Showing posts with label Health Care. Show all posts
Showing posts with label Health Care. Show all posts

February 12, 2017

Foreign Born Doctors in Underserved Areas at Risk for Deportation

Patients in Alexandria, La., were the friendliest people Dr. Muhammad Tauseef ever worked with. They'd drive long distances to see him, and often bring gifts.

"It's a small town, so they will sometimes bring you chickens, bring you eggs, bring you homemade cakes," he says.

One woman even brought him a puppy.

"That was really nice," he says.

Tauseef was born and raised in Pakistan. After going to medical school there, he applied to come to the U.S. to train as a pediatrician.

It's a path thousands of foreign-born medical students follow every year — a path that's been around for more than half a century. And, like most foreign-born physicians, Tauseef came on a J1 visa. That meant after training he had two options: return to Pakistan or work for three years in an area the U.S. government has identified as having a provider shortage.

He chose to work with mostly uninsured kids at a pediatric practice in Alexandria. "That was a challenge," he says. "But it was rewarding as well because you are taking care of people who there aren't many to take care for."

And the U.S. medical system depends on doctors like Tauseef, says Dr. Andrew Gurman, president of the American Medical Association. He worries that if President Trump's executive order on immigration takes effect, it will mean parts of the country that desperately need medical care may not have a doctor.

"International medical graduates have been a resource to provide medical care to areas that don't otherwise have access to physicians," he says. "With the current uncertainty about those physicians' immigration status, we don't know whether or not these areas are going to receive care."

According to the AMA, today there are about 280,000 international medical graduates in the U.S. That's about 1 in 4 doctors practicing here. Some are U.S. citizens who've gone abroad for medical school, but most aren't.

"They don't all have permanent visas, and so a lot of them are concerned about what their status is going to be, whether they can stay, whether they can go home to visit family and still come back, and the communities they serve have similar questions," he says.

And the care provided by the graduates of foreign medical schools is, by and large, top notch. A study published Feb. 3 in the journal The BMJ, formerly The British Medical Journal, shows Medicare patients treated by doctors with degrees from non-U.S. medical schools get just as good care — and sometimes better — than those treated by graduates of American medical schools.

The immigration uncertainty is hitting medical schools at a tough time. Dr. Salahuddin Kazi is in charge of recruiting top students from across the world for the University of Texas Southwestern residency program.

"Typically we have 3,000 people applying for our 61 positions — of those 3,000, at least half of them are international medical graduates," he says.

Applicants find out their program match in March and usually start working in June. That gives them about 90 days to get a visa. Kazi worries this year that won't be long enough and that students from countries included in the travel ban won't be admitted.

"That would create hardship for the hospital, for us and for our remaining residents," he says. "They'll have to pick up more shifts or give up vacation."

Pediatrician Tauseef left Louisiana two years ago but continues to care for low-income patients at Los Barrios Unidos Community Clinic in Dallas. Six of the 30 physicians who work at this clinic are from other countries.

Tauseef says they're all educated to do the same thing. "As a physician, being a foreign medical graduate, U.S. medical graduate, a Muslim doctor, a non-Muslim, we are trained to look for signs and symptoms," he says. "We do not look at anybody's color; we are not trained to look at anybody's religion or ethnicity."

Tauseef, who has been in America for 13 years, says he will apply for U.S. citizenship in March.


This story is part of a reporting partnership with NPR, KERA and Kaiser Health News.

February 6, 2017

On Obama Care Trump Voters Will Do the Heavy Lifting


Donald Trump's most ardent supporters are likely to be hit the hardest if he makes good on his promise to dismantle the Affordable Care Act and embark on trade wars with China and Mexico. 
"I think you're going to get a disproportionate impact on people who supported Donald Trump but maybe don't realize that his policies may end up hurting them instead of helping them," said Michael O. Moore, a professor of economics and international affairs at George Washington University. 
 How Immigration Went from Being Hotly Debated to Accepted in One Pennsylvania Town 1:59

Half of Republicans Have Obamacare 

According to Gallup data, the number of Americans without health insurance was just under 11 percent in the fourth quarter of last year, down from roughly 17 percent three years earlier. 
Odds are, a large number of those newly insured were Trump voters: An analysis by the Kaiser Family Foundation found that 6.3 million of the 11.5 million Americans who used the ACA marketplace to buy their insurance last year live in Republican Congressional districts. 
Policy analysts say that a rollback of the ACA would hurt older and rural Americans — two populations that favored Donald Trump over Hillary Clinton in the presidential election. 
One ACA rule that would likely disappear under a Congressional repeal put limits on how much more insurers could charge older customers, said Josh Bivens, director of research at the left-leaning Economic Policy Institute. Rolling back those caps would mean that older Americans trying to buy health insurance would pay more, especially in areas where there was little competition in the insurance market, as is the case in many rural states. 
"For older voters who aren't in great health and don't live in states that are densely populated, I think they're going to be really hammered," Bivens said. 
The Americans who have the most to lose from a repeal are low-income families living in the 32 states that expanded Medicaid to cover more than just the very poor, Bivens said, but even the comfortably middle class — an income bracket that broke for Trump by a narrow margin in the election — could see their costs rise. 
According to CNN's post-election exit poll, Trump edged out Clinton by three percentage points among Americans who earn between $50,000 and $99,999. The Affordable Care Act's premium subsidies are available to households with incomes of up to $97,200 for a family of four (to rise to $98,400 next year). 
Likewise, Trump's early trade agenda could hit a surprising number of American pocketbooks. 

Smaller Cities Hit Harder by Trade War 

By abandoning the Trans-Pacific Partnership, the new administration slammed the door on potentially lucrative Asian markets like Vietnam, said Daniel Ikenson, director of trade policy studies at the Cato Institute, a libertarian think tank. 
"They've been somewhat difficult for U.S. exporters to penetrate, so those barriers to trade would have gone away or would've been reduced considerably," he said. 
A recent Brookings Institution study shows that, by the numbers, a handful of big cities like New York and Los Angeles do the heavy lifting when it comes to U.S. exports. But when you look at how important exports are to a city's economy, a different picture emerges, one that shows smaller cities — many in red-state territory — with the most to lose from the isolationist policies Trump has embraced. 
"As a share of a local economy, the most export-intensive places in the country are smaller — they tend to be in the Midwest in places like Indiana and Michigan, or the South," said Joseph Parilla, a fellow in the Metropolitan Policy Program of the Brookings Institution. 
Parilla pointed to vice president Mike Pence's hometown of Columbus, Indiana, as one such example. "Half of its economy is devoted to exports… compared to about 10 percent of the nation's economy," he said. 
David Brown, deputy director for the economic program at the Third Way, said rural areas that depend on agriculture are especially likely to struggle. 
"Agriculture — it's not the biggest part of the American economy, but in some parts of America, it's virtually the whole economy," he said. "U.S. farmers had a lot to gain from the TPP… and they've gained a lot from NAFTA," he said. 

Lower-Income Families Will Pay the Higher Prices 

In addition to keeping American companies from growing exports, trade policy experts say the import tariffs Trump has threatened to impose on Mexico and other trading partners would wind up costing all consumers. 
"When you look at what Trump wants to do by restricting imports, your mind first goes to consumers. If you put a 20 percent tariff on goods coming from Mexico, it's a complete fallacy that this will be felt only in Mexico," Brown said. "These are products from cars to tomatoes — everyone's going to feel that effect," he said.  
Brown and other trade experts point out that the brunt of this will be borne by lower-income families, since poorer people spend a greater percentage of their income on goods than their wealthier peers. And rural Americans, living in places with less population density and less retail competition as a result, are more likely to notice those increasing prices. 
"I don't think many of the supposed jobs that are going to be created are going to be in those rural areas, so they're not going to get the benefits, but they're going to get the cost," Moore said. 
"One of the tricky things about tariffs is the benefits to seem to be concentrated and the costs are spread across the country," he said. People will be reminded of that." 


January 18, 2017

Regardless of What You Heard, , How do People Feel about Loosing Obama Care?

September 11, 2015

What if You Can’t Afford Your HIV Meds?

Last year, Howard Sellers says he faced an impossible choice: buy groceries or pay for his anti-viral HIV medicine. “There were times I would skip my doses of medication because I just didn’t have the money to pay for it,” Sellers told us. “It started getting so bad that I would literally miss about a month of meds.”
Sellers, who has worked for the Department of Education since 2002, had been at P.S./M.S. 165 on the Upper West Side for seven years, first as a teacher, then as a community coordinator and dean. 
“The DOE health plan didn’t cover all my anti-viral meds,” Sellers explained, noting that his monthly co-payments frequently added up to more than $400, in addition to his student loan payments and his $1,050/month apartment share in Fort Washington. 
Sellers, who graduated from SUNY New Paltz and Columbia Teachers College, says he made his starting salary, around $48,000 annually, for years until he recently received a small raise. 
“They bumped me up to 54. I was supposed to get a raise of 7K [more], which didn’t happen, but I came to work because it’s about the kids, and I was just hoping that it would happen eventually. It didn’t.” 
Skipping medication put a dangerous strain on Sellers's body—he estimates that he was hospitalized at least a half-dozen times during his last two years of work. Eventually, the 36-year-old educator says he lost roughly 30 pounds and survived on school lunches.
“I couldn’t even get a second job, because there was so much on my plate that when I left school at eight or nine at night, there was nowhere for me to go work, because I was back at school at seven the next morning.”
Last summer, Sellers began writing checks to himself from the school’s checkbook.
“I wrote exactly the amounts for my meds, so if my meds were $280, I’d write myself a check for $280. If my meds for the months were $330, I would put $330. I’d use my checks to supplement my co-payments for my meds.”
Over the course of five months, Sellers stole around $2,200. 
“I acted in desperation, and I got by for a little bit, but my conscience weighed on me.” 
That's when he decided to confess to his principal.
“I said to her, look, I have an illness that you haven’t known about that I’ve been suffering with. I haven’t gotten a pay raise, I’m stressed, I’m struggling here, I’m living paycheck to paycheck I don’t have food,” Sellers said. 
Still, given the relatively small sum, his confession, and his willingness to repay what he stole, Sellers hoped that his principal would contact the DOE’s Office of Special Investigations, which “investigates allegations of improper or unlawful behavior,” or the Special Commissioner of Investigation, which handles more serious cases of “fraud, misconduct, conflicts of interest, and other wrongdoing” in the city’s school system. 
Instead, the principal called the NYPD. 
“It was like, OK, I just outed myself to someone who I thought was my friend, and she just completely threw me under, and it’s just been crazy since.”
In January, the Manhattan DA’s office charged Sellers with grand larceny, a felony, and identity theft and criminal possession of a forged instrument, both misdemeanors. Sellers was suspended from his job without pay, leaving him without health insurance. He lost his room in the Fort Washington apartment share, and has been hospitalized three times, most recently for contracting the parasite cryptosporidium. 
After one stay at Presbyterian Hospital, Sellers says he was unable to afford his medication; a physician ended up buying it for him.
“He's been the rock in his family, put himself through school, got financial aid and scholarships for New Paltz, got his masters, went through Teach for America, worked full time for eleven years, and can't afford drugs he needs to keep him alive, with health insurance,” says Alice Fontier, Sellers’ attorney.
“It's incredible that we live in a society that allows that to happen to people and then punishes them for it.”
(Jessica Lehrman / Gothamist)
Advocates say that New York State has some of the best coverage options for people living with HIV/AIDS in the country, but that it can be difficult to match the services to people’s needs.
“Having people understand the full spectrum of benefits, and navigating that benefit system is really challenging, even for folks who understand the health care system,” says Wendy Stark, the executive director at Callen-Lorde Community Health Center in Chelsea. 
“Whether you're eligible for Medicaid or whether you're eligible for ADAP or for a qualified health plan under the health exchanges, or whether you can avail yourself of different subsidies at different institutions, even finding those institutions—it's a really tricky business.”
Those who aren’t eligible for HASA—which provides low-income New Yorkers with HIV or AIDS with housing, food stamps, and Medicaid, among other services—may be able to receive help from ADAP, the state’s AIDS Drug Assistance Program. 
Under ADAP, New Yorkers making up to 435% of the federal poverty level—or $51,200—can receive drugs free of charge to treat HIV/AIDS, even if they are insured. 
For those out of ADAP’s range, there are still options to receive help with co-payments, which can balloon under a treatment regimen that easily can include more than a dozen medications. Pharmacy discount cards (BigAppleRXNeedy Meds) and discount plans sponsored by drug manufacturers like Gilead or through public hospitals or community health centers can lower monthly co-payments.
Stark says the myriad options and resulting confusion is a result of “a system-wide problem with our nation's healthcare system.”
“Unfortunately, because of our complex health system, a really important part of how to treat these issues is just getting medication in the hands of people who need it, and not have those people have to make really hard choices between medication versus rent versus food versus other life necessities.”
Alexandra Remmel, the director for client advocacy at Gay Men’s Health Crisis, says that in order to meet the state’s goal of ending the HIV/AIDS epidemic by 2020, “we must grow our efforts to get information out about life saving services that can remove barriers to treatment.”
"Every doctor will tell you not to skip [medication], it's that extra inch that says: Now how are you handling the cost of this? What kind of insurance do you have? Is it covering what you need? Is the deductible too high?” Remmel says. “These are questions that are not scheduled into a visit, but should be."
Sellers says that at least one of his doctors warned him not to skip his medication, but that ADAP never came up while he was faced with his ordeal in school. Negative comments he said his principal made about men with HIV made him afraid he’d be stigmatized, which further discouraged him from seeking help. 
“It made me kind of live this secret, and I never felt comfortable sharing that, so I didn’t,” he says. 
Sellers is now on Medicaid through HASA, which pays for his medication, but HASA also requires him to reside at the St. Nicholas Hotel in Harlem, a converted SRO that he calls “filthy.” 
“To be very honest with you, I dragged my mother out of that hotel many years ago,” Sellers told us. “You can look at the sinks and the tubs there are old cigarette burns on them. It’s really gross.”
He has a job at the Gap making $11.50/hour, but if he earns more than around $400 a week, he stands to lose his Medicaid and his benefits.
“I feel like I've hit rock bottom. I'd rather work and have an income then have to sleep in a hotel room somewhere and be living off HRA and living in one of their shelters.” 
The DOE declined to comment on Sellers's case, other than to confirm his employment. 
There is still the matter of the criminal charges against him—Sellers is due back in court at the end of the month. His attorney says the Manhattan DA’s office is offering him a deal: pay back half of what he stole and the felony will turn into a misdemeanor; pay it back entirely and it will turn into a violation. 
Once the DA is finished with him, the DOE will determine whether he can go back to work.
“I want to clear my name. I want to get this over and done with,” Sellers says, adding that he is eager to work as an educator again. 
“I was a product of the New York City Department of Education; I came out well. There are many kids of color who look up to men in the system. I feel that they need to see someone in a suit who is pushing for their education and their success, someone who is there to listen.”
“I was desperate and I made a mistake. I don’t feel it defines me.”

August 3, 2015

Death in PR 5,000 Doctors Leave the Island-Only the beginning


MAYAGÜEZ, P.R. — The first visible sign that the health care system in Puerto Rico was seriously in trouble was when a steady stream of doctors — more than 3,000 in five years — began to leave the island for more lucrative, less stressful jobs on the mainland.

Now, as Puerto Rico faces another hefty cut to a popular Medicare program and grapples with an alarming shortage of Medicaid funds, its health care system is headed for an all-out crisis, which could further undermine the island’s gutted economy.

On an island where more than 60 percent of residents receive Medicare or Medicaid — an indicator of Puerto Rico’s poverty and rapidly aging population — the dwindling funds have set off outpourings of concern among patients and doctors, protest rallies and intense lobbying in Washington.
Protestors in San Juan's financial district demanded the island's public debt not be paid to bondholders.  Puerto Rico, Running Short of Cash, Misses a Debt Service DeadlineJULY 15, 2015
Paseo de Diego, a pedestrian corridor in San Juan, P.R., that once buzzed with shops and shoppers, sits nearly empty, as businesses have closed.Despair and Anger as Puerto Ricans Cope With Debt CrisisJULY 3, 2015
And while the crisis is playing out most vividly today, its cause dates back decades and stems, in large part, from a vast disparity in federal funding for health care on the island compared with the 50 states. This disparity is partly responsible for $25 billion of Puerto Rico’s $73 billion debt, as its government was forced to borrow over time to keep the Medicaid program afloat, according to economists.

Dr. Johnny Rullán, right, a former secretary of the island’s Health Department, is lobbying for equal funding.CreditDennis M. Rivera Pichardo for The New York Times

Dr. Johnny Rullán, right, a former secretary of the island’s Health Department, is lobbying for equal funding. Credit Dennis M. Rivera Pichardo for The New York Times
“These are a cascade of cuts that will have disastrous, gigantic implications,” said Dennis Rivera, the chairman of the Puerto Rico Healthcare Crisis Coalition, a group of doctors, hospitals, health care advocates, unions and insurance companies lobbying the Obama administration and Congress. “Health care in Puerto Rico is headed for a collapse.”

He added, “If we pay the same Medicare taxes and Social Security taxes, we should be treated equally.”

In January, the federal government is supposed to cut payments to Medicare Advantage plans in Puerto Rico by 11 percent. The plans, offered by private companies, are a popular alternative to Medicare, often providing extra benefits and accessibility.

Three-quarters of the Medicare population on the island is enrolled in Advantage, and patients, many of them poor and chronically ill, worry about the impact of the cuts on costs and benefits.

The cuts are expected to lead to higher co-pays for medication and hospitalization, among other things, said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company with three Advantage plans in Puerto Rico.

“There will also be certain services we might have provided in the past that we can’t now,” Dr. Shinto said. Free rides to doctor’s offices are an example.

In addition, several hundred doctors are already losing their contracts with major managed care companies. InnovaCare has terminated 200 contracts, Dr. Shinto said.

“That’s one way on the island we are trying to manage the significant revenue reductions we’re to have — narrow our network of physicians,” he added.

This is in part because of how doctors practice here; they tend to be in solo practices, making it difficult to meet all requirements. Lower funding levels also complicated efforts to meet standards.
The island’s Medicaid program — called Mi Salud, or My Health — serves nearly 1.6 million people, or 45 percent of the island’s population, the largest share in the United States, and it is also struggling, said Ricardo Rivera, the executive director of the Puerto Rico Health Insurance Administration, which carries out the Medicaid program.

Health care makes up 20 percent of the Puerto Rican economy, which has been in a slow decline as manufacturing jobs have disappeared and the government has borrowed more than it could pay back. Because of the island’s precarious finances, the Medicaid program lacks access to credit and is so short on cash that it owes providers $200 million, a figure it has whittled down from $350 million. It is also spending a one-time $6.4 billion federal grant at a much faster pace than expected, Mr. Rivera said.

The Medicaid program, which relies on both federal and commonwealth funds, could run out of the grant money as early as the end of 2016, three years earlier than anticipated, Mr. Rivera said. This could mean that 900,000 people will have to be dropped from the program.

Puerto Rico cannot use the federal health insurance exchange under the Affordable Care Act, and it chose not to create its own exchange because its citizens do not pay federal income taxes and thus are not eligible for the subsidies that make exchange plans more affordable.

A spokesman for the Centers for Medicare and Medicaid Services said the agency was aware of the growing concerns and was working weekly with a group of politicians, health care officials, advocates and insurance companies here to find solutions. So far, none have been offered.

The reduction in Medicare Advantage funding is meant to bring federal payments for that program more in line with traditional Medicare fee-for-service rates in Puerto Rico. Advantage plans on the mainland have received cuts in recent years for the same reason, although generally not as big.

But Puerto Rican officials and health care experts have long criticized the federal formula for calculating its fee-for-service rates as unfair, and point out that even the Virgin Islands, a much smaller commonwealth, gets considerably more money for Advantage.

Puerto Rican lawmakers and doctors warn that it will be more expensive for the United States to ignore the problem for one reason: Those who need medical care can quickly settle with relatives on the mainland, where it is pricier.

 Medical records at Dr. Luis Vicenty’s office. 
The crush of doctors who have left Puerto Rico have created a serious shortage of specialists.Credit
                                                                                 Dennis M. Rivera Pichardo for The New York Time

“My message to the federal government is simple: If you continue to treat Americans living in Puerto Rico poorly, they will exercise their rights and move to the U.S. mainland, where they will immediately be entitled to equal treatment,” said Pedro R. Pierluisi, Puerto Rico’s nonvoting delegate in the House of Representatives.

Sitting in the waiting room of his doctor’s office in this large, poor Puerto Rican city, Santos De Hoyos, one of the 275,000 patients who are on both Medicare Advantage and Medicaid, said he was bracing for higher co-pays for medication. At 63, he has a heart ailment, asthma and diabetes and takes numerous medications, including one that costs $150 per dose.
“If the medical plan stops covering it or I lose the plan, I die,” said Mr. De Hoyos, a former worker at a canned tuna factory. “I am praying that God puts his hands into this.”

Mr. De Hoyos typifies the health care challenges facing Puerto Rico, which has among the highest rates of diabetes and asthma in the United States. The same is true of Mayagüez, a city that once relied on manufacturing but now depends greatly on the health care industry.

“There are health conditions on the island that are just mind-blowing,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. “You’ve got a tremendous burden of poor health, tremendous costs, a tremendously dependent population and a Medicaid program whose per-capita payment is a fraction of the U.S. per-capita rate.”

In San Juan, the Puerto Rican capital, beds in hospital emergency rooms line the hallways. There are so few nurses that people often hire their own private nurses during hospital stays.

Doctors, too, are preparing themselves.

“Medicare Advantage allows us to live and pay our bills,” said Dr. Carlos Román, a family doctor here. “And the companies are not going to cut into their profits; they will cut into our pay and limit treatments, services and medicine.”

Dr. Luis R. Vicenty, 55, a longtime Mayagüez internist, recently received termination letters from two Advantage companies.

Like many doctors from the island, a group that is well-trained, board-certified and bilingual, Dr. Vicenty received a job offer on the mainland, at a hospital in Washington State.

The crush of doctors who have left has created a serious shortage of specialists. Most medical school graduates do not even bother looking for jobs here; almost none are available, and those on the mainland typically pay double.

“Doctors can leave,” Dr. Vicenty said. “So this will get worse.”

Easy solutions to the health care crisis do not exist, mostly because it stems from the disparity in funding, something that only Congress can change. Mr. Pierluisi has introduced legislation to address some of the problems.

Puerto Rico’s health care woes began in 1968, when Congress placed a cap on Medicaid in the United States territories that sharply limited the federal government’s contribution.

For Medicaid, this means that Puerto Rico typically gets $373 million a year from the federal government and has to pick up the rest of the $2.5 billion tab, Mr. Rivera of the Puerto Rico Health Care Coalition said. Last year, Oklahoma, which is wealthier than Puerto Rico, received $3 billion from the federal government, according to data compiled by the coalition. Mississippi, also not as poor as the island, received $3.6 billion.

A similar discrepancy exists with Medicare and Medicare Advantage. Puerto Rico’s Medicare reimbursement rates for doctors are 40 percent lower than the mainland’s, and the Medicare Advantage program is paid 60 percent of the average rate in the states, according to coalition data.

Dr. Johnny Rullán, a health care expert who was once head of the island’s Health Department, said Puerto Rico was not asking for more. It was asking for equity.

“We just need equal funding,” he said. “That will take care of the problem.”

A version of this article appears in print on August 3, 2015, on page A1 of the New York edition with the headline: PUERTO RICANS BRACE FOR CRISIS IN HEALTH 

June 9, 2015

Supreme Court’s Gay Marriage and Obama Care Educated Prediction


June is always the most exciting month of the year for the Supreme Court. Typically, the court decides its most high-profile cases then, usually late in the month. And this June is no exception. It will bring important decisions regarding the Confederate flag on license plates, lethal injection drugs, regulating emissions of coal and power plants, housing discrimination and more. 
But those decisions will be decided in the shadows of two of the highest-profile cases the court has had in years, or possibly decades: Obergefell v. Hodges, the same-sex marriage case, and King v. Burwell, the decision about whether to gut Obamacare and end affordable health care access for millions of people in the United States.
Here's what to expect with both those cases.

The case: Obergefell v. Hodges
Background: Does the Constitution require marriage equality? The Supreme Court came close to answering this question back in 2013, but avoided it on technical grounds. This time, with Obergefell, it will address the issue head-on.
It may be hard to remember, but in May of 2004, there wasn't a single state in the country that permitted same-sex marriage. Eleven years later, 37 states and the District of Columbia have marriage equality, and nearly 72 percent of Americans live in a state that allows same-sex couples to marry. That is remarkably sweeping change in a very short period of time.
Now, the Supreme Court has to decide whether the remaining states have to permit same-sex marriage. The case – originating from the four non-equality states of Ohio, Tennessee, Kentucky and Michigan – was argued in late April, and all eyes are now on Justice Anthony Kennedy. (Based on their questioning at oral argument, neither the more liberal nor the more conservative justices gave us any reason to doubt how they will rule, though some people are still holding out for Chief Justice Roberts to surprise us and vote for equality.)
This case will likely be decided the last day of the court's term, currently scheduled to be June 29.
Prediction: A historic 5-4 decision for equality.
Evidence: Predicting how Kennedy will vote requires us to probe the beliefs he's expressed in the past about gay rights. And you could say – stay with me here – that his beliefs are well expressed by Whitney Houston lyrics. You see, Kennedy has authored each of the high court's three major gay rights decisions over the past two decades, and in those cases he's returned to the same themes: "the children are our future," and the law "can't take away [gay people's] dignity."
During oral arguments in April, he did this once again, peppering the lawyers defending the same-sex marriage bans with questions about how children of gay and lesbian couples are harmed by denying their parents the right to marry, and how gay and lesbian individuals lose their dignity by not being able to marry. Once again, he seemed this close to breaking into "The Greatest Love of All."
Although we can't know for sure what the Supreme Court will do, when Justice Kennedy channels his inner Whitney like this, it's good news for supporters of marriage equality.
The case: King v. Burwell
Background: Is the Obama administration implementing its signature legislative achievement, the Affordable Care Act, in a way that flouts the language of the law? That is what the court has to decide, and it's a question that could affect health insurance coverage for millions of Americans.
Obamacare has been a wildly successful social welfare program. According to recently released data, more than ten million people signed up for subsidized health insurance through Obamacare this year, and almost nine out of ten adults now have health insurance, a huge improvement from the pre-Obamacare rate.
This could all come to an end if the Supreme Court decides the program is not being implemented properly. At issue is whether people who bought insurance in states that did not set up their own health insurance exchange can get subsidies from the federal government to help them pay for that insurance. The law very clearly allows subsidies for people who buy insurance through state-run exchanges, but does it allow them to do so if the state relies on a federal exchange because it refused to set up its own? 
If the court rules against the Obama administration, most experts predict that more than six million people would lose subsidies, making most of them unable to afford insurance and possibly destroying the health insurance market in the affected states.
As with the same-sex marriage case, expect a decision the last day of the term.
Prediction: I wouldn't bet my life savings on it, but we're looking at a possible 5-4 win for Obamacare. 
Evidence: If the court ruled against Obamacare, most experts believe the health insurance market would suffer what's called a "death spiral" without the subsidies. Healthy people in states without subsidies would drop their coverage because it would start costing too much. Then insurance would become more expensive, because premiums would go up with healthier people dropping out of the pool. Then more people would drop their coverage as it got even more expensive. Then premiums would go up once again. And rinse and repeat, ad nauseum. This downward spiral could destroy Obamacare's advances with respect to private health insurance.
But the threat of this descent into chaos could also be what saves Obamacare. The Supreme Court justices are well aware that if they rule the subsidies are not allowed, the law would basically implode and millions of real people would be harmed. The hope is that at least one of the five conservative justices bows to this reality. To do so, they'd have to move beyond the hostility they espoused toward the law in 2011 when the court barely upheld Obamacare in the face of a constitutional challenge. 
The millions of people who now have health insurance thanks to Obamacare are banking on it. 

April 5, 2015

For Non Cancer Pain Opioids Can Still Help Some

The American Academy of Neurology and other groups have found no solid evidence that opioids are effective for chronic noncancer pain, yet many patients with such pain swear that opioids are the only treatment that helps them.
We contacted pain management experts and a variety of healthcare professionals to ask:  Guideline Pros and Cons
James McGowan, MD: "On a whole, the use of chronic opiates over the last 20 years has done nothing to decrease rates of chronic pain in this country and very little to improve the lives of most patients who deal with chronic pain. At the same time, I do believe that some patients can experience long-term improvement in pain control and increased functioning with chronic opiates if these patients are carefully chosen and closely monitored. We swung the pendulum much too far in one direction with the use of opiates over the last 20 years, but I think we need to be very careful about swinging it too far in the opposite direction and completely abandoning the use of chronic opiates altogether. A balance must be struck in which judicious use of opiates in limited patient populations replaces widespread and unregulated usage."
Jack Freer, MD: "In general, the AAN position paper is a thoughtful and useful guide to the use of opioids in chronic noncancer pain (CNCP). In practice, however, it may be difficult for physicians to adhere to this kind of rigorous program. It is time consuming, since it requires an initial abuse risk assessment, individualized treatment contract, and ongoing monitoring with random urine testing. The regular re-evaluation of the treatment effectiveness needs to be function-oriented, and should, almost always, include other modalities (such as physical therapy). It also requires a physician to 'pull rank' and refuse requests to keep increasing the dose. A practitioner must be prepared to tell a patient (who says that the dose is inadequate), 'maybe this is not the right medicine for your pain.' Many physicians are not prepared to spend this time and energy and take one of two easier paths: either they become very loose in their prescribing of opioids, or they stop prescribing them altogether."
Lewis Nelson, MD: “These guidelines                
are well thought and provide a     balanced overview of the benefits and risks of using opioids for chronic pain. Unlike many other guidelines that focus more on efficacy of therapy, particularly on the reduction of pain, this AAN guideline highlights the importance of considering functional outcome. Further, the guideline better focuses on the safety of chronic opioid therapy, which carries significant risks, including addiction, overdose, and death, even with therapeutic use. In addition, the guideline captures the large public health burden, measured by both addiction treatment and mortality that has paralleled the rise in the use of such therapy."
Applications Across Specialties
Sabine Kost-Byerly, MD: "Patients may benefit from opioids to facilitate more effective physical therapy but if opioids make them too drowsy to participate, nothing has been gained. They may also benefit from opioids if recurrent reconstructive surgeries are needed after severe trauma. Pediatric and adolescent patients may receive opioids for weeks and sometimes months in these cases. It is important for providers to critically assess their patients during this time as it is all too easy for patients to seek the soothing effects of opioids to manage depressive symptoms that may have arisen due to their change in body image or prospects for an independent life. There is nothing wrong with acknowledging such feeling but opioids are the wrong drugs to treat them. "
Nelson: "In the emergency department I care for many patients being treated with chronic opioid therapy for a chronic pain syndrome. Most present for exacerbation of chronic pain, although complications related to the use of opioid therapy are a frequent reason as well. Management of chronic pain in the ED is complicated by the limited availability of a patient's medical record in the setting of nonobjective complaints (i.e., pain). Tolerance and hyperalgesia add to the complexity. However, the widespread use of prescription drug monitoring programs has allowed more judicious consideration of opioid use. In general, EDs do not prescribe the types of opioids most frequently used in this group of patients (those that are extended release or long acting)."
McGowan: "There are groups of patients whom I will sometimes treat with chronic opiates. In general, these are patients in whom I can clearly demonstrate an anatomic source of pain, such as severe arthritis, significant spinal degeneration, or a history of major trauma, as opposed to patients in whom the cause of pain is not easily identified. I will also consider opiates in patients with medical contraindications to other therapies, such as patients with severe arthritis who cannot take anti-inflammatories because of chronic kidney disease."
Prescribe with Caution                      

Kost-Byerly: "Although chronic pain in children is not as rare as we once thought, management of such pain with opioids actually remains rare, so rare that researchers have had a difficult time finding patients to evaluate the efficacy and safety of prolonged opioid therapy in younger patients. Most pharmacological therapy of chronic pain in children is based on studies performed in adults. Ideally, assessment and treatment of chronic pain in children and adolescents is interdisciplinary, including a number of healthcare providers such as the primary care physicians, physical therapists, behavioral psychologists, and for complex cases, pain specialists. Accordingly, limiting treatment to pharmacological interventions, including opioids, is often insufficient to help the patient."
McGowan: "I will usually avoid opiates in patients who seem fixated on opiates as 'the only thing that works' as opposed to those who are open to using other treatment modalities such as non-opiate medications, interventional pain techniques, and physical therapies. I also will generally avoid opiates in patients with history of misuse or abuse of prescription opiates, patients with other significant substance abuse problems, or patients with significant psychiatric issues. Although there is no 100% foolproof way to prevent bad outcomes with chronic opiates, I find that by sticking to these guidelines, chronic opiates can be used for the betterment of some patients.”

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