THE PROGNOSIS

Advocates of Medicaid expansion got some positive reinforcement in several recently released studies. 

This year, the perennial struggle over the future of the health-care program for low-income Americans became even more pronounced. After an epic political battle, Virginia's government agreed to expand Medicaid under the Affordable Care Act to more low-income residents beginning next year. And three conservative states -- Utah, Idaho and Nebraska -- are considering it, too. Meanwhile, 11 states have filed applications with the federal government to effectively scale back the program by adding new eligibility requirements.

President Trump and his administration have targeted Obamacare, weakening several of its key provisions, while Republicans in Congress, after failing to repeal and replace the ACA last summer, are trying to scale back some entitlements that help the poor: food stamps, housing programs and Medicaid (they argue a strong economy allows more able-bodied adults to work). Democrats have responded by taking up the mantle of "Medicare for all" and some states are considering "Medicaid for more" programs.

With that backdrop in mind, it's notable to point out the results of recent research: one report that aimed to disprove a common charge against Medicaid expansion; and another intended to highlight its virtues.

A frequent argument against Medicaid expansion is there aren't enough doctors accepting Medicaid patients to go around. Republicans contend the Affordable Care Act has exacerbated that problem because it allows states to expand Medicaid. Early last year, our Post Fact Checkers gave Speaker of the House Paul D. Ryan (R-Wis.) “two Pinocchios” for saying that “more and more doctors just won’t take Medicaid,” writing there wasn't sufficient evidence to back up his statement. 

Now, there might be. New research, led by Hannah T. Neprash, a professor of health policy at the University of Minnesota, concludes that expansion has not caused doctors to take fewer Medicaid patients.

Using claims data from primary-care physicians nationwide, Neprash found that after comparing 2013 to 2015, — the years before and after states began expanding Medicaid — there was a slight uptick in doctors' patient population on the government program. In the states that chose to expand (then 30, plus Washington, D.C.), the average share of a doctor's patients on Medicaid went from 10.2 percent in 2013 to 13.6 percent in 2015. In non-expansion states, there was no notable difference either way, according to the study. 

“Folks in Virginia are nervous about whether physicians will accept Medicaid patients, and this is definitely — as Medicare for all, or Medicaid buy-ins gain traction -- this is an important policy question to be asking. It’s one thing to expand insurance; there has to be a willingness to treat those patients," Neprash told me. “Our results are in no way a slam dunk, but for the most part it’s a good news story.”

Neprash's findings, published in last month's Health Affairs, are consistent with other research that has studied Medicaid populations. Our Post Fact Checker wrote that, absent the type of data Neprash analyzed, one way to measure Medicaid patients' access to doctors is how often they actually get care. According to a survey by the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan legislative branch research agency, adults with Medicaid were "as likely to have seen a doctor in the past year as adults with private insurance." And, unsurprisingly, compared with uninsured adults, "Medicaid enrollees were considerably more likely to have seen a doctor in the past year."

Another study released Monday afternoon by Health Affairs found that in states that expanded Medicaid, there was a 40 percent increase in patients filling their diabetes prescriptions. The chronic health condition, which requires daily medication to maintain, is prevalent among poorer Americans. The price of insulin has increased sharply in the last decade. Untreated, diabetes can lead to more serious complications like kidney damage or heart disease.

The study, as reported by Kaiser Health News, “shows that the Medicaid expansion can help patients manage their health and also limit unnecessary spending. An analysis by the Centers for Disease Control and Prevention cited by the study shows that each diabetic patient who is treated for the condition can lead to a $6,394 reduction in health care costs (in 2017 dollars) because of fewer hospital admissions,” Kaiser's Pauline Bartolone writes. 

The same has been found in other studies of major public health issues, like opioid abuse, which disproportionately affects low-income Americans. A study published last month in the Journal of Health Economics found admission to treatment facilities increased 18 percent in expansion states, largely due to a 113 percent increase in admissions for opioid treatment by Medicaid beneficiaries.

As noted by Kaiser Family Foundation last week in a piece about community health centers' role in treating opioid addiction, evidence like this will influence the debate as the tussle over the future of Medicaid continues.

Adding eligibility requirements, the independent organization writes, creates additional barriers to Medicaid coverage for those patients dealing with chronic health issues, whereas expansion of Medicaid helps more people address those conditions before they get worse — and even more costly.

Let's not forget that such additional medical costs, whatever they may be, may fall on the taxpayer. 

 

AHH, OOF and OUCH

AHH: Major cuts to Medicaid threaten to hit hard a U.S. territory that is still grappling with the aftermath of a devastating natural disaster. Even before Hurricane Maria hit the island, Puerto Rico faced a $70 million debt, which Kaiser Health News’s Sarah Varney and Carmen Heredia Rodriguez report was largely “due to the territory’s historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.”

And now, Puerto Rico will move forward with massive cuts that will impact more than one million poor residents. “The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government as the island claws its way back from fiscal oblivion,” Sarah and Carmen write. “The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island’s Medicaid budget, compared to what it contributes to the 50 U.S. states.”

OOF: Here’s a new one: Plastic surgeons are facing an emerging phenomenon known as “Snapchat dysmorphia,” where patients are bringing in selfies of themselves, edited with certain filters, as inspiration for augmentation.

The filtered photos, via Snapchat and Instagram, or paid applications like Facetune, show people with “freckles, longer eyelashes, wider eyes and flawless skin, among other augmentations,” our Post colleague Allyson Chiu reports. According to an article published in JAMA Facial Plastic Surgery, the phenomenon is “causing widespread concern among experts who are worried about its negative effect on people’s self-esteem and its potential to trigger body dysmorphic disorder, a mental illness classified on the obsessive-compulsive spectrum," Allyson adds.

She reports the JAMA article notes “Snapchat dysmorphia” is a “form of body dysmorphic disorder. Also known as body dysmorphia or BDD, the condition is a mental disorder that causes people to be ‘extremely preoccupied with a perceived flaw in appearance that to others can’t be seen or appears minor,’ according to the Mayo Clinic. People who have BDD tend to obsess over their appearance and body image, often checking the mirror, grooming or seeking reassurance for many hours a day, the clinic said.”

TRUMP TEMPERATURE

OUCH: The health ministry in Congo said over the weekend the latest outbreak of Ebola virus is believed to have killed at least 33 people, Reuters reportsYesterday, the ministry said the outbreak is suspected to have infected 43 people, though it did not update the reported death toll. "Giving the latest figures on the epidemic, which was declared just days after an outbreak in northwestern Congo 2,500 miles away was declared over, the ministry said of the 43 suspected cases, 16 were now confirmed,"  Reuters reports. "There were three new cases confirmed and four new deaths, as of Monday, it said."

Stat’s Helen Branswell reports the latest outbreak will “give the world another shot at testing an experimental Ebola vaccine.”

Helen adds: “Despite the potential of a vaccine to help in this outbreak, delivering it could prove challenging, warned Dr. Peter Salama, the head of the World Health Organization’s emergency response program. Battling factions operate in the area, and there are roughly 1 million displaced people in the province. The danger inherent in operating in this part of DRC means a modified approach to the vaccination rollout may be needed, Salama said.”

The treatment strategy will rely on how the vaccine is transported into the region.

— The Trump administration is already facing an uphill battle as state governments and regulators express concern following the announcement that it will allow people to buy cheaper, short-term health plans that aren't necessarily ACA compliant. State officials worry that means healthy people will leave the marketplaces.

“State insurance regulators, gathered over the past three days for a meeting of the National Association of Insurance Commissioners, expressed deep concern that short-term plans were being aggressively marketed in ways likely to mislead consumers,” the New York Times’s Robert Pear reports. “Many said the plans, which need not comply with the Affordable Care Act’s coverage mandates, were a poor substitute for comprehensive insurance.”

States have the authority to restrict or prohibit these short-term policies, Robert notes, making their concerns notable. And some states are already fighting back. Republican governors in Maryland and Vermont have both signed bills limiting the short-term policies to three months or less. Virginia’s Democratic governor vetoed a bill to sell plans that last up to a year, and Hawaii set a new law imposing a three months limit and limiting the short term health plans to those who cannot buy insurance through the Obamacare marketplace, Robert reports.

— Phones at the White House VA hotline are ringing off the hook. Our Post colleague Jessica Contrera reports from the hotline’s center in Shepherdstown, W. Va. where a “Donald Trump campaign promise is being fulfilled.”

“He told the country’s 20 million veterans that if they had an issue with the Department of Veterans Affairs, there would be a number they could call 24 hours a day to talk to a real person,” Jessica writes. The president had promised better care for veterans overall, but for now there’s a hotline, where the responders can only listen to the concerns expressed by the veterans who call day in and day out.

“Listen. Type. Send. This was what the 60 customer service agents could do for the 107,000 calls that had come in since June 2017. On this day, there would be 584 more,” Jessica writes. “The new hotline, 855-948-2311, joins nearly 20 phone numbers VA has listed on its website as national hotlines, help lines or call centers. These are in addition to the call centers run by individual VA hospitals and veterans service organizations. The allure of a hotline is that problems cannot be remedied unless they are first reported. But just because problems are reported doesn’t mean they will be fixed, said Joe Plenzler, spokesman for the American Legion.”

— The latest figures from the Trump administration reveal the number of migrant parents who waived the right to be reunified with their children after being separated from the border “is significantly lower” than what the government initially reported, our Post colleague Amy Goldstein reported late last week.

“The latest figures show that 34 parents waived the chance to be back together with their children — compared with the 120 that the government reported a week earlier,” Amy writes. “Migrants’ advocates and congressional Democrats have challenged the idea that large numbers of parents were signing away those rights, contending that some — traumatized by the separations — were misled, did not understand the form or never signed in the first place.” She added the updated data “shows a modest increase in the number of youngsters returned to their parents after being separated at the southern U.S. border.”

U.S. District Judge Dana M. Sabraw on Friday criticized the administration for making minimal progress in locating adults who had been deported or who had otherwise left the United States. He also criticized the lack of a stated plan for reuniting remaining families, Amy wrote. “The reality is, for every parent who is not located, there will be a permanently orphaned child, and that is 100 percent the responsibility of the administration,” Sabraw said.

AGENCY ALERT

Yesterday, the Food and Drug Administration said it would shift its approach to evaluating drugs that treat opioid addiction, moving beyond just a look at whether treatment helps patients stop using opioids. The FDA will now consider whether the treatment reduces opioid relapse rates or infectious disease transmission, Commissioner Scott Gottlieb explained in a statement.

The announcement is the latest in a string of efforts to improve the federal government’s response to the growing opioid crisis, which also includes legislation on Capitol Hill that aims to ensure treatment is evidence-based and, separately, to ensure more federal programs will pay for methadone treatment,” Stat’s Lev Facher reports about the new announcement.

“We’re committed to doing our part to expand access to high-quality, effective medication-assisted treatments and encouraging health care professionals to ensure patients with opioid use disorder are offered an adequate chance to benefit from these therapies,” Gottlieb said in the statement. “This work also includes improving understanding about the treatment options available for patients and countering the unfortunate stigma that’s sometimes associated with their use.”

— The FDA has declined for the fourth time to approve an opioid drug developed by Pain Therapeutics for the use of severe-pain management. Reuters reports the FDA found the “benefits of the drug did not outweigh the risk” and added the company “also said it had initiated a strategic reorganization to align its resources to focus on Alzheimer’s disease.”

MEDICAL MISSIVES

— Organs for Life, a new nonprofit that had hoped to replace the nation’s current organ transplant network, will not have the chance to do so. The nonprofit lodged a protest after the Department of Health and Human Services said that any applicant bidding for the 2019 contract to take over the transplant program would have to demonstrate three years of experience “managing projects of similar scope and complexity in the field of organ transplantation,” our Post colleague Lenny Bernstein reports.

Organs for Life claimed that the requirement allows only the current operator, the United Network for Organ Sharing, to meet such a standard. But "the Government Accountability Office, ruling on a protest by Organs for Life, said the three-year requirement set by the Health Resources and Services Administration (HRSA), part of HHS, is reasonable,” Lenny writes. “An HRSA spokesman said in a statement that the agency had no comment on the decision and plans to award next year’s contract later this year. The agency solicitation includes options to renew the contract for four more years, one year at a time.”

— Is that glass of red wine — or any moderate drinking in general — actually healthy for you?

Our Post colleague Joel Achenbach reports research and evidence around alcohol consumption are “stubbornly ambiguous,” referring to studies that have previously found that people who drink alcohol in moderation have lower rates of heart disease compared with people who drink heavily or don’t drink at all.

But research around the topic is at a crossroads. A solution was supposed to be in the works this year, in the form of a $100 million trial sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. But that trial was terminated over concerns about its credibility, the source of the study’s funding, the communication between researchers and industry representatives, as well as concerns about the study’s design itself.

“Where does the field go now?” Joel asks. “The CDC’s [Robert Brewer] says it’s time to think of new approaches to curbing excessive drinking. Among the possibilities: increasing alcohol taxes, limiting the density of alcohol retailers, limiting the hours alcohol can be sold and creating a public awareness campaign on the dangers of binge drinking…. Given the known dangers and catastrophic consequences of binge drinking, the questions surrounding moderate drinking are arguably esoteric, or at least not an urgent public health issue.”

STATE SCAN

— There are at least a dozen Democrats running for governor across the country who are vowing to bring “Medicare for all” to the state, our Post colleague Dave Weigel reports.

“The passage of the Affordable Care Act in 2010 fueled a backlash that powered Republicans in that year’s midterm elections. The Trump administration’s attempts to unwind the law — including a lawsuit that would knock out popular protections for Americans with preexisting conditions — have put health care at the top of Democrats’ 2018 agenda,” Dave reports. “Yet while Democrats running for the House and Senate talk about Medicare for all in aspirational terms, as a post-Trump national goal, liberal candidates for governor suggest that their states could quickly become laboratories for universal coverage.”

Dave writes from Michigan, where candidate Abdul El-Sayed campaigned this week with Sen. Bernie Sanders (I-Vt.), who has championed single-payer health care. And in Massachusetts, Dave writes Democratic candidate Jay Gonzalez “believes the issue will give him an opening against a popular Republican governor.” “We’re at a moment when Democrats need to stand for something,” Gonzalez told Dave. “If we do this right, the total amount of money we spend on health care in Massachusetts should go down. We’re going to get from here to there in a very thoughtful way.”

— Politico’s Jennifer Haberkorn also has a dispatch from Denver where the issue is embedded in Colorado’s gubernatorial race. “Colorado squarely encapsulates how the Democratic base is quickly embracing the decidedly progressive idea of a universal health system — as well as the big gap between their fervor and the realities of creating such a system,” Jennifer writes.

“The ballot measure failed in part because of well-funded industry opposition, questions over financing the plan and the politically dicey question of whether abortion would be covered. Despite the lessons learned, the political enthusiasm for single payer may still be outpacing the policy. That schism is what drove over a 100 single-payer activists to a Denver-area union hall on a recent Saturday to strategize about how to capitalize on the political momentum.”

— A new class-action lawsuit was filed late last week against the New York State Department of Health over a Medicaid ban on dental implants and denture replacement limits, charging that the “the state is denying medically necessary treatments for thousands of low-income New Yorkers,” the New York Times’s Tyler Pager reports.

Tyler writes about a 57-year-old Frank Ciaramella, a plaintiff leading the suit. Ciaramella doesn’t have any teeth, and while he had dentures temporarily, he had issues with the fit of his bottom dentures and his top dentures fell out and were run over by a car, Tyler explains. Medicaid has declined to pay for a replacement until 2024. Ciaramella has another problem – he’s been waiting on a kidney transplant and needs to be on a high protein diet, but no teeth means he can’t chew the right foods. But he can’t afford a food processor and dialysis limits the amount of liquids he can drink.

“While this case is really about getting people like Frank the access to medically necessary dental care that they need, it’s also to continue taking on categorical bans generally in the hopes that the practice dies out eventually,” said Wesley R. Powell, a lawyer for Willkie Farr & Gallagher, who filed the suit along with The Legal Aid Society. 

Arkansas, the first state to add work requirements for its Medicaid enrollment, saw spending decrease by $22 million for the program this year compared to last.

But this drop in spending, due to less people enrolled in the state's program, is not yet due to the new work requirements, which went into effect in June, according to the Arkansas Times. 

"Eventually, the work requirement will likely cause some people to lose coverage: If beneficiaries fail to report 80 hours of "work activities" per month for any three months in the calendar year, their insurance will be terminated and they'll be locked out of the program for the rest of that calendar year. However, such closures wouldn't show up until September at the earliest."

Governor Asa Hutchinson said it was the first time in the state's history that Medicaid spending didn't increase. He credited the drop off in Medicaid enrollment to an improving economy with more people working thus earning above the income level for Medicaid. 

OPIOID OPTICS

— The House Energy and Commerce Committee, along with its Oversight and Investigations Subcommittee, is calling on pharmaceutical companies PurduePharma, Mallinckrodt Pharmaceuticals and Insys Therapeutics “to answer questions and provide documents about their internal practices, including when they learned prescription opioids could be addictive and how they have marketed the drugs,” our Post colleague Katie Zezima reports.

Lawmakers sent letters to all three drug manufacturers. They are “asking Purdue for numerous internal documents relating to when the company knew its product was addictive, including minutes from board meetings and committees at which abuse or the potential for abuse was discussed,” Katie reports. The letter to Mallinckrodt requests more information about the company’s practice of “chargeback,” which Katie explains is "when a manufacturer gives a discount to a drug distributor in exchange for direct consumer information."

The letter asks Mallinckrodt when it "started receiving the data and for its policies and procedures on suspicious order reporting. The letter also asks if the company marketed opioids directly to doctors, used sales-based incentive programs and reviewed whether its product could be addictive. The committee is also calling on Insys to provide information about “how doctors were chosen for a speaker’s program about the drug and whether the program is still operational. It also requests minutes from any meetings from Jan. 1, 2012, to the present at which abuse or potential abuse of the drug were discussed," Katie reports.

HEALTH ON THE HILL

— Democrats pushing for Medicare-for-all, along with Sen. Sanders, have jumped onto a report released by the Mercatus Center at George Mason University, claiming that it shows there would be $2 trillion in savings if it were to be fully implemented. But Charles Blahous, the report’s author, a former economic adviser to George W. Bush and a public trustee for Social Security and Medicare from 2010 through 2015, is “crying foul” at the misrepresentation of his report, our Post colleague Glenn Kessler reports.

The claim gets the Fact Checker treatment, as Glenn breaks down a remark from Democratic candidate for Florida governor Andrew Gillum, who was quoted in a story mentioned above by our Post colleague Dave Weigel as touting the $2 trillion in savings point in a debate.

The Facts: “The main point of his study is being ignored by Democrats — that even by generously accepting Sanders’s assumptions that he could squeeze providers so much, the plan would still raise government expenditures by $32.6 trillion,” Glenn writes. “Sanders has said his plan would cost $1.38 trillion a year, paid for in part with new taxes on employers and an income-based premium, but under Blahaus’s analysis it would be closer to $3.3 trillion.”

The Pinocchios: Glenn gives the claim three Pinocchios. “We don’t intend to pick on Gillum, who appears to have picked up a talking point that is circulating among Democrats. But we do want to lay down a marker because this goes too far,” he writes. “All too often, politicians mischaracterize conclusions that are contained in academic or think tank studies. At the Fact Checker, we rely heavily on how a study’s author says the data should be presented. In this case, it’s clear that Blahous bent over backward to accept Sanders’s assumptions, only to find they did not add up. Democrats cannot seize on one cherry-picked fact without acknowledging the broader implications of Blahous’s research.”

— And here are a few more good reads: 

Fact Checker
A super PAC accused Democrat Danny O'Connor of wanting to cut Medicare by $800 billion. Not so.
Glenn Kessler
INDUSTRY RX
Randomized controlled trials, despite their flaws, remain a powerful tool.
The New York Times
Hospitals will be required to post the prices they charge for surgeries and other medical procedures online under a new Trump administration rule.
Washington Examiner
Morning Mix
"What I've learned is that this illness is not something that disappears or fades with time,” Demi Lovato wrote in a letter on Instagram. “It is something I must continue to overcome and have not done yet."
Samantha Schmidt
To Your Health
The mix up happened during an ongoing, decades-long debate about what, exactly, is milk.
Cleve R. Wootson Jr.
DAYBOOK

Coming Up

  • The FDA holds its antimicrobial drugs advisory committee meeting today and Wednesday.
  • The CATO Institute holds an event on short-term health plans on Wednesday.
  • FDA Commissioner Scott Gottlieb speaks at an event hosted by the National Health Council on Friday.
SUGAR RUSH

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