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Docs Raise Familiar and New Issues with Legislators


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The return of doctors in white coats on Wednesday brought issues new and old to the General Assembly.

By Hyun Namkoong

Familiar topics such as Medicaid reform and expansion and improving access to care were on physicians’ agendas when they met with lawmakers Wednesday at the General Assembly.

Diane Hanke, Miriam Schwarz and Robert Henderson traveled from Asheville to advocate for better access to care in the west,  higher Medicaid reimbursements and Medicaid expansion.

Diane Hanke, Miriam Schwarz and Robert Henderson traveled from Asheville to advocate for better access to care in the west, higher Medicaid reimbursements and Medicaid expansion. Photo credit: Hyun Namkoong

Newer topics such as cuts to Medicaid reimbursement and reform of the rules that govern hospitals also floated around during their conversations with legislators.

Diane Hanke and Robert Henderson are physicians who drove from Asheville to meet with representatives. They said the western part of the state is often overlooked when it comes to ensuring access to care.

Both said high levels of poverty, geographic barriers such as mountainous terrain and a disproportionate number of residents who rely on Medicaid negatively impact care.

Miriam Schwarz, executive director of the Western Carolina Medical Society, said recruiting people to practice in the mountains is difficult due to a lack of resources and a preference among people to live in more urban areas.

“We really need to have resources and reimbursement to keep people [in the west] engaged in helping the community,” she said. Hanke estimated that some 80 percent of residents in the western region rely on Medicaid or Medicare. She added that most counties in Western North Carolina don’t have community clinics, putting a strain on emergency departments.

Medicaid cuts

Physicians who receive Medicaid payments face a 3 percent retroactive cut from the state going back to January 2014, something that High Point physician Ric Leinbach said would be especially detrimental to small rural practices. “Not everyone’s going to make it,” Henderson added. “We already lose money on Medicaid patients.”

Hanke and Henderson said inadequate reimbursement for Medicaid patients is causing many physicians in Western North Carolina to stop accepting Medicaid or to retire early because they can’t afford to practice.

Henderson said fewer health care providers in a region of the state that already faces physician shortages could result in worse health outcomes and even higher inappropriate utilization of the emergency department.

Eileen Raynor, a pediatric surgeon at Duke Children’s Hospital, said low Medicaid reimbursement rates affect private hospitals too.

“I see a lot of Medicaid patients because they can’t get services in their home county [due to] problems with Medicaid reimbursement,” she said.

Certificate of Need

Raynor said House Bill 200 and the certificate of need issue brought her to the General Assembly to meet with legislators.

The certificate of need  statute requires providers or hospitals to first get approval from the Department of Health and Human Services to add or upgrade facilities so that services aren’t unnecessarily duplicated in the same area. The rationale behind a certificate of need is to control the costs and utilization of services.

But some providers disagree.

“We have the most restrictive rules in the United States,” Raynor said. “[We’re] trying to allow access to drive down costs so that patients can have choices.”

“House Bill 200 is a relatively nice middle-of-the-road [compromise], where it loosens restrictions without completely eliminating certificate of need, because I think that would be detrimental to North Carolina,” she said.

HB 200 would exempt certain health care centers such as ambulatory surgical facilities and psychiatric hospitals from the certificate of need statute. It would also prohibit the state from restricting the number of operating rooms and gastrointestinal endoscopy rooms.

Vaccine Exemption Bill Draws Objections


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By Rose Hoban

In the wake of legislators filing a new bill that would all but remove religious exemptions from childhood vaccinations for schoolchildren, several dozen opponents of vaccine mandates descended on Jones Street Tuesday to protest the measure.

Standing in front of the General Assembly Tuesday morning with a sign reading “Stop Medical Terrorism,” Lisa Jillani, who heads a Charlotte-based organization called People Advocating Vaccine Education, called the bill “draconian.”

Anti-vaccine advocates Lisa Jillani (r) and Michael Horwin (l), who both said they both believed parents had the right to choose vaccines for their children, came to the General Assembly to protest on Tuesday.

Anti-vaccine advocates Lisa Jillani (r) and Michael Horwin (l), who both said they both believed parents had the right to choose vaccines for their children, came to the General Assembly to protest on Tuesday. Photo credit: Rose Hoban

“I have religious exemption to vaccinations, and contrary to what Jeff Tarte says it’s not a bogus exemption; it is my personally held religious belief that I should not vaccinate myself or my children,” Jillani said.

When asked her religious denomination, Jillani said she had none. She said she has a “very, very close relationship with God. I pray every day. I see God’s guidance in everything. And there is no way… I will go to any lengths to keep myself and my children vaccinated.”

Bill sponsor Sen. Jeff Tarte (R-Cornelius) said he understood that people have their personal beliefs and that those can be the basis for not getting a child vaccinated. But he also said the state has an interest in seeing that schoolchildren get vaccinated.

“You have a loud vocal group who has a position and you have others who have other positions,” Tarte said. “There’s probably multiple positions in this particular issue. But it’s also important [to ask], ‘How do we balance individual rights with the greater good in the case of the whole population?’”

Jillani was not so sure about the obligations of parents with regard to the rest of the population.

“It will probably sound cold to say this, but it’s each parent’s responsibility to protect their child,” she said. “If my child were immune-compromised, I would never expect another parent to have a procedure performed that might risk their child just to protect mine.”

Competing rights

The issue of parents’ rights was on the mind of Kerri Pechin, who came to the legislature from Youngsville with most of her eight children. Only the oldest two of her children are vaccinated, and one of her children was holding up a sign reading: “Don’t confuse the real issue, it’s not about safety, it’s about a parent’s right to choose.”

“I gave birth to these children and I believe in God,” Pechin said. “He made human beings. He gave these children to me, he did not give them to the state.”

She pointed at the grassy field behind the legislative building and said, “As far as I know, they were not born in the middle of this field by the state.”

Pechin also said she doesn’t try to tell others not to vaccinate their children, that the decision should be a parent’s choice.

But according to civil libertarians, the issue is murkier, said Sarah Preston, the governmental affairs representative for the ACLU of North Carolina, which has not taken a position for or against the bill.

“While parents have wide leeway in how they bring up their children, the state unquestionably has a compelling interest in protecting children from dangerous diseases,” Preston said.

She said the ACLU is monitoring the bill closely for changes in the language that might alter her organization’s stance.

“At the moment, we think that the bill as written appropriately balances those interests,” Preston said.

She said things that might alter the ACLU’s position would be changes to the number of diseases vaccinated against, how effective those vaccines are and how dangerous the diseases vaccinated against are.

She also said her organization would have an issue if the bill attempted to extend the vaccine requirement to people who homeschool their children.

Opposition anticipated

Sen. Terry Van Duyn (D-Asheville), another of the bill’s sponsors, said she had expected opposition to the bill. She said she’s sympathetic to people’s fears, as she has a son who is autistic, that she is firm on the public health issues.

“In the county where I live, we have pockets of the population where vaccination opt-out rates are as high as 30 percent,” she said. “[Public health officials] talk about how as a state we have 95 percent vaccination rates, but that’s the average. That doesn’t tell the whole story.”

Van Duyn also said she’s heard from many of her constituents who are unhappy with her sponsorship of the bill.

“I understand that they’re concerned, but I’m hoping that they’re willing to stick it out with me as we get more information and find a way to thread the needle,” she said. “It’s not my intention to make people do anything; it’s my intention to get more people vaccinated to protect our kids.”

Both Van Duyn and Tarte said the hearing process would be deliberate and transparent. Tarte said hearings would take place in the coming weeks, and that they were lining up experts to speak on the bill.

“We want sunlight on the process. I’m hoping when we’re all done, that [people] will be happy with the process,” Van Duyn said, “even if they may or may not be happy with the outcome.”

Rural Hospitals, One of the Cornerstones of Small-town Life, Face Increasing Pressure


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Guy Gugliotta

Kaiser Health News

Despite residents’ concerns and a continuing need for services, the 25-bed hospital that served this small East Texas town for more than 25 years closed its doors at the end of 2014, joining the ranks of dozens of other small rural hospitals that have been unable to weather the punishment of a changing national health care environment.

For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis.

“I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”

The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas alone, 10 have changed. 

“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from UNC-Chapel Hill, whose rural health research program studies national trends in rural health care. “But there are a lot of things going on.”

Experts and practitioners cite declining federal reimbursements for hospitals under the Affordable Care Act as the principal reason for the recent closures. Besides cutting back on Medicare, the law reduced payments to hospitals for the uninsured, a decision based on the assumption that states would expand their Medicaid programs. However, almost two dozen states have refused to do so. Other Medicare cuts caused by a budget disagreement in Congress have also hurt hospitals’ bottom lines.

But rural hospitals also suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.

These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.

‘Another disaster’ 

Rural health care experts caution that national and state officials need to address the problems for rural hospitals or they could face a repeat of the catastrophic closings that followed changes in the Medicare payment system 30 years ago. That 1983 change, called the “prospective payment system,” established fixed reimbursements for care instead of payments based on a hospital’s reported costs. The change rewarded large, efficient providers, but 440 small hospitals closed before the system was adjusted in 1997 to help them. Those adjustments created the designation of critical access hospitals for some small, isolated facilities, which are exempted from the fixed-payment system.

“And now, beginning in 2010, we’ve had another series of cuts that are all combining to create another expansion of closures just like we saw in the ‘90s,” said Brock Slabach, senior vice president of the Rural Health Association. “We don’t want to wake up with another disaster.”

The current surge in closures means federal officials need to come up with new legislation to halt the recent cuts to small hospitals in order to “buy time” to figure out how rural hospitals should effectively operate in the future, said the association’s chief lobbyist, Maggie Elehwany. “It is important to stop the bleeding right now.”

In Mount Vernon, a town of 2,678 people nestled in grassland and dairy country about two hours east of Dallas, family practitioner Jean Latortue has taken out a lease on the now-vacant hospital building to convert it into an outpatient and urgent care clinic at his own expense. Reopening may be a risky move, he acknowledged, but the need is there.

“The community went into panic mode,” he said. “I figured I had to step up.”

The nonprofit ETMC Regional Healthcare System, based in Tyler, Texas, closed the Mount Vernon hospital and two others of its then-12 rural hospital affiliates because it could no longer sustain operating losses that had persisted for five years.

“There was no ill will,” Franklin County Judge Scott Lee said in an interview from his Mount Vernon office. “They were losing money. We had a good working relationship for years, and they had a business decision to make.”

Mount Vernon’s issues 

Perry Henderson, senior vice president of affiliate hospitals for ETMC, a major health care provider in East Texas, noted that rural hospitals have many uninsured patients, and Medicare accounts for “60 to 70 percent of the business,” while in “Dallas or Houston it’s a fraction of that.”

Mount Vernon, with lakefront properties that are attractive to retirees, has its share of elderly patients. Henderson also noted that many rural hospitals also have to deal with large numbers of agricultural accidents. Farming, another Mount Vernon staple, is one of the country’s most dangerous occupations. Finally, he added, country roads bring large numbers of traffic accidents. When there’s no hospital, emergencies mean longer trips to get help.

Henderson and other experts cite three reasons for the rash of closures nationally. Sequestration, the across-the-board federal budget cut that arose out of the legislative impasse between the Obama administration and congressional Republicans, has resulted in a 2 percent reduction in Medicare reimbursements since 2013.

“If Medicare is 50 percent of your revenue and you lose two points,” UNC’s Holmes said, “it can be a killer.”

Rural hospitals took a second hit from the federal health law’s reductions in “disproportionate share hospital” payments to hospitals with large numbers of indigent and uninsured patients. Federal officials made the cuts assuming that the law would assure that more patients had insurance.

It hasn’t worked well in rural areas, the Rural Health Association’s Elehwany said, because annual deductibles for the new insurance plans, which come out of consumers’ pockets, “are running between $2,500 and $5,000,” and people can’t pay them.

And in communities such as Mount Vernon, this problem is exacerbated because Texas, along with 22 other states, has refused to expand Medicaid, a key provision of the Affordable Care Act.

“That’s a big deal,” ETMC’s Henderson said. “That’s when we had the hurt.”

Latortue, who came to Mount Vernon as an ETMC hospital doctor in 2008, appears undaunted by the challenges of reinventing the hospital, which was treating an average of eight inpatients a week when it closed. Still, he said, “I’m very busy, and patients need to be seen. We’ll be all right.”

He intends to provide both outpatient services, including lab work, at the new clinic, and emergency care, stabilizing patients until they can be transferred to the Titus Regional Medical Center in Mt. Pleasant, 16 miles away, or to a smaller facility in Winfield, eight miles away. He also plans a wellness clinic to treat obesity and will offer Botox and laser cosmetic services. A cardiologist and a gastroenterologist will make weekly visits, and he is also looking for an ob-gyn.

Latortue got a favorable lease from the town of Mount Vernon and inherited an X-ray machine and other equipment from ETMC. But he still took out $150,000 in loans for remodeling and needs another $60,000 to $70,000 for equipment.

Still, none of this will replace the hospital, and his patients know it.

“I live right behind the building,” said Mary Hunter, a very fit grandmother of 73. “I’ve had very good health until my blood pressure spiked last week. We retired in 2006 and moved here, partly because of the hospital. And now it’s gone.”

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

Nurse Practitioners Ask Lawmakers to Ease Restrictions for Practice


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A wave of 115 nurse practitioners flooded the General Assembly to meet with lawmakers about easing practice restrictions.

By Hyun Namkoong

Nurse practitioners from across North Carolina came to the General Assembly on Tuesday to advocate for loosening the grip on the way they are allowed to practice.

In light of a new study conducted by Duke University economist Chris Conover and commissioned by the North Carolina Nurses Association, nurse practitioners swarmed the legislature with optimism that they’d be able to convince lawmakers on the positive economic and health care impacts of allowing nurse practitioners to practice without license restrictions.

Nurse practitioners Katerina  , Stephanie Limesand and Jan Disantostefano came to the General Assembly with more than 100 other NPs to advocate for fewer restrictions on their practice.

Nurse practitioners Katerina Jones, Stephanie Limesand and Jan Disantostefano came to the General Assembly with more than 100 other NPs to advocate for fewer restrictions on their practice. Photo credit: Rose Hoban

If lawmakers lift some of the restrictions on nurse practitioners, nurse midwives, nurse anesthetists and other “advanced practice” nurses, it could fill gaps in access to primary care providers, create at least 3,800 jobs statewide, and generate more than $20 million in income tax revenues annually, according to the study.

Nurse practitioners are trained to perform advanced care beyond that of a registered nurse. For example, nurse practitioners can write prescriptions, diagnose straightforward conditions like colds and perform routine check-ups. But in North Carolina, they have to do that under the “supervision” of a physician.

Under state law, physicians don’t have to be physically present to supervise. They are only required to have a two-times per year review of patient standards and the delivery of care. The nurse practitioner should be able to contact a physician for questions.

Brunswick county nurse practitioner Angela Bertsch said at her own health department clinic, which she recently retired from, their supervising physician lived 25 miles away.

“His requirement is that we would see him once a month,” Bertsch said. “The state statute only requires twice a year contact. Right now the supervisory agreement is a piece of paper in a drawer.”

But, physicians aren’t always willing to supervise and some nurse practitioners find themselves unable to work.

Tay Kopanos, vice president of state government affairs of the American Association of Nurse Practitioners said the bureaucracy limits patients’ ability to get direct access to care.

“Nurse practitioners can’t find a physician to do collaborative agreement or pay money to [for the supervision],” she said. “The laws for nursing here are decades old and they really haven’t kept pace with changes.”

Bertsch said one of her colleagues in a nearby clinic has been compelled to pay a physician about $16,000 for her supervision agreement.

Time for change

Kopanos said North Carolina is at a crossroads to implement some solutions that can address health care needs across the state.

She said legislation will be introduced in the coming weeks to match the educational and professional expertise of nurse practitioners to the legal limits of care they can provide in the state.

“Here in North Carolina, licensure laws limit the amount of care [nurse practitioners] can provide to patients, unless they have a mandated agreement with the physician,” Kopanos said. “This legislation will look at retiring that so that patients get full and direct access.”

Rep. Gale Adcock (D-Cary) said many nurse practitioners want to work in rural, underserved areas, something that could help ease the primary care provider shortage in the state.

After Arizona granted full autonomy to its nurse practitioners in 2001, the state saw a 73 percent increase in the number of nurse practitioners working in rural areas between 2002-07.

Adcock acknowledged that any legislation giving nurse practitioners more autonomy would likely be met with resistance and that change is hard to implement.

“When you do the same thing over and over you get the same result,” Adcock said. “And the result we’re getting in this state are huge pockets of people who have no access to health care.”

Access to primary care is important because it’s more cost-effective and easier to treat illnesses when they’re caught early on and not in advanced stages that require intensive treatment. The primary care provider shortage has led 18 states to grant full autonomy to nurse practitioners.

“If you catch diabetes early on, you may not end up on dialysis,” said Stephanie Limesand, a nurse practitioner from Gastonia who works in urgent care. “There’s such a shortage of primary care providers. We can help fill that gap.”

Tina Gordon, chief executive officer of North Carolina Nurses Association said in some areas nurse practitioners are the main option for getting care.

Gordon said the nurse practitioners met with the legislators from their own district and with members of the health and human services committee to tell them how nurse practitioners are trained, educated and experienced in providing safe and quality care.

Where do Nurse Practioners in NC Work?
Group Medical Practice/Physician Office 2182
Group Nursing Practice 17
HMO/Insurance 38
Home Health Care 59
Hospital (Other than In-Patient, Emergency, Out-Patient) 121
Hospital Emergency 177
Hospital In-Patient 890
Hospital Out-Patient 477
Industry/Occupational Setting 93
Long Term Care 142
Medical School 21
Mental Health 166
Nursing School 4
Other 429
Public/Community Health 367
Retail Clinic 209
School Health 40
Self Employed NP 89
Grand Total 5521

Racial and Ethnic Disparities Persist in Teen Pregnancy Rates


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Although teen pregnancy and birth rates have dropped the past two decades, states still face the reality that black and Latina teens are more than twice as likely as white teens to become pregnant.

By Teresa Wiltz

Stateline

It’s a problem once thought to be intractable, and yet pregnancy and birth rates for black and Latina teens have dropped precipitously in the past two decades, at a much faster clip than that of white teens.

Despite this, black and Latina girls are more than twice as likely as white girls to become pregnant before they leave adolescence.

EPT_pregnantThis glass half-full, half-empty scenario is a dilemma that continues to confound states. The racial and ethnic disparities surrounding teen pregnancy are stubborn, often a cause and consequence of poverty and a complex array of societal factors.

Teen pregnancies are usually unplanned and come with a steep price tag, costing U.S. taxpayers up to $28 billion a year, according to the Office of Adolescent Health, which is part of the U.S. Department of Health and Human Services.

Some states like Mississippi have found innovative ways to tackle the problem by targeting specific populations, while others like Kansas are serving up bills that make it more difficult for teens to access sex education, which is a critical component of preventing pregnancy in adolescence, according to advocates such as the National Campaign to Prevent Teen and Unplanned Pregnancy.

To truly solve the problem, these advocates argue, there needs to be a multipronged approach involving funding from the federal government and from the states, as well as intensive community outreach and culturally specific programming.

“You can correctly point to the extraordinary, off-the-charts success in reducing teen pregnancy and childbearing in the African-American and Latina communities,” said Bill Albert, chief program officer for the National Campaign. “But these rates remain far, far higher than among whites. And that needs our full and undivided attention. There’s a role for state and local efforts, and not all of it costs money.”

According to Kate Blackman, a research analyst in the health program at the National Conference of State Legislatures, “states do a lot to raise awareness. We’ve seen some reductions in teen pregnancy, when it’s been a priority.”

A persistent problem

Over the past two decades, the teen pregnancy rate, defined as the number of girls per 1,000 girls aged 15 to 19 who become pregnant, has been steadily decreasing. Progress has been made in all 50 states and among all racial and ethnic groups, according to Albert.

Since 1991, the overall teen birth rate has declined by 57 percent. The most dramatic decreases were among teens of color. Since 1991, teen birth rates among black girls declined 67 percent; among Latinas, it declined 60 percent, while among American Indian/Native Alaskans and Asian/Pacific Islanders it declined 63 and 68 percent, respectively. Birth rates among white teens declined 57 percent during that time.

Photo credit: Frank de Kleine, flickr creative commons

Photo credit: Frank de Kleine, flickr creative commons

A variety of factors contributed to the decline.

Since the 1990s, there has been an increased use of highly effective, low-maintenance birth control methods like the IUD and contraceptive implants, according to Albert.

The Obama administration’s Teen Pregnancy Prevention Initiative, which awards $105 million in grants to programs tackling adolescent pregnancy, has been successful in helping reduce birth rates because it funds programs that have been proven to work, Albert said.

Above all, teens are having less sex for a variety of reasons, from the Great Recession to peer pressure to watching cautionary horror stories on reality TV. A 2014 study by economists at the University of Maryland and Wellesley College found that one-third of the drop in the teen birth rate between 2008 and 2011 could be attributed to teens watching shows like MTV’s “16 & Pregnant” and “Teen Mom.”

“We adults always talk about peer pressure as a negative thing, but it can be a force for good,” Albert said. “We know teenagers whose friends are having sex are more likely to have it for themselves. But now, there’s a growing social norm of not getting pregnant while you’re young.”

But when you look at actual rates, they demonstrate a stark reality: Girls of color are much more likely to become pregnant.

Among non-Hispanic white teens, the birth rate in 2013 was 19 births per 1,000, while among black teens it was 39 births per 1,000. Latina teens have the highest birth rate, at 42 births per 1,000 teens. The birth rate for Native American teens was 31 births per 1,000, while among Asian/Pacific Islander teens it was nine births per 1,000.

Poverty plays a big role in high teen birth rates, as does geography. Rural teens have higher rates of pregnancy than do urban and suburban teens. Southern states, which tend to be poorer and have the highest rates of HIV infections, also report the highest number of teen births. Education and access to contraceptives play a larger role in teen pregnancy rates than do cultural or religious differences, teen advocates suggest.

“When you look at these disparities, it has a lot more to do with a lack of opportunity than with the color of your skin,” Albert said.

Poor teens of color are less likely to have access to quality health care and contraceptive services, and are much more likely to live in neighborhoods where jobs and opportunities for advancement are scarce, according to Gail Wyatt, a clinical psychologist and sex researcher at UCLA.

Data courtesy Adolescent Pregnancy Prevention Campaign of North Carolina

Data courtesy Adolescent Pregnancy Prevention Campaign of North Carolina

“We’re talking about income; we’re talking about sub-par education … with no education about sex and your body,” Wyatt said. “This pretty much leaves these girls extremely vulnerable…. It’s simply an incompatible combination of circumstances that these girls are involved and captured in.”

Many teen girls having sex are being exploited by older men, Wyatt said. Many underprivileged girls face peer pressure to have sex early, sometimes egged on by girls who aren’t yet having sex themselves, she said.

Then too, teen pregnancy is often cyclical, said Lee Warner, associate director for science in the Division of Reproductive Health at the Centers for Disease Control and Prevention. “A lot of the kids having kids are the kids of teen parents themselves. It’s generational.”

According to the National Campaign, the daughters of teen mothers are three times as likely to become teen mothers.

Young disadvantaged women need to hear positive reasons about the benefits of avoiding early pregnancy, Albert said.

“We haven’t done a good job as a nation about telling young people why we think it’s a good idea to delay pregnancy and parenthood,” he said. “I think sometimes these messages come off as anti-family and anti-baby rather than talking about when and under what circumstances it is good to start a family.”

Reducing teen pregnancy

For the past 15 years, the CDC has spearheaded programming that targets racial and ethnic disparities in teen pregnancy, according to Taleria Fuller, a health scientist in the CDC’s Division of Reproductive Health. The agency focuses on communities where there are high rates of teen pregnancies and birth, particularly among black and Latina youth, she said.

The CDC uses a five-pronged approach to address the problem, she said: enlisting community involvement, investing in programs that have been demonstrated to reduce teen pregnancy, increasing youth access to contraceptives and culturally oriented health care services, educating community leaders and parents and raising awareness in diverse communities about the link between teen pregnancy and other social ills.

The CDC also funds programs tailored to different ethnic groups, like ¡Cuídate!, which means “Take care of yourself!,” and is targeted toward Latino youth for whom Spanish is usually their first language. The program consists of six one-hour classes among small groups of teens and incorporates role playing, music and video games to educate youth about abstinence and condom use. The program emphasizes Latino values of family and specific gender roles in the community.

“You’ve got to have room for adaptation,” Fuller said. “Your group may be different from another group.”

In Mississippi, which has the second highest teen birth rate in the country, legislators last year passed a bill asking community colleges and universities to come up with a plan to target teen pregnancy on their campuses. Earlier this year, Gov. Phil Bryant, a Republican, proposed spending $1.2 million to support health clinics at the colleges.

There’s a reason: In Mississippi, births among older teens (ages 18 and 19), a key demographic at community colleges, accounted for 70 percent of all teen births in the state in 2012. What’s more, the vast majority of community college students are poor, and 61 percent of women who become pregnant while attending community college do not finish school, according to the Women’s Foundation of Mississippi.

“This was a pretty innovative legislative angle: ‘These people are coming to our campuses; let’s provide them with skills and not derail their goals,’” said the NCSL’s Blackman.

But not all states are taking that approach. In Kansas, legislators last month introduced a bill that would require schools to obtain written parental consent to teach sex education. Another bill would make teachers criminally liable for displaying some sex education materials. Education groups have lobbied strenuously against the bill, arguing that it would severely restrict the materials that teachers could use in the classroom.

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

New Federal Rule Will Extend Medical Leave Rights to Same-Sex Couples In All States


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Kaiser Health News

Starting March 27, legally married same-sex couples will be able to take unpaid time off to care for a spouse or sick family members even if they live in a state that doesn’t recognize their marriage.

The final rule issued by the Department of Labor revises the definition of “spouse” in the Family and Medical Leave Act to recognize legally married same-sex couples regardless of where they live. Prior to that, only couples that lived in a state that recognized same-sex marriage could take advantage of the act’s benefits.

Currently, 37 states plus the District of Columbia permit same-sex marriages; North Carolina is among those 37 states.

“We’re really excited about it,” says Robin Maril, senior legislative counsel at the Human Rights Campaign, a lesbian, gay, bisexual and transgender advocacy group, of the final rule. The old interpretation “wasn’t fair for employees. It meant they had different federal benefits based on their zip code.”

The new rule was prompted by President Barack Obama’s instructions to federal agencies to review federal statutes following the 2013 Supreme Court decision in United States v. Windsor. That decision struck down part of the Defense of Marriage Act that said that a marriage must be between a man and a woman.

The Family and Medical Leave Act entitles workers to take up to 12 weeks of unpaid leave annually to care for a spouse or family member for medical or family reasons without losing their jobs. It applies to private-sector companies with 50 or more workers and public-sector agencies and schools of any size.

In addition to legally married same- and opposite-sex couples, the final rule’s revised definition of spouse applies to common law marriages and those that took place outside the United States if they would have met legal standards in at least one state.

“There are many good corporate policies, but companies look to the FMLA” as the mandated standards, said Maril.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Employed White Southerners Most Likely to Lose Coverage in Supreme Court Case


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Gov. Pat McCrory has said he is reluctant to talk about expanding Medicaid until the Supreme Court issues a decision on the King v. Burwell case in June. What is the case all about? And who stands to lose?

By Michael Ollove

Stateline

If the U.S. Supreme Court strikes down tax credits for people buying health insurance on the federal exchange, about 8.2 million Americans in 34 states could lose their coverage under the Affordable Care Act. Most of the people likely to be affected are white, employed and low- to middle-class. They also are concentrated in a single region of the country: the South.

North Carolina joined in a legal brief filed by Virginia (another state without its own exchange) opposing the plaintiffs in the lawsuit. Health insurance rates in those states are expected to rise by as much as 35 percent, which may make coverage unaffordable even for those who don’t qualify for tax credits. Some believe that if the tax credits are disallowed by the Supreme Court, the underpinnings of President Barack Obama’s signature health care law would collapse.

“It will be a horror movie if [the credits are struck down],” said Georges Benjamin, executive director of the American Public Health Association, which supported passage of the ACA.

Supreme Court Building, Image by dbking, Flickr Creative Commons

Supreme Court Building, Image by dbking, Flickr Creative Commons

At issue in King v. Burwell, scheduled for oral arguments next month, is whether people in states that use the federal government’s exchange (Healthcare.gov) to buy insurance are eligible for federal subsidies in the form of tax credits to help them pay their premiums.

The case hinges on the fact that the ACA provision governing tax credits refers to people enrolled “through an Exchange established by the State,” without mentioning the federal exchange. The ACA anticipated that all states would create their own state exchanges, but it allowed states that did not want to set up their own exchanges to use the federal one instead.

The lawsuit originated at a 2010 meeting of conservative lawyers convened by the American Enterprise Institute to explore “legal vulnerabilities” in the ACA. After the lawyers identified the tax credit as a promising point of attack, a related right-leaning group, the Competitive Enterprise Institute, found four Virginia plaintiffs to launch the lawsuits (King v. Burwell consolidated them). According to its website, CEI is coordinating and financing the legal effort.

Opponents – including the drafters of the original law, 21 states and the District of Columbia – say that whatever the exact language of the statute, Congress did not intend to make any distinction between federal and state exchanges when it came to tax credits. When questions were raised about the language, the IRS announced in 2011 it would issue the credits in states with federal exchanges too.

King v. Burwell is scheduled to be argued in the Supreme Court March 4, but a ruling is not expected until June.In the 34 states where people use the federal exchange, an estimated 9.3 million people are expected to receive $36.1 billion in tax subsidies in 2016. A recent analysis by the Robert Wood Johnson Foundation and the Urban Institute estimated that if the Supreme Court blocked these subsidies, 8.2 million of these residents would not be able to find affordable health insurance in 2016.

“[A King win] disenfranchises millions of Americans from affordable health coverage, most of them working people,” said Trish Riley, executive director of the National Academy for State Health Policy.

Not the poor

Of those 8.2 million, the study found, 61 percent are non-Hispanic whites, 62 percent live in the South, 71 percent work at least part time and 82 percent are considered, by federal measures, to be low- or middle-income rather than poor. The tax credits are available for people with incomes between 100 percent and 400 percent of the federal poverty level. For a family of four, the eligible income range is between $23,850 and $95,400.

Gov. Pat McCrory and Department of Health and Human Services Sec.  Aldona Wos have both said they cannot push for Medicaid expansion until the results of the case are announced in June.In 2014, the first year the exchanges were open, the Obama administration reported that 87 percent of the 5.4 million Americans who chose a health plan through the federal health exchange were eligible for some financial help. Those who qualified for tax credits on the federal exchange paid an average of $82 a month in premiums for their coverage, which was about one-fourth of what they would have paid without the federal assistance.

But even people who don’t qualify for the tax credits would be affected by their disappearance. Because many of the people who receive the credits are relatively healthy, their departure from the insurance pool would lead to a 35 percent increase in premiums, according to the report.  That increase would make coverage unaffordable for about a quarter of the 4.9 million Americans who bought insurance on the federal exchange without a tax credit.

The Supreme Court’s ruling in King v. Burwell will not affect tax credits in the 13 states and the District of Columbia which operate their own exchanges. Nor would it affect the three states – Nevada, New Mexico and Oregon – which have federally supported, state-based exchanges, that perform all of the functions of a state exchange while relying on the federal government for technology support.

Many of the states that declined to create their own insurance exchanges were expressing their opposition to the Affordable Care Act. However some of them, such as Delaware, decided they didn’t have the technical capacity to create one.

A congressional fix?

Congress could provide a fix, but no one believes that Republicans and Democrats could agree on a solution. That leaves the states to step in, but they may not have the time, resources, technical ability or political will to prevent large-scale disruption.

Originally, North Carolina planned to create its own exchange, but SB 4, passed in 2013, forbade the state from pursuing a separate health insurance exchange.States now using the federal exchange could try to convert to state exchanges. But some states, such as Missouri, Montana and North Carolina, have passed legislation prohibiting the creation of a state exchange, and the Republican governors and legislatures in many of those states may still object to taking any steps to support the ACA.

There are nonpolitical problems as well. The ACA provided nearly $5 billion in federal financial assistance for states that built their own exchanges prior to 2014. That money is no longer available. States would have to spend tens of millions of dollars of their own money to develop their own exchanges.

Timing is also a factor. Presuming the Supreme Court’s ruling comes in June as anticipated, states would have only five months to build sophisticated insurance operations and websites. By the time the first state exchanges opened in 2013, a number of states – Maryland, Vermont and Oregon, among others – had already devoted years to fashioning their systems, and those still failed spectacularly in the first year of operation.

The seven states that operate exchanges in partnership with the federal government – Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia – may have an easier time. Those states already handle some exchange responsibilities, such as consumer assistance, and may be able to assume the rest. Arkansas already has plans to launch its own exchange in 2017, although that would be a year late for the 95,000 Arkansans who would lose their federal tax credit for next year.

Theoretically, it’s possible that states could switch to a state exchange. But Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at the George Washington University, said it wouldn’t be easy.

“There is no assurance of that because it takes money, it takes technology, said Rosenbaum, who worked on an amicus brief siding with the Obama administration on behalf of the deans of university schools of public health.

What would happen to the 8.2 million who could lose their health insurance is unclear. They could turn to the charity of hospitals for health care, although hospitals receive far less federal money for such care than they did before implementation of the ACA. The sharp reduction in patients with insurance also would cost doctors, perhaps forcing some of them to close their practices, according to Benjamin of the American Public Health Association.

Some worry the ACA, which is designed to provide affordable health care coverage to the vast majority of Americans, would collapse if the federal tax subsidies are not available everywhere. Without the tax credits, said Rosenbaum, the entire package of reforms that constitutes the ACA “would be unthinkable.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

 

Government To Grade Nursing Homes on Tougher Scale


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Kaiser Health News

Starting immediately, the federal government is making it harder for nursing homes to get top grades on a public report card, in part by increasing scrutiny of their use of anti-psychotic drugs and raising the bar on an array of quality measures.

Sweet Nursing Home Resident

Image courtesy of robinsan, Flickr Creative Commons

Those grades – in the form of one- to five-star ratings – are part of Nursing Home Compare, a government website to help consumers evaluate nursing homes. While the star ratings, which debuted in December 2008, are lauded as an important tool, critics say they rely too heavily on self-reported data and allow a majority of homes to score high ratings.

The website rates more than 15,000 nursing homes in three broad categories: government inspections, quality measures and staffing levels. An overall score is a fourth category.

The system has come under recent criticism, with complaints that some highly rated nursing homes have numerous problems and face fines and other enforcement actions. On Thursday, the federal government said it would require nursing homes to do more to get higher-quality scores.

Among the better-known measures that go into quality scores are the percentages of residents who develop bed sores or are injured in falls. The scores will now count the percentage of residents given anti-psychotic drugs, reflecting concern that too many are unnecessarily drugged to make them easier to manage. All of those measures will continue to be reported by the homes themselves, however.

The changes mean many homes could drop a star or more from their January levels, even though nothing may have changed, said officials from the Center for Medicare & Medicaid Services. They declined to say how many might see a ratings drop.

The Medicare Inspector General found nursing home patients who died had problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

In a previous report, the Medicare inspector general found nursing home patients who died had problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure. Image courtesy Thomas Nemcsek, flickr creative commons

Consumer advocates welcomed the adjustments, but industry officials said the new rules may confuse patients and their families if scores change suddenly.

“If centers across the country start losing star ratings overnight, it sends a signal to families and residents that quality is on the decline, ” said Mark Parkinson, president and CEO of the American Health Care Association, the industry lobby.

But Brian Lee with Families for Better Care, a Florida-based advocacy group for nursing home residents and their families, said the shift was necessary.  More information is always better, he said. He and other advocates had raised concerns that high rates were too easy to achieve.

Lee said about 55 percent of the nation’s nursing homes had overall scores of either four or five stars on Nursing  Home Compare in January. Drilling down, Lee said only about one-third of them got four or five stars on the website for inspections, which he calls the most objective measure because it is based on government rather than self-reported data.

“But when you look at the quality-scores portion, 80 percent of homes are four- or five-star rated,” Lee said. “Something is not coming out in the wash.”

The new ratings will  be reflected on the website as of Feb. 20.  Nursing home administrators will be able to see their scores under the new system starting Friday.

The changes follow others announced in October that require additional verification of self-reported staffing levels and other efforts to confirm quality data submitted by the homes.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

Study: Physicians Report Few Requests By Patients for ‘Unnecessary’ Treatments


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Kaiser Health News

Though medically unnecessary tests and procedures are often blamed for the nation’s high health care costs, patients’ requests for such superfluous treatments may not be what triggers them, suggests a study published today in the JAMA Oncology.

Photo courtesy Seattle Municipal Archives

Photo courtesy Seattle Municipal Archives

Conventional wisdom suggests that doctors often give unnecessary treatments because patients demand them. Some estimate this care accounts for a third of the $2.8 trillion spent annually.

But the survey, which tracked 60 Philadelphia-based clinicians’ interactions with about 3,600 cancer patients, found that patients asked for a particular treatment in only 8.7 percent of those exchanges. Of those requests, doctors considered only 11.4 percent to be for inappropriate or unnecessary care.

Those findings, the paper’s authors write, indicate that patient demands are likely not the impetus for unnecessary procedures. That might suggest doctors provide extraneous treatments for other reasons, though the authors didn’t speculate on what those could be.

“There just aren’t many patients’ demands or requests for unnecessary tests and treatments, and when there are doctors comply with very few of them,” said Ezekiel Emanuel, one of the authors and chair of the University of Pennsylvania’s Department of Medical Ethics and Health Policy.

It’s not entirely clear whether the findings from this study, which focused on oncologists and cancer patients, can be generalized to medicine at large. Though cancer seems like a fitting condition to study due to its “extremely high stakes and very expensive treatments,” it is possible other specialties, such as primary care, actually elicit a lot more patient-requested procedures, said Emanuel, who also is a former White House health policy adviser.

He recommended other researchers conduct similar studies investigating specialties in cities other than Philadelphia to see whether those results echo this study’s conclusions. When it comes to patient requests, “if you don’t see them in oncology, it’s kind of unlikely you’re going to see them a lot of other places, like cardiology or rheumatology or surgery,” he added.

The authors may be correct that patients in general don’t seek unnecessary treatment, said Jason Doctor, an associate professor at the University of Southern California’s School of Pharmacy, who was not involved in the study. “But they need to test it in a broader, more general clinical setting,” such as outpatient facilities, he said.

It would make sense to expect similar results in other specialties, said Katherine Kahn, a professor of medicine at the University of California, Los Angeles and a senior scientist at the RAND Corp., which researches health costs, among other subjects. Still, Kahn, who is not affiliated with the study, cautioned against using the results to make a definitive statement about what drives health costs.

The study indicates that patient requests can be a valuable part of practicing medicine, she said, highlighting needs doctors otherwise might not notice. “Patients often have information about their symptoms or their values or their priorities that clinicians might not know,” Kahn said.

But it takes a bit of a jump, she added, to go from establishing that idea to answering questions around “overuse and costs associated with overuse in the United States.”

That’s especially true in this study, she said, because doctors were the ones who determined and reported what wasn’t an appropriate request, and that potential bias or perspective makes it hard to know how often wasteful or unnecessary procedures actually took place.

Even so, Emanuel said, it highlights a larger point.

Anecdotally, “It’s doctors who say, ‘We had a lot of patients ask for inappropriate tests and treatments.” By quantifying how often doctors actually think this happens – and by noting that, in practice, doctors rarely indicate this is the case – the findings suggests patient demands aren’t the source of wasteful procedures, he said.

“There’s always this question about provision of inappropriate treatment: Is it driven by patient demand or provider supply, and what’s the best way to address the problem?”

Doctor said. “People should study this through, then we can understand whether we should do supply-side intervention or demand-side interventions to reduce inappropriate treatment.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

In States with Looser Immunization Laws, Lower Rates


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North Carolina’s immunization rate is one of the highest in the nation. The only way parents can ask for exemption is with a letter signed by a physician.

By Christine Vestal

Stateline

The U.S. Centers for Disease Control and Prevention issued a health advisory this month about an ongoing measles outbreak, with more than 102 cases in 14 states so far. The highly contagious disease can cause severe health complications, including pneumonia, encephalitis and death.

More than 1500 pharmacists in North Carolina have gone through the approval proces to give immunizations.

Photo courtesy U.S. Army Corps of Engineers Europe District, flickr creative commons

By 2000, measles had been nearly wiped out in the U.S., with fewer than 60 cases per year, most connected with foreign travel. Public health officials declared victory, the result of effective state-based immunization campaigns requiring kids to be vaccinated before they enter public schools.

Since then, however, the number of cases has risen along with the number of parents who have received religious or philosophical exceptions to state rules. In 2014, there were at least 23 outbreaks and more than 600 cases.

The federal government’s goal is to immunize at least 90 percent of all children before they enter school to keep measles and other childhood diseases at bay.  Although the national average immunization rate (91.1 percent) exceeds that number, several states fall below it.

“To have pockets where community immunity is below 90 percent is worrisome, as they will be the ones most vulnerable to a case of measles exploding into an outbreak,” said Litjen (L.J) Tan, chief strategy officer of the Immunization Action Coalition, which advocates for higher levels of immunization.

State immunization rates vary widely, with generally lower rates of inoculation occurring in states that make it relatively easy to get an exception. Lawmakers in California, Oregon and Washington state are trying to tighten their laws to allow fewer nonmedical exemptions. Laws allowing religious exemptions have been around longer than those allowing philosophical or “personal belief” exemptions, said Joy Wilson of the National Conference of State Legislatures.

In many but not all states, philosophical exemptions are easier to get than religious exemptions, which typically require parents to cite and explain the religious doctrine in question. Overall, states with philosophical exemptions have 2.5 times the rate of opt-outs than states with only religious exemptions.

SLN_Feb09_vaccinationRates

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

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