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Monthly Archives: January 2016

First Edition: January 29, 2016

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Study Finds ‘Mortality Gap’ Among Middle-Aged Whites

Don’t blame suicide and substance abuse entirely for rising death rates among middle-aged white Americans, asserts a new study out Friday.

They’re both factors, but the bigger culprit is almost two decades of stalled progress in fighting leading causes of death — such as heart disease, diabetes and respiratory disease — according to a Commonwealth Fund analysis of data from the federal Centers for Disease Control and Prevention. The fund studied actual and expected death rates, and causes of death, for working-age adults from ᎄ8 through 2014.

Its analysis follows a much-discussed study circulated late last year that found death rates had been rising for non-Hispanic, white Americans between ages 45 and 54 since 1999, following several decades of decline. The two Princeton economists who authored that study — one was Angus Deaton, last year’s winner of the Nobel Memorial Prize in economic science — attributed the turnabout to rising rates of drug abuse, suicides and alcohol-related liver disease.

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This KHN story can be republished for free (details).

“White Americans are now facing a substantial ‘mortality gap’,” according to Commonwealth, which cited higher-than-expected death rates for white adults ages 45 to 54 in 2014.

Since 1ᚈ, death rates had fallen nearly 2 percent a year across most middle-age groups, races and ethnicities. Other high-income countries experienced similar trends, Commonwealth said.

But that shifted in 1999. From 썏 to 2014, death rates in the U.S. rose for non-Hispanic white adults between the ages of 22 and 56, peaking at about age 30 and age 50, the fund said.

Without a health crisis, mortality rates for those white Americans should have been falling, the authors said.

According to Commonwealth’s analysis, death rates for that group would have been expected to fall 1.8 percent annually, but instead mortality rates in 2014 resulted in more than 100 excess deaths for every 100,000 middle-aged white adults.

whiteman_770Commonwealth said the “death gap” was most pronounced in seven states: West Virginia, Mississippi, Oklahoma, Tennessee, Kentucky, Alabama and Arkansas. The difference between observed and expected rates was narrowest in New York, New Jersey, California, Connecticut, Minnesota, Massachusetts and Illinois, the study found.

Deaths from suicide and substance abuse explain about 40 percent of the “mortality gap,” while 60 percent is tied to death rates failing to drop as expected for nearly all of the top-ranked causes of death of middle-aged whites, Commonwealth said.

Commonwealth suggested the root causes might be tied to that population’s decline in social and economic status.

“For working-age whites — especially 45-to-54-year-olds — we are witnessing regression that has little precedent in the industrialized world over the past half century,” the report said.

For example, they have lower incomes, fewer are employed and fewer are married, it said. Research published last year found that the higher death rate for the group was concentrated among whites without four-year college degrees.

Commonwealth said its findings increase concerns about continuing lack of health insurance — some states with the highest mortality rates did not expand their Medicaid programs to low-income adults. But insurance expansion alone won’t close the mortality gap, it said.

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Federal Officials Clarify Rules On Getting New Health Coverage After A Move

After the open enrollment period ends on Sunday for buying coverage on the health insurance marketplaces, people can generally sign up for or switch marketplace plans only if they have certain major life changes, such as losing their on-the-job coverage or getting married. Following insurance industry criticism, last week the federal government said it will scrutinize people’s applications for such “special enrollment periods” more closely, including one of the most commonly cited reasons — relocating to a new state.

The Centers for Medicare and Medicaid Services (CMS) issued new guidelines to help consumers and those who assist them in enrolling understand what qualifies as a permanent relocation versus a temporary one.

More from this series

People who move to a new state and “intend to reside” there may be eligible for a special enrollment period on the marketplace to pick a new plan. There’s no waiting period to establish residency for coverage after people move.

Still, determining residency intentions could be a head scratcher. CMS clarified that traveling to a state for business, pleasure or to get medical care will not meet the residency requirements for a permanent move.

People may have more than one residence and may qualify for marketplace coverage in both places. Someone who keeps two homes in different states and spends entire seasons or lengthy periods of time in each could sign up for marketplace coverage in either or both states after each move, according to CMS.

moving_770Students and other children younger than 21 are generally assumed to have the same state of residence as their parents. However, if “you’re under 21, you can attest you live elsewhere and intend to reside there,” you may qualify for a special enrollment period to buy a new marketplace plan, said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms.

Insurers have complained that people are waiting until they become sick, then claiming they’re entitled to a special enrollment period for marketplace coverage. In response, the federal government announced that a number of events will no longer trigger a special enrollment period, including certain errors in marketplace income and tax credit determinations.

In addition, the administration said it will examine a sample of records from consumers who were deemed eligible for special enrollment periods because of a permanent move or a loss of coverage to determine if the rules were properly applied. If consumers should not have been granted access to a special sign-up period, they could be subject to penalties for perjury, CMS said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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Combined Effects Of Maternal Obesity, Diabetes ‘Substantially’ Raise Autism Risks

While the incidence of autism spectrum disorder has increased in recent years, what’s behind it remains relatively mysterious and even controversial. But a major study could shed new light on some of the maternal health factors that may increase children’s risk of developing the condition.

Autism is a neurodevelopmental disorder marked by difficulties with communication and social interaction as well as repetitive or obsessive behaviors. The range and severity of symptoms can vary widely.

The study, which was released Friday and appears in the February issue of the journal Pediatrics, followed almost 3,ዀ children who visited the Boston Medical Center between 1998 and 2014. It used electronic health records to track whether these children were diagnosed with autism, along with factors like the mother’s pre-pregnancy weight and whether she had been diagnosed with diabetes before or during her pregnancy.

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Though previous research has looked at the roles of maternal obesity and diabetes on autism risk, this study is the first to examine both the independent and combined effects of the two.

The researchers found that of the nearly 3,000 children in the study, about 100 were identified as on the autism spectrum.

They also concluded that obese women who contracted diabetes while pregnant — a condition known as gestational diabetes — were about three times as likely to have children with autism. Women who were obese and had diabetes before pregnancy were almost four times as likely. In addition, children with autism were more often boys, more often born before 32 weeks and more often had very low birth weight. Beyond being obese and diabetic, their mothers were also more likely to be older.

Having just one of the conditions, however, posed only a slight risk increase.

Overall, though, the risk was “substantially higher” when women had both, according to the study.

pregnancy_autism_770It “calls attention to the idea that maternal prenatal health and maybe even pre-pregnancy health may be important factors for autism — and may be important opportunities for protection from autism,” said study co-author Daniele Fallin, who chairs the department of mental health and directs the Wendy Klag Center for Autism and Developmental Disabilities at the Johns Hopkins Bloomberg School of Public Health.

The findings are important because, if doctors have a better sense of autism’s causes, they can try to reverse the current trend lines and stem its growth, Fallin said.

In 2010, the most recent year for which there’s data, about 1 in 68 children were estimated to have autism. That’s a contrast to 10 years prior, in 2000, when 1 out of 150 children were believed to have it. Experts say part of the growth likely is because people are simply getting better at recognizing and diagnosing the disease. But, according to the Centers for Disease Control and Prevention, the disorder is also probably occurring more often than it used to.

“The cost per family per year of having a child on the spectrum is enormous — therefore societal costs are enormous,” Fallin said. “If you can do anything to stem the tide of rising prevalence, or even drop the prevalence, then absolutely, you should. Not only individual families benefit, but society benefits.”

A different study published last year in the Journal of Autism and Development Disorders estimated that taking care of people with autism cost the country about $268 billion in 2015 — a figure that accounts for medical expenses, other kinds of caregiving and the decreased productivity both from people who care for autistic relatives and for adults on the spectrum.

If the increase in prevalence continues at its current rate, this expense will grow markedly, that study noted.

From a cost standpoint, then, the new research underscores the importance of preventing obesity and diabetes, said Paul Leigh, a professor of public health sciences at the University of California, Davis, who authored the autism cost study. Because of the autism tie, “there are more reasons to be worried about [obesity and diabetes], and to direct resources to removing this problem.”

The Pediatrics paper is significant, both for its findings and for its comprehensiveness in examining medical records from a large sample, said Alycia Halladay, chief science officer at the Autism Science Foundation. It suggests that if policymakers and insurers put more money into treating diabetes and obesity, the public as a whole could benefit, especially if that fuels a decline in autism cases.

“Instead of demonizing mothers with diabetes, we need to be using this as an opportunity to help them mitigate their risks as much as possible,” she said.

But, she added, it’s important to recognize that the study examines two of many factors that could put a child at risk for autism. Giving birth later in life, getting a viral infection while pregnant or being exposed to air pollution or certain medications can also be factors — so preventing autism will require a multi-pronged strategy.

“I don’t think you can look at any one of them and say, ‘Oh, it’s because of this, it’s because of air pollution, it’s because women are waiting to have babies,’” she said. “It’s a combination.”

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Obamacare Sign-Ups Strong In N.C., Despite High Rate Hikes

North Carolina’s average premium increases on the Obamacare exchange are among the highest in the country, according to federal data. The Obama administration warned this open enrollment period, which closes Jan. 31, could be particularly tough because many of the sickest, and therefore most motivated, people already bought plans.

And yet, sign-ups in North Carolina are on pace to be substantially higher than the two previous years. Roughly 95,000 more North Carolinians selected a plan during the first two months of this enrollment period compared with the last one. Across the country, only two states using the federal exchange saw more sign-ups over the same period: Florida and Texas.

Sue Martin, who’s from the small town of Mebane, North Carolina, about two hours northeast of Charlotte, said, “I hate to sound hyperbolic, but it’s kind of a matter of life and death.” Her experience is a case study of how the health law is playing out in the state and how individuals have navigated surging premiums.

This story is part of a partnership that includes WFAE, NPR and Kaiser Health News. It can be republished for free. (details)logo npr

Martin couldn’t afford treatment for Lyme disease and a thyroid condition without health insurance. She got covered through healthcare.gov two years ago, and a federal subsidy cut her premium to $238 a month.

But the insurance company cancelled that plan for 2016 and suggested a similar one, with a big caveat. Martin said it would cost her $491 a month.

“To go up that much on premium, that’s prohibitive for me,” she said. “There’s no way, being a retired single lady. That’s, well, double what I was paying before.”

The company behind that plan, Aetna, declined our interview request. Instead, Aetna provided a statement that said its goal is to use rates that’ll cover the cost of doing business.

Tomsic_770In North Carolina and nationwide, health insurance rates were still a work in progress in this third year of Obamacare open enrollment. Coverage got cheaper in states like Indiana and Mississippi but more expensive in North Carolina, Arizona and Pennsylvania, among others, according to federal data.

Insurers aim for a sweet spot regarding premium price tags. They want them high enough to cover the cost of people’s medical care, but low enough to attract customers.

Georgetown University researcher Sabrina Corlette said when the Obamacare exchanges first opened, “for many insurance companies, that was a real guessing game.”

“They didn’t know what kind of policyholder they would attract,” she said. “They just had no idea what their costs would be.”

Now that companies have actual data on who signed up and how much care they needed, “they’re saying, ‘Whoa, wait a minute, we didn’t price the way we should have to actually reflect our costs, and so we need to adjust,’” Corlette said.

In North Carolina, the adjustments were huge. All three insurers on the exchange raised average premiums at least 20 percent. Sue Martin’s insurer, Aetna, raised rates 24 percent. The state’s dominant player, BlueCross BlueShield of North Carolina (BCBSNC), raised rates 33 percent.

Managing Actuary Brian Tajlili said BCBSNC landed a long way from that sweet spot.

“The assumption was the sick would come in the first year in 썞 but then in 2015, healthier people would enroll,” he said. “We made that assumption. Many others in the industry did as well.”

Preliminary research is mixed on whether that happened nationally. But Tajlili said it didn’t in North Carolina.

“Another thing that we had assumed is many people would go in, get a lot of services done all at once in the first year — something we sometimes call pent-up demand — and that cost would level out after that,” he said. “That proved to not be the case either.”

Instead, he said, the enrollees’ care started off expensive and stayed that way.

The bad projections meant premiums weren’t even close to covering costs, Tajlili said, and BCBSNC lost more than $120 million on that part of its business.

Still, it’s a small part of the business: less than 10 percent of BCBSNC customers are on the exchange. The premium increases of Obamacare plans don’t affect most people who have insurance through their jobs.

So were North Carolina’s insurance companies just worse at predicting who’d sign up?

“Premium increases really vary state by state, and there hasn’t been, at least at this point, a really clear pattern that has emerged,” said Elizabeth Carpenter of Avalere Health. She consults with insurance companies and other clients navigating the exchanges.

North Carolina Insurance Commissioner Wayne Goodwin has his own theory for why premiums are so high in this state.

“North Carolinians would have had lower rate adjustments and more competition and more choices for plans if we had gone a state-based route,” he said.

Goodwin said Republican state lawmakers and the governor made a mistake by choosing the federal exchange (as about three dozen other states did) rather than setting up their own.

The data is not clear on that. Jon Gabel at the University of Chicago has researched this point.

“Last year, the rate of increase in state-based exchanges and the federal exchanges was basically [the same.] There was no statistical difference,” he said.

Government data show that a benchmark plan for Indiana dropped an average of 13 percent, while the same plan in Oklahoma rose an average of 36 percent — and both states use the federal exchange.

Gabel acknowledged, though, that there can be advantages to the state exchanges.

“You have much more decision-making power, that is for sure,” he said.

In other words, you’re in control of the red tape. Commissioner Goodwin argued that could have allowed North Carolina to attract more insurance companies.

“That alone would’ve been a major factor for consumers here if there were more companies available,” Goodwin said.

The data does back up the idea that more competition equals lower premiums. North Carolina and the other states with the highest increases tend to have the fewest insurance companies selling on the exchange.

Back in Mebane, Sue Martin shopped around healthcare.gov and found a new plan she could afford, albeit with skimpier benefits.

“Even if the premiums are a little higher than I like or everything isn’t covered or whatever, I still have the option to see my doctor,” she said. “I can still afford my medications.”

One factor working in Martin’s favor is that federal subsidies rose in North Carolina, along with the insurance rates. That’s because the premium increase for North Carolina’s second-lowest-cost silver plan — the benchmark plan — was 22.8 percent.

Martin is among about 150,000 North Carolinians who already had coverage on the Obamacare exchange but switched plans during this open enrollment, according to a federal report. She’s also among the roughly 90 percent of North Carolinians who signed up with the help of federal subsidies.

This story is part of a reporting partnership that includes WFAE, NPR and Kaiser Health News.

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California Voters Will Have Their Say On Drug Prices

California voters will weigh in this November on a high-stakes ballot proposition intended to help control the cost of prescription drugs – the latest attempt to limit soaring prices that have prompted public criticism nationwide.

The proposition would require the state to drive a harder bargain with drug companies so it doesn’t pay more for medications than the U.S. Department of Veterans Affairs.

The initiative would affect about 5 million people whose health care is covered by the state, proponents said. They include retired state workers, inmates and some low-income residents in the Medi-Cal insurance program.

Across the nation, prices have spawned state legislative proposals as well as federal hearings and task forces. Dozens of bills have been proposed to address the high cost of specialty drugs, according to the National Conference of State Legislatures.

This KHN story also ran on CNN.com. It can be republished for free (details).

Political leaders in Virginia and New Jersey have introduced legislation that would require manufacturers to report production costs of some high-priced drugs. A bill in New Mexico would create a task force on pharmaceutical pricing, while a proposed law in Washington state would cap consumers’ out-of-pocket spending on prescription medications.

Even presidential candidates have offered proposals to make expensive prescription drugs more accessible.

Among the catalysts for public outrage are the sky-high price of treatments for diseases such ashepatitis C and the unapologetic markups for specialty drugs by former pharmaceutical executive Martin Shkreli.

“It’s a universal issue,” said Geoffrey Joyce, a professor and director at the USC Schaeffer Center for Health Policy & Economics. “How do we control these prices and at the same time not dampen incentives to innovate?”

Limiting prices could bolster state budgets in the short-term but might diminish the drug companies’ incentive to create future drugs, he said.

According to AARP, the retail price for 98 specialty drugs widely used to treat chronic conditions rose dramatically between 2005 and 2013. As indicated in the graph, the annual retail price of therapy per drug increased from $18,240 in 2005 to $53,384 in 2013.

According to AARP, the retail price for 98 specialty drugs widely used to treat chronic conditions rose dramatically between 20ǥ and 2013. As indicated in the graph, the annual retail price of therapy per drug increased from $18,240 in 2005 to $53,384 in 2013.

The California ballot measure is sponsored by the AIDS Healthcare Foundation, a Los Angeles-based organization that provides HIV and AIDS care around the world. “Everybody is angry about drug prices,” said Michael Weinstein, president of the group, which has proposed a similar initiative in Ohio. “When is enough enough?”

Pharmaceutical Research and Manufacturers of America (PhRMA), the chief opponent of the measure, says it is misleading and would “negatively impact millions” of Californians by causing drug prices to rise.

Kathy Fairbanks, spokeswoman for the opponents, said price controls for one segment of the population would only shift the cost to others. “It’s not going to help veterans, families, kids,” she said.

Recent polling by the Kaiser Family Foundation showed that 77 percent of Americans believe making medications affordable to people with chronic conditions is a top health care priority for politicians. And 72 percent said drug costs are unreasonable. (Kaiser Health News is an editorially independent program of the foundation.)

The California initiative is being closely watched, as states cope with high-cost specialty drugs and drug manufacturers fear a potential precedent in a bellwether state.

The pharmaceutical industry is already outspending advocates of the initiative by a large margin. With the election more than nine months away, several companies have contributed a total of nearly $39 million to defeat the proposition. Pfizer and Johnson & Johnson, among the biggest contributors, have donated almost $6 million each.

By contrast, proponents have raised only about $4 million, according to the Secretary of State’s office, which announced in December that the initiative had qualified for the ballot.

Though support for the proposition has been led by the AIDS Healthcare Foundation up to this point, Weinstein said he plans to reach out to other groups. “We have the people on our side and the political mood could not be better,” he said. “This is the beginning of real reform in drug pricing.”

Similarly, Fairbanks said the opposition campaign plans to contact veterans, patient advocates and businesses. “We expect to have a broad coalition in the near future,” she said.

The measure would exclude the vast majority of Medi-Cal beneficiaries, who are in managed care plans that negotiate their own prices. It also would not affect people on Medicare, with employer-sponsored coverage, or who those purchase private plans on the open market or through Covered California, the state’s insurance exchange.

Whatley at her apartment in Sylmar, Calif., on Friday, January 22, 2016. Whatley, an unemployed teacher, says it’s a good idea for drug prices to be regulated. (Heidi de Marco/KHN)

The state Legislative Analyst’s Office has not yet been able to conduct a fiscal analysis of the measure because some of the price data is not publicly available and it’s impossible to know how drug manufacturers would respond to caps, said Amber Didier, an analyst in the nonpartisan state office.

The lack of public information on prices could make enforcement of the initiative impossible, Fairbanks argued.

For people covered by state programs, the costs of specialty drugs largely fall to taxpayers rather than individual consumers. But some Medi-Cal recipients still support curbing prices.

Chaz Whatley, 31, said medication she takes for bipolar disorder costs about $550 a month and Medi-Cal covers all but $1. Whatley, an unemployed teacher in Los Angeles, worries that if her drugs become more expensive, Medi-Cal won’t pay and her doctor may have to prescribe something less effective.

“It’s a great idea to regulate the prices in some sort of way,” she said. “Otherwise, it’s just making the pharmaceutical companies really rich.”

Consumers in the private market already have some new protections from high out-of-pocket drug costs.

Beginning this year, most people with plans through Covered California, the state insurance exchange, won’t have to pay more than $250 a month per prescription. The exchange is the first in the nation to set caps on co-pays. And Gov. Jerry Brown signed a law late last year with similar effect for other privately insured residents who take expensive drugs for cancer, epilepsy and other diseases. That law takes effect in 2017.

San Diego resident Maggie Crine said she hopes there will be more such relief for patients in the future. She takes care of her mother, who has private insurance and pays over $200 a month for medications to treat chronic lung disease and high blood pressure. “We struggle to pay,” she said. “Where is the money going?”

Attempts by California state legislators to impose more transparency on pharmaceutical companies haven’t gotten much traction. Assembly member David Chiu (D-San Francisco) withdrew a bill this month that would have required drug manufacturers to publicly report profits and costs of production, marketing and advertising on any drug priced at more than $10,000 annually.

Anthony Wright, executive director of the consumer group Health Access, said sponsored a ballot measure in 2005 that would have pressured them to reduce drug prices for low-income Californians, but it was defeated after the drug manufacturers spent tens of millions of dollars to oppose it, Wright said.

The California Association of Health Plans, the state’s principal insurance lobby, supported the Chiu bill but hasn’t taken a position on the ballot initiative, said spokeswoman Nicole Evans. Nevertheless, Evans acknowledged the intensity of the public backlash against high drug prices.

It started as a “low roar,” she said. “Now it’s just deafening.”

Blue Shield of California Foundation helps fund KHN coverage in California.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Viewpoints: Fiorina’s Obamacare Replacement Plan; The Clinton-Sanders Clash

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Longer Looks: Nullifying Pain, Zika, Anti-Abortion Activists

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State Highlights: Bill Would Let Californians Know About Unreasonable Rate Hikes; Mental Health Advocates Push For Reforms

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Iowa Critics Argue Private Medicaid Plan Doesn’t Provide Consumers Chance To Voice Complaints

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