on the public program. But some states, including Iowa, are particularly aggressive about the collections, national reports show.

Joy Higgins was stunned by a letter she received a few weeks after her 41-year-old daughter, Kristin, died last May. The letter was written on Iowa Department of Health and Human Services stationery. At the top, in bold letters, it said, “Re: Kristin Higgins.”

“Dear Joy Higgins,” the letter read. “Our sincere condolences to you, as we understand the above person is deceased.”

The letter explained that any money Kristin Higgins left behind would have to be remitted to the state to help repay Medicaid $4,263,148.67. Her family had 30 days to respond.

Joy Higgins, who lives in Council Bluffs, wonders why state debt collectors would send a massive bill to the family of someone like her daughter, who had little income because of a severe developmental disability stemming from a premature birth.

“What are they gaining? That’s my question. Except for kicking someone in the face right after they lost a loved one?” Higgins said.

Kristin Higgins’ only income was a Social Security disability benefit of $1,105 monthly. Most of that went directly to the state institution, where she lived for more than 30 years. Just $50 was set aside monthly as an allowance for personal expenses, according to a state ledger obtained by her family. “They knew exactly how much she had,” her mother said.

When she died, Kristin’s personal account had a balance of $2,239.84. The family put that money toward her funeral, an allowed expense. Nothing was left for the state to take. Higgins said receiving the letter was traumatic even though the family didn’t have to pay the Medicaid bill.

The Higginses have heard about similar attempts to collect from other families, including that of Eric Tomlyn, who died in 2020 at age 29 after spending most of his life at the Glenwood Resource Center.

Shortly after his death, the Tomlyn family received a Medicaid bill of more than $4.2 million. His mother, Susan Tomlyn, was shocked by the letter. “I was like, ‘What? What? Oh my God,’” she recalled.

She filled out a form explaining that the small balance in her son’s personal account had gone toward his funeral. “That’s the last I heard of it,” Tomlyn said.

Supporters of estate recovery efforts say the rules encourage people to pay for their own care before applying for Medicaid, which is mainly intended to help those with little money.

Critics of estate recovery programs say they often target families with little to give. Wealthier families tend to have lawyers who can structure estates in ways that avoid Medicaid repayment demands, the critics note.

Like Higgins, Tomlyn thought her Medicaid recovery bill came from state officials because it was printed on letterhead from the Iowa Department of Health and Human Services. The people who signed the letters identified themselves as being from the “Estate Recovery Program.” But the people who produce such letters work for private contractors hired to collect Medicaid debts, according to Alex Murphy, a spokesperson for the state agency. Their contract requires them to use state stationery.

Murphy said in an email to KFF Health News that such letters are sent after every death of an Iowa Medicaid recipient who was at least 55 years old or who lived in a long-term care facility. He said the letters “request information from family members regarding the deceased person’s assets and expenses,” and the letters note that repayments are expected only from the person’s estate.

Iowa’s Medicaid collections are handled by Sumo Group, a Des Moines company. Its director, Ben Chatman, declined to answer questions, including why the company sent bills to families of people with disabilities who lived most of their lives in state institutions. “I don’t do media relations,” Chatman said.

Sumo Group is a subcontractor of a national company, Gainwell Technologies, which has handled Medicaid collections for several states. In Iowa, the company is paid 11% of whatever it can collect from the estates of Medicaid participants. A spokesperson for Gainwell declined to comment.

Iowa’s Medicaid estate recovery program brought in $40.2 million in the fiscal year that ended last June, up nearly 14% from two years earlier, state records show. That total represents a sliver of the state’s total Medicaid budget, which is expected to hit $9 billion this year.

Nearly two-thirds of Iowa estate recovery cases wound up being closed with no collection of money last fiscal year, according to the state. In cases in which money was recouped, the average amount paid was about $10,000.

Thirty-five Iowa families were granted hardship waivers, which the state allows if an heir’s health or life would be endangered because payment of the Medicaid bill would deprive them of food, clothing, shelter, or medical care. Officials denied an additional 20 requests for hardship waivers.

A 2021 report to Congress estimated states collected more than $700 million annually from Medicaid participants’ estates. That money is shared with the federal government, which helps finance Medicaid. Some states claw back much less than others. Hawaii, for example, collected just $31,000 in 2019, the latest year analyzed in the federal report. Iowa, with about twice as many residents as Hawaii, raked back more than $26 million that year.

Americans aren’t subject to such clawbacks for using any other federal health program, including Medicare, which covers older people of all income levels.

The national group Justice in Aging has helped lead opposition to Medicaid estate recovery programs. Eric Carlson, a California attorney for the group, said the issue usually comes into play after the death of a person who had nursing home care covered by Medicaid. Recovery demands often force survivors to sell homes that are their families’ main form of wealth, he said.

Carlson said he hadn’t previously heard of Medicaid estate recovery bills topping $4 million, like the ones sent to survivors of the two Iowans with disabilities.

He wondered why debt collectors would pursue such cases, which are unlikely to yield any money but could cause anxiety for families. “Of course, if you open up a piece of mail that says you owe millions of dollars, you’re going to think the worst,” he said.

Carlson said he would advise anyone who receives such a letter to respond to it with documentation showing that their loved one’s estate can’t repay a Medicaid debt. “It’s never a good idea to ignore it,” he said. Failure to respond to the bill could lead to continued collection efforts, which could threaten a family member’s finances or property, he said.

Some states have reined in their Medicaid clawback efforts. For example, Massachusetts legislators last year voted to drastically limit their program. This was the second time Massachusetts reduced its Medicaid estate recovery effort, which once was one of the most aggressive in the U.S.

Critics in Congress have also tried to limit the practice.

Rep. Jan Schakowsky (D-Ill.) has twice introduced bills to eliminate the federal requirement that states claw back Medicaid spending from recipients’ estates. Last year’s bill gained 47 Democratic co-sponsors, but it received no support from the Republicans controlling the chamber, and there was no similar bill in the Senate. She plans to try again this year, even though her party remains in the minority.

Schakowsky said in an interview that she’d never heard of Medicaid estate recovery demands reaching millions of dollars, as the Iowa families faced. But demands for hundreds of thousands of dollars are common. For many families, “that’s still impossible” to meet, she said.

Schakowsky hopes that members of Congress from both parties will agree to curtail the program once they realize how much angst it causes their constituents and how relatively little money it returns to the government. “The whole program is ridiculous,” she said.

Her quest could become even tougher if the Trump administration moves ahead with proposals to trim Medicaid spending.

The office of Sen. Chuck Grassley, who is the senior member of Iowa’s all-Republican congressional delegation and has taken leading roles in many health policy debates, declined to comment on the issue.

The Iowa Department of Health and Human Services said it notifies families about the estate recovery process when they apply for Medicaid. Joy Higgins said she doesn’t recall seeing such a notice.

The institution where Kristin Higgins spent most of her life was closed last year after federal officials investigated complaints of poor medical care. But Joy Higgins said her daughter was treated well there overall. “If I had millions in the bank, I’d give it to the state,” she said. “I would. It was worth it.”

Has your family been sent bills for repayment of Medicaid expenses after the death of a loved one who was covered by the program? Click here to tell KFF Health News your story.

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Se busca médico: estrategias de un pueblito de Florida para atraer a un doctor generalista

HAVANA, Florida. — Para ser una comunidad rural, este pueblo de 1,750 habitantes ha sido más afortunado que la mayoría. Aquí ha ejercido un médico de familia durante los últimos 30 años.

Pero eso se acabó en diciembre cuando Mark Newberry se jubiló.

Para atraer a un nuevo médico, los líderes de Havana publicaron anuncios clasificados en los periódicos locales, avisos en las redes sociales y llegaron a un atractivo acuerdo con un consultorio médico libre de renta equipado con una máquina de rayos X, una máquina de ultrasonido y un escáner para medir la densidad ósea, todo propiedad de la ciudad.

Los líderes locales esperan que la campaña de reclutamiento ayude a atraer candidatos en medio de una escasez nacional de médicos.

“Esto es importante para nuestra comunidad”, dijo Kendrah Wilkerson, administradora de Havana, “de la misma manera que los parques son importantes y una buena planificación futura es importante”.

Según un informe del Departamento de Salud de Florida, la escasez de médicos afecta a la totalidad o a parte de casi todos los condados, pero los menos poblados, como Gadsden, donde se encuentra Havana, tienen el menor número de médicos por cada 10,000 habitantes.

Se espera que la escasez de médicos en Florida aumente en la próxima década, y un estudio prevé una necesidad de 18.000 médicos en todo el estado, incluidos 6.000 de atención primaria, para 2035.

“Es un problema enorme”, señaló Matthew Smeltzer, socio de Capstone Recruiting Advisors, una empresa que ayuda a hospitales, consultorios médicos y otros empleadores a encontrar y contratar doctores. “Probablemente, los pueblos pequeños son los más afectados, simplemente porque la mayoría de las personas prefiere vivir en una comunidad mediana o grande”.

En este entorno desafiante, los líderes de Havana esperan que los anuncios y las ventajas de renta gratuita hagan que su pueblo llame la atención y poder atraer a un médico.

Wilkerson describe a la comunidad, situada junto a la frontera sur de Georgia, como un lugar ideal para formar una familia. Sus caminos rurales están bordeados de iglesias, granjas y prados. La calle principal del pueblo tiene tiendas de antigüedades, de regalos, almacenes y restaurantes.

“Todo lo que te imaginas de una película de Hallmark es un poco lo que tenemos aquí”, afirmó Wilkerson. “Las personas todavía se preocupan por los demás y se cuidan, y los vecinos son realmente amigos”.

Ofreciendo generosos incentivos fue como los líderes de la municipalidad consiguieron que Newberry comenzara a ejercer en Havana, en 1993. La ciudad le dio a Newberry un trato inicial similar al que ofrece ahora, y más tarde comenzó a proporcionarle unos $15.000 al año en apoyo financiero.

Newberry, que atendió a unos 2.000 pacientes, no quiso que lo entrevistaran. “¡Me estoy jubilando!”, escribió en un correo electrónico, y agregó que “el pueblo ha elegido formas poco convencionales” de contratar a un médico.

Al subvencionar el consultorio y el uso de equipos médicos para atraer a un médico, Havana está velando por las necesidades de sus residentes, añadió Wilkerson.

Al perder a su médico local, algunos de los antiguos pacientes de Newberry tienen que viajar a Tallahassee, a unos 30 minutos en coche al sureste de Havana. Otros ven a médicos en Quincy, a unos 20 minutos en coche al oeste.

“Esperamos que vuelvan cuando encontremos un nuevo médico”, dijo el alcalde de Havana, Eddie Bass.

Susan Freiden, ex administradora de la municipalidad que se jubiló en 2006, señaló que tener un médico local también es importante para satisfacer las necesidades de los residentes de bajos ingresos, muchos de los cuales son adultos mayores. “No todo el mundo puede ir a Tallahassee para ver a un médico”, dijo. “No todo el mundo tiene transporte”.

Pero queda por ver si toda la oferta es suficiente para atraer a un médico a Havana. La campaña de reclutamiento ha despertado mucho interés entre las enfermeras, pero pocos médicos de atención primaria han solicitado el puesto.

Los líderes del pueblo dicen que no pierden la esperanza de encontrar un médico de familia, que pueda ejercer y recetar medicamentos de forma independiente.

“Realmente preferiríamos tener un médico de verdad que pueda ocuparse de todo esto por nosotros”, afirmó Bass.

Smeltzer, el caza talentos de médicos, apuntó que los médicos de atención primaria son especialmente escasos. Y aunque, según su experiencia, Florida, Carolina del Norte, Tennessee y Texas se encuentran entre los lugares donde los médicos quieren vivir y trabajar, a menudo se necesita algo más para persuadirlos de que trabajen en un pequeño municipio, dijo.

“Si alguien quiere ejercer en un pueblo pequeño, es más probable que vaya a donde tenga vínculos, ya sean ellos mismos o su cónyuge o pareja”, apuntó.

Smeltzer dijo que el reto para una comunidad del tamaño de Havana es que “puede que, literalmente, no haya nadie de ese pueblo que haya ido a la facultad de medicina. O, si lo hay, tal vez sea uno. Pero, ¿era médico de atención primaria?”.

Aun así, hay esperanza. Smeltzer señaló que los médicos jóvenes están dando mucha importancia al equilibrio entre la vida laboral y la personal, y la relación con el paciente, cualidades que pueden dar ventaja a una consulta independiente en un pueblo pequeño.

“Hemos oído hablar de la calidad de vida y del equilibrio entre la vida laboral y la personal mucho más en los últimos tres o cinco años que nunca antes”, agregó, “y eso va casi de la mano con la compensación en cuanto a lo que buscan”.

Freiden, la ex administradora de Havana, dijo que esos son los mismos valores que tenía Newberry cuando comenzó a ejercer aquí. Ella mismo se convirtió en una de sus pacientes.

“Era perfecto”, señaló, “porque no todo era dinero, como puedes imaginar. Era un médico diferente”.

Afortunadamente para Havana, la ciudad ha despertado recientemente el interés de un médico de familia que creció aquí, estudió medicina y espera terminar una residencia de tres años en el Tallahassee Memorial HealthCare en junio.

Camron Browning, graduado en 2003 de la escuela secundaria Northside Havana, declaró ante el Consejo Municipal de siete miembros, en diciembre, que se estaba especializando en medicina familiar y que, durante su residencia, había visto a miles de pacientes, asistido partos y adquirido experiencia como médico de hospitalización.

“Mi objetivo”, dijo, “es poder volver a casa y servir a mi pueblo natal”.

Smeltzer indicó que los incentivos de Havana podrían ser atractivos para los nuevos médicos como Browning, que se enfrentarían a unos costos iniciales desalentadores para establecer una consulta independiente.

Tras la entrevista de diciembre, el Consejo votó por unanimidad iniciar las negociaciones del contrato con Browning, quien dijo que tenía previsto estar listo para atender a los pacientes lo antes posible tras completar su residencia.

“Estoy aquí para quedarme”, dijo Browning al Consejo. “Este siempre fue mi sueño”.

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Journalists Talk Southern Health Care: HIV Drug Access, Medicaid Expansion, Vaccination Rates

KFF Health News contributor Sarah Boden discussed cats and bird flu on KVPR’s “Central Valley Daily” on Feb. 12.

Click here to hear Boden on “Central Valley Daily”
Read Boden’s “House Cats With Bird Flu Could Pose a Risk to Public Health”

KFF Health News South Carolina correspondent Lauren Sausser juxtaposed the increasing trendiness of rural health care and the lack of Medicaid expansion in the South on America’s Heroes Group on Feb. 12.

KFF Health News contributor Rebecca Grapevine, of Healthbeat, discussed the barriers to lifesaving HIV drugs in Georgia on America’s Heroes Group on Feb. 12.

KFF Health News Southern correspondent Sam Whitehead discussed childhood vaccination rates on WUGA’s “The Georgia Health Report” on Feb. 7.

Click here to hear Whitehead on “The Georgia Health Report”
Read Whitehead’s “Childhood Vaccination Rates, a Rare Health Bright Spot in Struggling States, Are Slipping,” co-reported with Daniel Chang

KFF Health News public health local editor and correspondent Amy Maxmen discussed the U.S.’ pulling out of the World Health Organization on America’s Heroes Group on Feb. 5.

Click here to watch Maxmen on America’s Heroes Group
Read Maxmen’s “What a US Exit From the WHO Means for Global Health”

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Urgent CDC Data and Analyses on Influenza and Bird Flu Go Missing as Outbreaks Escalate

Sonya Stokes, an emergency room physician in the San Francisco Bay Area, braces herself for a daily deluge of patients sick with coughs, soreness, fevers, vomiting, and other flu-like symptoms.

She’s desperate for information, but the Centers for Disease Control and Prevention, a critical source of urgent analyses of the flu and other public health threats, has gone quiet in the weeks since President Donald Trump took office.

“Without more information, we are blind,” she said.

Flu has been brutal this season. The CDC estimates at least 24 million illnesses, 310,000 hospitalizations, and 13,000 deaths from the flu since the start of October. At the same time, the bird flu outbreak continues to infect cattle and farmworkers. But CDC analyses that would inform people about these situations are delayed, and the CDC has cut off communication with doctors, researchers, and the World Health Organization, say doctors and public health experts.

“CDC right now is not reporting influenza data through the WHO global platforms, FluNet [and] FluID, that they’ve been providing information [on] for many, many years,” Maria Van Kerkhove, interim director of epidemic and pandemic preparedness at the WHO, said at a Feb. 12 press briefing.

“We are communicating with them,” she added, “but we haven’t heard anything back.”

On his first day in office, President Donald Trump announced the U.S. would withdraw from the WHO.

A critical analysis of the seasonal flu selected for distribution through the CDC’s Health Alert Network has stalled, according to people close to the CDC. They asked not to be identified because of fears of retaliation. The network, abbreviated as HAN, is the CDC’s main method of sharing urgent public health information with health officials, doctors, and, sometimes, the public.

A chart from that analysis, reviewed by KFF Health News, suggests that flu may be at a record high. About 7.7% of patients who visited clinics and hospitals without being admitted had flu-like symptoms in early February, a ratio higher than in four other flu seasons depicted in the graph. That includes 2003-04, when an atypical strain of flu fueled a particularly treacherous season that killed at least 153 children.

Without a complete analysis, however, it’s unclear whether this tidal wave of sickness foreshadows a spike in hospitalizations and deaths that hospitals, pharmacies, and schools must prepare for. Specifically, other data could relay how many of the flu-like illnesses are caused by flu viruses — or which flu strain is infecting people. A deeper report might also reveal whether the flu is more severe or contagious than usual.

“I need to know if we are dealing with a more virulent strain or a coinfection with another virus that is making my patients sicker, and what to look for so that I know if my patients are in danger,” Stokes said. “Delays in data create dangerous situations on the front line.”

Although the CDC’s flu dashboard shows a surge of influenza, it doesn’t include all data needed to interpret the situation. Nor does it offer the tailored advice found in HAN alerts that tells health care workers how to protect patients and the public. In 2023, for example, a report urged clinics to test patients with respiratory symptoms rather than assume cases are the flu, since other viruses were causing similar issues that year.

“This is incredibly disturbing,” said Rachel Hardeman, a member of the Advisory Committee to the Director of the CDC. On Feb. 10, Hardeman and other committee members wrote to acting CDC Director Susan Monarez asking the agency to explain missing data, delayed studies, and potentially severe staff cuts. “The CDC is vital to our nation’s security,” the letter said.

Several studies have also been delayed or remain missing from the CDC’s preeminent scientific publication, the Morbidity and Mortality Weekly Report. Anne Schuchat, a former principal deputy director at the CDC, said she would be concerned if there was political oversight of scientific material: “Suppressing information is potentially confusing, possibly dangerous, and it can backfire.”

CDC spokesperson Melissa Dibble declined to comment on delayed or missing analyses. “It is not unexpected to see flu activity elevated and increasing at this time of the year,” she said.

A draft of one unpublished study, reviewed by KFF Health News, that has been withheld from the MMWR for three weeks describes how a milk hauler and a dairy worker in Michigan may have spread bird flu to their pet cats. The indoor cats became severely sick and died. Although the workers weren’t tested, the study says that one of them had irritated eyes before the cat fell ill — a common bird flu symptom. That person told researchers that the pet “would roll in their work clothes.”

After one cat became sick, the investigation reports, an adolescent in the household developed a cough. But the report says this young person tested negative for the flu, and positive for a cold-causing virus.

Corresponding CDC documents summarizing the cat study and another as-yet unpublished bird flu analysis said the reports were scheduled to be published Jan. 23. These were reviewed by KFF Health News. The briefing on cats advises dairy farmworkers to “remove clothing and footwear, and rinse off any animal biproduct residue before entering the household to protect others in the household, including potentially indoor-only cats.”

The second summary refers to “the most comprehensive” analysis of bird flu virus detected in wastewater in the United States.

Jennifer Nuzzo, director of the Pandemic Center at Brown University, said delays of bird flu reports are upsetting because they’re needed to inform the public about a worsening situation with many unknown elements. Citing “insufficient data” and “high uncertainty,” the United Kingdom raised its assessment of the risk posed by the U.S. outbreak on dairies.

“Missing and delayed data causes uncertainty,” Nuzzo said. “It also potentially makes us react in ways that are counterproductive.”

Another bird flu study slated for January publication showed up in the MMWR on Feb. 13, three weeks after it was expected. It revealed that three cattle veterinarians had been unknowingly infected last year, based on the discovery of antibodies against the bird flu virus in their blood. One of the veterinarians worked in Georgia and South Carolina, states that haven’t reported outbreaks on dairy farms.

The study provides further evidence that the United States is not adequately detecting cases in cows and people. Nuzzo said it also highlights how data can supply reassuring news. Only three of 150 cattle veterinarians had signs of prior infections, suggesting that the virus doesn’t easily spread from the animals into people. More than 40 dairy workers have been infected, but they generally have had more sustained contact with sick cattle and their virus-laden milk than veterinarians.

Instead, recently released reports have been about wildfires in California and Hawaii.

“Interesting but not urgent,” Nuzzo said, considering the acute fire emergencies have ended. The bird flu outbreak, she said, is an ongoing “urgent health threat for which we need up-to-the-minute information to know how to protect people.”

“The American public is at greater risk when we don’t have information on a timely basis,” Schuchat said.

This week, a federal judge ordered the CDC and other health agencies to “restore” datasets and websites that the organization Doctors for America had identified in a lawsuit as having been altered. Further, the judge ordered the agencies to “identify any other resources that DFA members rely on to provide medical care” and restore them by Feb. 14.

In their letter, CDC advisory committee members requested an investigation into missing data and delayed reports. Hardeman, an adviser who is a health policy expert at the University of Minnesota, said the group didn’t know why data and scientific findings were being withheld or removed. Still, she added, “I hold accountable the acting director of the CDC, the head of HHS, and the White House.”

Hardeman said the Trump administration has the power to disband the advisory committee. She said the group expects that to happen but proceeded with its demands regardless.

“We want to safeguard the rigor of the work at the CDC because we care deeply about public health,” she said. “We aren’t here to be silent.”

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A Dose of Love: The Winning Health Policy Valentines

Nothing sweeps us off our feet like a health policy valentine. Readers showed their love this season, writing poetic lines about surprise medical bills, bird flu, the cost of health care, and more.

Here are some of our favorites, starting with the grand prize winner, whose entry was turned into a cartoon by staff illustrator Oona Zenda.

1st Place

Runner-Up

What to make for my valentine?Maybe a cake on which we can dine!But raw milk and flu-ish eggs won’t do.Perhaps some fluoridated water in lieu?

– Holly Ainsworth

Other Newsroom Favorites

Measles are red.Chickenpox is too.Let’s stick with vaccinesAnd fight covid and flu.

– Arielle Levin Becker

The donut hole is closed, my dear;Our Part D costs are capped.Let’s hope our love survives alongsideThe Inflation Reduction Act.

– Brandy Bauer

My love for you is like health care as a percentage of GDP. It grows larger every year.

– David Schleifer

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Montana Looks To Regulate Prior Authorization as Patients, Providers Decry Obstacles to Care

HELENA, Mont. — When Lou and Lindsay Volpe’s son was diagnosed with a chronic bowel disease at age 11, their health insurer required constant preapproval of drugs and treatments — a process the Volpes say often delayed critical care for their son.

“You subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,” Lou Volpe said. “And finally, when you knock on the door and say, ‘Hey guys, we need some help,’ they just start backpedaling.”

The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana — including a four-month wait last year for approval of costly infusions that worked to control their son’s disease where other treatments had failed.

“It just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,” Lindsay Volpe said.

Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it’s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as “prior authorization.”

This month, a Democratic and a Republican lawmaker introduced or were drafting separate bills restricting health insurers’ ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.

Many of the state’s medical providers are behind the effort, saying prior authorization is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.

“It has increased incredibly in the last couple of decades, to the point that it’s one of the leading causes of burnout for physicians,” said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. “It’s just delaying patient care for no good reason.”

Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.

Blue Cross and Blue Shield of Montana said it doesn’t comment on individual cases, such as the Volpes’, but said it approves the “vast majority” of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.

“Prior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,” the company said in a statement.

Denial of care through insurers’ prior authorization processes has struck a nerve nationwide as well.

In the wake of the December shooting death of UnitedHealthcare CEO Brian Thompson in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.

And since then, one of the nation’s largest health insurers, The Cigna Group, announced it would spend $150 million this year to reform its prior authorization process and related services for patients and health care providers.

In the past two years, multiple states have passed laws restricting prior authorization, according to the American Medical Association, with New Jersey enacting restrictions over New Year’s. The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.

Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.

In Montana, local health insurers aren’t quietly giving in to increased regulation.

They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance, because large, self-insured plans managed by national health insurers are under federal rules.

State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say — and, eventually, their customers.

“We feel like our job is to say, ‘Is that the best use of money for our membership?’” Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. “If we approve something, we are doing it for every patient like them.”

Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.

Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: one to remove prior authorization for most generic drugs, inhalers, and insulin, and another that says patients can’t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. The second bill also says a procedure or treatment may be denied only by a physician with a matching specialty.

Karlen said insurers are putting up barriers to care to increase their profits and said it’s time to break those barriers down.

“People should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,” he said. “If a doctor says you need a medication, that’s why you have insurance — so you can get that.”

Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes’ son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don’t meet the deadline, the drug would be automatically approved.

Buttrey’s bill also would eliminate most retroactive denials — when insurers refuse to pay for treatment they’d authorized.

State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.

Health care providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it’s time for the state to step in.

“When there are no consequences and no teeth to anything, I can complain all I want, but it doesn’t seem to incite change,” said Kim Longcake, the pediatric nurse practitioner who’s treating the Volpes’ son.

Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.

“Depending on where you want to see me, I’m booking out four to six months,” Longcake said. “If I wasn’t spending 12 hours a week doing prior authorization stuff, it would improve access to care.”

The Volpes said their son, now 13, couldn’t absorb food and didn’t gain any weight for a year and a half while he went through treatments that didn’t work and repeated preauthorization waits, including for his current treatment, which appears to be working.

“What he’s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn’t get the care that he needed,” his mother said. “If we didn’t get switched to this medication, he’d still be doing that.”

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Un año después del tiroteo en el desfile del Super Bowl, los sobrevivientes suman confusión al trauma

Emily Tavis estaba en una primera cita en diciembre cuando levantó la vista y se dio cuenta que estaban pasando por la esquina del centro de Kansas City, Missouri, en donde una bala le atravesó la pierna durante el desfile del Super Bowl, el año pasado.

“Oh, c…”, dijo Tavis, desconcertando a su cita.

Tavis vive a 35 millas de distancia, en Leavenworth, Kansas, y todavía no había vuelto a Union Station, donde ocurrió el tiroteo masivo. Sintió ganas de llorar. O tal vez fue un ataque de pánico. Levantó un dedo para indicarle a su cita que necesitaba un momento. Fue entonces cuando él entendió lo que estaba pasando.

“Oh, ni siquiera me di cuenta”, dijo, y siguió conduciendo en silencio.

Tavis contuvo las lágrimas hasta que la estación desapareció de su vista.

“Ok…”, dijo en voz alta, mientras pensaba para sí misma, “bien. Ataque de pánico, primera cita”.

Un año después del tiroteo del 14 de febrero que mató a una persona e hirió al menos a 24, los sobrevivientes y sus familias todavía están conmocionados.

Las relaciones se han tensionado. Los padres están preocupados por sus hijos. El generoso apoyo financiero y los buenos deseos que recibieron en los primeros días ya se han agotado. Y tienen sentimientos encontrados sobre el equipo al que siguen vitoreando: mientras los Chiefs avanzaban hacia otro Super Bowl, muchos se preguntaban por qué su amado equipo parecía ni haber advertido lo que todos estaban pasando.

“No puedo creer que los Chiefs no hayan hecho nada por nosotros”, dijo Jacob Gooch Sr., quien recibió un disparo en el pie. El equipo, la fundación de la familia propietaria y la Liga Nacional de Fútbol Americano (NFL) donaron un total de $200.000 a un fondo para sobrevivientes, pero Gooch dijo que nadie de la organización se acercó a su familia, tres de los cuales recibieron disparos.

Lo que les está sucediendo a estas familias no es nada inusual. Muchos sobrevivientes se “paralizan” emocionalmente como un mecanismo de afrontamiento para evitar sentir por completo el trauma que sufrieron. Pero, con el tiempo, experimentan lo que los terapeutas llaman “descongelamiento”, y la intensidad de lo que sucedió puede volver a dominarlos de repente como le pasó a Tavis.

“El trauma nos lleva al pasado”, dijo Gary Behrman, terapeuta que publicó un modelo de intervención en crisis basado en su trabajo con testigos de los ataques del 11 de septiembre en Nueva York.

Las imágenes, los olores, los sonidos, los sabores y el tacto pueden desencadenar flashbacks que apagan el cerebro como un disyuntor sobrecargado. Es una respuesta de supervivencia, el cerebro es un amigo, dijo Behrman.

La clave para la recuperación es ayudar a los sobrevivientes a encontrar formas saludables de manejar esos desencadenantes, cuando estén listos.

Los sobrevivientes se “descongelan” a su propio ritmo. Recuperar el control después de un evento potencialmente mortal es un proceso que puede llevar semanas, meses o años.

Puede ser fácil sentirse olvidado cuando la vida continúa alrededor. Mientras los fanáticos se juntaban en torno a los Chiefs esta temporada, a los sobrevivientes les resultó difícil ver los juegos. Los Chiefs perdieron ante los Philadelphia Eagles en el Super Bowl del domingo 9 de febrero. Philadelphia celebra su propio desfile el viernes 14, exactamente un año después del tiroteo.

“Es una lástima porque todos los demás siguieron adelante”, dijo Jason Barton.

Barton le practicó resucitación a un hombre que ahora cree que era uno de los presuntos tiradores, su esposa encontró un proyectil de bala en su mochila y su hijastra se quemó con las chispas de una bala que rebotó.

“Si hubiéramos estado al otro lado de ese lugar”, dijo. “No nos habría afectado”.

Viaje de regreso a Union Station

Tavis no es la única sobreviviente que se encontró sin querer en Union Station un año después del tiroteo.

Los niños hicieron excursiones a Science City, ubicado dentro de la estación. Las visitas médicas de seguimiento se realizaban a menudo en vecino Hospital Hill. Una cena de octubre organizada para sobrevivientes por un grupo religioso local estaba a menos de una milla de distancia: una joven sobreviviente rechazó la invitación.

Tavis había planeado regresar a Union Station como parte de su proceso de curación. Pensó que iría cuando se cumpliera un año para tener un momento a solas y sentir las emociones que la invadieran.

Tal vez Dios le estaba mostrando que estaba lista al colocarla allí inesperadamente, le dijo su terapeuta. Tal vez. Pero ella no se sentía lista en ese momento. Quiso ver a un terapeuta justo después del tiroteo. Pero no buscó uno hasta julio, después que la United Way local distribuyera la asistencia financiera a los sobrevivientes y aliviara la tensión económica de meses de trabajo perdido y facturas médicas.

Tavis y su pareja en ese momento habían sacado una tarjeta de crédito adicional para cubrir los gastos mientras esperaban la ayuda prometida.

Después de dos meses de visitas, su terapeuta comenzó a preparar a Tavis para la desensibilización y reprocesamiento del movimiento ocular, una técnica para ayudar a los sobrevivientes de traumas. Ahora, sesión por medio, revisa una hoja de recuerdos del desfile, visualizándolos y reprocesándolos uno por uno.

Está nerviosa porque se acerca el año de aniversario. Es el día de San Valentín y le preocupa que sea deprimente.

Decidió invitar a Gooch, su ex pareja, a que la acompañara a Union Station ese día. Con todo lo que han pasado, él entiende. Estaban en el desfile junto con su hijo y los dos hijos mayores de Jacob. Gooch Sr. y su hijo mayor, Jacob Gooch Jr., recibieron disparos.

El trauma cambia quiénes somos

Gooch Sr. no ha trabajado desde el desfile. Su trabajo requería estar de pie durante turnos de 10 horas cuatro días a la semana, pero no pudo caminar durante meses después de que una bala le destrozara un hueso del pie y se le volviera a fusionar lentamente.

Esperaba volver a trabajar en julio, pero su pie no sanó correctamente y tuvo que operarse en agosto, a lo que siguieron semanas de recuperación.

La cobertura por discapacidad se agotó, al igual que su seguro médico a través del trabajo. Su empleador mantuvo su trabajo durante un tiempo antes de despedirlo en agosto. Ha buscado otros empleos en Leavenworth y sus alrededores: producción, agencias de personal, reparación de automóviles. No ha conseguido nada.

“Todos hemos pasado por problemas, no solo yo”, dijo Gooch Sr. “Me dispararon en el pie y no he trabajado durante un año. Hay gente que ha pasado por cosas mucho peores durante el último año”.

Ahora se siente bien al caminar y puede correr distancias cortas sin dolor. Pero no sabe si alguna vez volverá a jugar al fútbol americano, un pilar de su vida desde que tiene memoria. Jugó como safety para los Kansas City Reapers, un equipo semi profesional, y, antes del desfile, el jugador de 38 años estaba considerando que la de 2024 fuera su última temporada como jugador.

“Me han robado mucho más que el fútbol americano en este último año. Como si me hubieran robado toda mi vida”, dijo Gooch Sr. “Realmente odio esa parte”.

Y esas emociones son dolorosamente reales. El trauma amenaza nuestras creencias sobre nosotros mismos, dijo el terapeuta Behrman. Cada persona carga su propia historia a un evento traumático, una identidad diferente que corre el riesgo de ser destrozada. El trabajo de sanación que viene después a menudo implica dar vuelta la página, y construir algo nuevo.

Recientemente, Gooch Sr. comenzó a ir a una nueva iglesia, dirigida por el esposo de alguien con quien cantó en un coro cuando era niño. En un servicio dominical de este mes, el pastor habló sobre encontrar un camino cuando uno está perdido.

“Estoy buscando el camino. Estoy en el campo ahora mismo”, dijo Gooch Sr. en su casa más tarde esa noche.

“Obviamente estoy en un camino, pero no sé hacia dónde voy”.

“Hice lo mejor que pude”

Todos los días antes de que Jason Barton se vaya a trabajar, le pregunta a su esposa, Bridget, si debería quedarse en casa con ella.

Ella ha dicho que sí lo suficiente como para que se le acabara el tiempo libre remunerado. Jason, que ha sobrevivido al cáncer y a un ataque cardíaco, tuvo que tomarse una licencia sin goce de sueldo en enero cuando un caso grave de gripe lo llevó al hospital. Eso es amor verdadero, dijo Bridget con lágrimas en los ojos, sentada con Jason y su hija de 14 años, Gabriella, en su casa en Osawatomie, Kansas.

Bridget se ha conectado con la madre de otra niña herida en el tiroteo. Han intercambiado mensajes de texto y de voz durante todo el año. Bridget dijo que es bueno tener a alguien con quien hablar que entienda. Tienen la esperanza de reunir a las niñas para que también construyan una conexión.

Con excepción de ir a terapia una vez por semana, Bridget ya no sale mucho de casa. Puede sentirse como una prisión, dijo, pero tiene demasiado miedo de salir. “Es mi propio infierno interno”, dijo. No deja de pensar en esa bala que se alojó en su mochila. ¿Qué hubiera pasado si hubiera estado parada de otra manera? ¿Qué hubiera pasado si se hubieran ido 10 segundos antes? ¿Las cosas serían diferentes?

Una nota adhesiva en su cocina le recuerda: “Estoy a salvo. Gabriella está a salvo. Hice lo mejor que pude”.

Siente mucha culpa. Por Jason quedándose en casa. Por no salir de casa, ni siquiera para ver a sus nietos. Por querer que la familia fuera al desfile en primer lugar. Al mismo tiempo, sabe que de alguna manera prosperó en el caos después del tiroteo, haciéndose cargo de su hija, hablando con la policía. Todo es confuso.

La familia ha sobrellevado el trauma de manera diferente.

En los seis meses posteriores al desfile, Jason vio reality shows que lo mantenían distraído: 23 temporadas de “Deadliest Catch” y 21 temporadas de “Gold Rush”, incluidos los spin-offs, según calculó.

Últimamente ha mantenido su mente ocupada con un nuevo pasatiempo: construir modelos de autos y aviones. Acaba de terminar un Shelby Mustang negro de 1968, y lo próximo es un avión F4U-4 Corsair que Bridget le regaló.

Gabriella pudo regresar a Union Station para una excursión escolar a Science City, pero se sobresaltó cuando vio a un grupo de policías dentro de la estación. Su madre veía en dónde estaba por el celular, y le envió mensajes de texto durante todo el día.

Después del desfile, Gabriella comenzó a practicar boxeo, luego se pasó a la lucha libre. Le había ido bien, incluso se sentía empoderada. Pero dejó de ir, y Bridget cree que se debe en parte a la emoción del aniversario: el primero siempre es el más difícil, dijo su terapeuta. Gabriella insistió en que la lucha libre la estaba agotando.

Como no les dispararon, la familia no se benefició de los recursos disponibles para otros sobrevivientes. Entienden que otras familias se están recuperando de heridas de bala o incluso están de luto por una muerte.

Aun así, sería bueno que se reconociera de alguna manera su trauma emocional. Sus nombres han estado en las noticias. Uno pensaría que los Chiefs al menos habrían enviado una carta.

Jason dijo: “Lamentamos que esto te haya pasado”.

Jason le propuso matrimonio a Bridget en un partido de los Chiefs. Ahora, ver los partidos por televisión desencadena recuerdos.

“Quiero volver a ser parte del Reino de los Chiefs”, dijo Bridget, “pero no puedo. Y ese es un sentimiento enorme y muy solitario”.

“Hay una palabra llamada ‘resiliencia’”

Una noche del pasado octubre, los sobrevivientes se reunieron con sus familias en un restaurante mexicano en el centro de Kansas City.

Algunos vinieron vestidos con sus mejores galas, otros con camisetas rojas de fútbol americano. De todas las edades, desde niños pequeños hasta personas de 70 y tantos años, algunos de Missouri, algunos de Kansas. Algunos hablaban solo español, algunos solo inglés. La mayoría de las dos docenas de personas nunca se habían visto antes. Pero mientras hablaban, descubrieron que el tiroteo que los une también les dio un lenguaje común.

Dos niños pequeños se dieron cuenta de que habían lanzado una pelota de fútbol durante el jubileo antes de que estallara la violencia. Una mujer de unos 70 años llamada Sarai Holguín recordó haberlos visto jugar en ese cálido día de febrero. Después de una bendición y una cena, Holguín, que recibió un disparo en la rodilla y ha sido sometida a cuatro cirugías, se puso de pie para dirigirse a la sala.

“Fui la primera víctima que llevaron a la carpa médica”, dijo en español, sus palabras traducidas por un familiar de otro sobreviviente. Ella vio todo, explicó, mientras, uno por uno, más sobrevivientes eran trasladados a la carpa para recibir tratamiento, incluida Lisa López-Galván, una madre de 43 años que fue asesinada ese día.

Sin embargo, en esa tragedia, Holguín vio la belleza de la gente que se ayuda entre sí.

“Esto nos mostró que la humanidad todavía está viva, que el amor todavía está vivo. Hay una palabra que se llama ‘resiliencia’”, dijo Holguín. Mientras el traductor se esforzaba por entender la última palabra, la gente del público la captó y la gritó: “Resiliencia”.

“Esta palabra nos ayuda a superar los problemas que enfrentamos”, dijo Holguín. “Para tratar de dejar atrás el momento trágico que todos vivimos y seguir adelante, debemos recordar los momentos hermosos”.

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An Arm and a Leg: How Do You Deal With Wild Drug Prices?

Prices for brand-name drugs in the U.S. are three times what the same drugs cost in other countries. And in a recent KFF survey, 3 in 10 adults reported not taking their medicine as prescribed at some point in the past year because of costs.

“An Arm and a Leg” is collecting stories from listeners about what they’ve done to get the drugs they need when facing sticker shock.

If you’ve ever faced difficult choices in order to afford your medicine, “An Arm and a Leg” would love to hear about it. If you’re interested in contributing, you can learn more and submit your stories using this form.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

Credits

Emily Pisacreta Producer Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: How Do You Deal With Wild Drug Prices?

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

So, first: Whoa. There is a LOT going on. I’m recording this on January 30th. I’m not gonna try to summarize what the Trump administration has been doing so far on health care — because by the time you hear this, I have no idea what else might have happened.

Oh boy. We will definitely have a lot to talk about as this year goes on. And in the meantime, all the things we’ve been talking on this show … they are still happening.

So, we’ve got a project cooking, and I need your help with it. It’s about how freaking much we pay for medicine. And what we can maybe do about it.

This problem is something that hits a lot of us. A big recent survey asked: Have you skipped a medication in the last year because of cost? A quarter of people answered yes.

And we know that a ton of people spend all kinds of time and energy trying to make sure they don’t have to go without meds that cost more than they can afford, or go broke paying for them.

Looking for coupons, haggling endlessly with insurance, ordering drugs from online pharmacies — even pharmacies in other countries. And in some cases, undertaking all kinds of epic adventures.

One of the very first episodes of this show was about Laura Derrick, of Austin Texas. And how she turned her life upside down in 2011. She had just started a new drug.

A drug that may have saved her life. And then, almost immediately, two things happened. Thing one: Laura found out what that drug cost.

Laura Derrick: I was covered by insurance. So this is not what I paid, but the first bill was over $55,000.

Dan (talking to Laura): And this is for like a month supply

Laura: A month’s supply.

Dan (talking to Laura): And how much was your share of that?

Laura: Um, my share was about $20.

Dan: And then, thing two: her husband was diagnosed with cancer. Late-stage cancer. He needed intensive treatment, which meant he couldn’t work. Which meant, he was about to lose his insurance.

And this was before the Affordable Care Act was implemented. If you had a pre-existing condition, and you didn’t get insurance from your job, you basically couldn’t buy insurance.

So Laura Derrick needed a job. She knew people who were eager to hire her, but there was a catch.

Laura: My, my daughter’s last year of high school, my son’s last year of college. I left our family with my husband in cancer treatment because the only job they could offer was in Ohio.

And it offered us an insurance policy with a zero deductible that cost $20 a month for the whole family and covered everything we needed. But it meant I had to be gone for almost a year and a half.

Dan: That job, by the way, was with Barack Obama’s 2012 re-election campaign. Laura was determined to win — so the ACA could get implemented, so that people, including her — and her family, could get insurance without going quite as far as she did.

But to say the least, having insurance does not mean having no problems. For some people, getting their meds — it may not mean taking a job far away from family — but fighting with insurance can become a very frustrating part-time job of its own.

When I talked with Lillian Karabaic, in 2022, she was grinding away: trying to avoid a crushing bill for Enbrel. That’s an expensive rheumatoid arthritis drug she’d been taking for years.

Lillian is a financial journalist, who teaches financial self-help to millennials. So, as you can imagine, she’s very organized.

And as we talked about the adventure she was on at that point, she pulled up the time-tracking software she uses:

Lillian Karabaic: Okay, so it has been nine hours and 32 minutes in the past two weeks that I have spent on healthcare admin, which is mostly being on phone calls.

Dan: What kicked off all those phone calls had been a rude awakening. Literally. From her phone.

Lillian: I just got all of a sudden a text message from my specialty pharmacy saying that I have a $3,000 co-pay. That’s not a text message that anybody wants to wake up to.

Dan: When we talked — two weeks and almost ten hours of phone calls after that text message — Lillian was … giving up on getting out of that three-thousand dollar copay. And getting to work on figuring out how to pay it.

Lillian: But I’m kind of delaying the inevitable at least long enough to apply for a credit card that has a decent point signup bonus. So at least I can get something out of this entire situation.

Dan: So, yes: We know how tough this can be. Has been. Is.

I have a feeling you may know a bit about this too. Like, you may not have gotten a text message saying you owe three thousand bucks.

But you definitely may have been in the situation of asking, “Holy crap, I’m supposed to pay THIS MUCH for my meds? What?”

— and THIS MUCH could be thousands of dollars, or hundreds of dollars, or 60 dollars. If it’s a lot to you, it’s a lot. And that’s why I want your help:

If you’ve been in that situation, what have you done? And what did you learn? Maybe you learned a strategy that actually worked for you. Maybe it was, “Man, I learned about a new way I’m getting screwed.”

However things went — however they’re going: What did you learn that you want other people to know? It doesn’t have to be a big secret. Just something you’d tell a friend about if they asked.

But I’m pretty sure there are strategies not enough people know enough about. I’m also pretty sure there are new ways we’re getting beat up.

And the more we learn about those, the more we can work together to do something about them. So I’m asking you to share all that with me.

By the way, I know that you may not be doing this for yourself, for your own meds. You may be doing this for a family member, or maybe you’re a health care worker trying to help a patient — or patients. Or an advocate or a social worker.

You’ve been working on this? You’ve been learning something the rest of us should know about? I wanna hear about it. I’d love it if you head over to https://armandalegshow.com/drugs/ — and tell me about it. You can keep it brief, or go long.

That’s https://armandalegshow.com/drugs/. We’ll have a link wherever you’re finding this, and you can just click that.

And if you HAVEN’T been on an adventure like this- – well, one: Good. I actually would love to hear about that too. I do not mind hearing good news about good people. Not everything has to be a nightmare.

And I would love it if you passed this request around. Because probably, somebody you know has a story we should hear about.

Please encourage them to bring that story right here. A story with a lesson or a question. Like, “Can they freaking DO that?!? Is there anything I can do about it? Is there anything SOMEBODY can do about that?”

Over the next month or two, we’ll dig into everything you bring us. We may call you for more details. And we’ll call some experts to get answers to some of your questions.

Then, this spring, we’ll start sharing what we learn. The place to bring it is https://armandalegshow.com/drugs/. 

We’ll have a link wherever you’re listening. Along with a link to some resources you might find helpful. Thank you SO much!

Meanwhile, I’ll catch you in a few weeks with a new episode. Till then, take care of yourself.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it.

An Arm and a Leg February 3, 2025 Season 13, Episode 2 p.5

An Arm and a Leg is produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show. We are distributed by KUOW, Seattle’s NPR News Station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at armandalegshow.com/support/.

And thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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