McConnell Has About $200B In ‘Candy’ To Make Deals On Obamacare Repeal

WASHINGTON — The path to 50 votes for an Obamacare replacement bill seemed to narrow dramatically Thursday as efforts to craft a quick compromise foundered — but Senate Majority Leader Mitch McConnell has $200 billion to build a bridge to victory. His dealmaking may be just beginning.

While many policy experts, lobbyists and senators Kaiser Health News spoke to this week seemed skeptical that the Better Care Reconciliation Act could be saved, they said they could envision a way for McConnell (R-Ky.) to succeed in crafting a bill that would partially replace the Affordable Care Act.

McConnell has significant wiggle room in his repeal bill. Under the budget rules he is using to move the legislation, he needs to reach $133 billion in deficit reduction over 10 years. The Congressional Budget Office estimated that the BCRA would save $321 billion.

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That leaves about $200 billion in deficit savings that McConnell can afford to give back and use to make deals with as many as a dozen senators who oppose his draft bill.

“There’s clearly a path to do this,” said Matt Salo, the executive director of the National Association of Medicaid Directors. “McConnell has enough candy to do it, and enough time. It’s still a very real possibility.”

Figuring out exactly how to spread the confectionery around, though, is no simple matter.

The key problem for the bill is very similar to the one that nearly brought down the House version of similar legislation: Conservatives want to repeal more of Obamacare and do it quickly while more centrist Republicans are worried about the damage that would be done by extracting $772 billion from Medicaid and eliminating popular consumer protections for health insurance.

To start with, moderate senators such as Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.), Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) all want the expansion of Medicaid under Obamacare preserved or at least rolled back much more gently than the Senate and House bills propose. And they want to preserve treatment dollars for the opioid crises raging through their states. Two Republican senators up for re-election in tight races next year — Dean Heller in Nevada and Jeff Flake in Arizona — have similar concerns.

“Obviously, anybody who had expanded the Medicaid population wants some kind of softer landing than is outlined. That’s a biggie,” said Flake.

But even a senator from deeply conservative Kansas, Sen. Jerry Moran, opposed the bill’s draconian cuts, which likely would punish the rural hospitals in his state.

All of them need money added back to Medicaid, especially after a new CBO analysis released Thursday said the program’s cuts jump from 25 percent after the first 10 years to a staggering 35 percent in the second decade.

They also have concerns about provisions that would allow states to waive minimum standards in the ACA, including its essential health benefits and protections for people with preexisting conditions.

On the conservative side, the pressure has been on to cut taxes established by the health law, and to roll back insurance regulations, so that states could craft whatever rules they want. The House repeal bill would let states get waivers for the 10 essential benefits in Obamacare. Sen. Ted Cruz (R-Texas) sponsored an amendment that goes further and would let insurers directly offer plans that don’t comply with the ACA standards as long as they also offered one plan that did in the affected state.

These competing interests would seem to be diametrically opposed. But McConnell’s ability to tap that $200 billion could go a long way to ease the friction, and Sen. Mike Rounds (R-S.D.) stepped forward Wednesday and Thursday to suggest which tax cut to forgo — a politically toxic one that primarily benefits the rich. That’s the 3.8 percent net investment tax on families that earn more than $250,000.

Not only would this provide McConnell with an additional $172 billion for his dealmaking, it would mute Democrats’ criticism of the bill as a mechanism to reward rich Republican donors while depriving poorer Americans of health care.

How McConnell doles out that largesse is another part of the puzzle. Capito and Portman had asked for $45 billion to fight the opioid crisis that is so critical to Ohio, West Virginia and other states, and aides speaking on background say they are likely to get it.

Senators like Flake, Moran and Heller could certainly be tempted by easing the blow to Medicaid and, in spite of long styling themselves fiscal conservatives, could keep a tax hike in place.

“That’s not the issue Nevada’s worried about,” said Heller, referring to the taxes. “It’s insurance for poor people.”

Even Sen. Ron Johnson (R-Wis.), who initially aligned himself against the Senate bill with Cruz and Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah), sounded open to Rounds’ idea.

“We’re $20 trillion in debt, so I think we should seriously consider retaining some of the tax revenue that funds the subsidies,” Johnson told reporters as he fast-walked to a closed-door meeting of the GOP caucus with Vice President Mike Pence on Thursday.

On the conservative side, even Lee suggested he was sensitive to the charge that Republicans were cutting taxes for the rich to stiff the poor. But Cruz hasn’t said he would be willing to keep the taxes in place. Pressed by reporters Thursday on whether the tax was a deal killer for him, he strolled onto an elevator and stayed deliberately silent as he waited for the doors to close.

There are some other levers McConnell has, but they are issues unrelated to the health bill. McConnell and senators would have to act as if it is not quid pro quo. For instance, Murkowski might be swayed by an offer of an unrelated bill to open the Arctic National Wildlife Refuge to oil drilling. (She laughed when a reporter made that suggestion earlier this year but didn’t say she’d turn it down.) Heller is locked in a battle with the administration to ensure that the Yucca Mountain nuclear waste storage facility never opens in his state. McConnell’s support keeping it closed would appeal to him, although it would be hard for him to brag about it later in connection to the health bill.

One Republican health care lobbyist and former Capitol Hill aide said the behavior of the conservatives showed that if the bill is to pass, they will have to cave.

“The conservatives are going to have to capitulate a long way, but when they do that, are they getting anything in return?” the lobbyist said.

What they could get in return is some version of Cruz’s amendment, but the lobbyist and others noted it could not be as extreme, since essential health benefits and protections for people with preexisting conditions were among the top concerns for Senate moderates when the House passed its bill.

Several GOP insiders and a couple of Democrats said it would still be a stretch to get to the 50-vote mark, but none would rule it out.

Speaking privately so they could be candid, aides from both parties saw similar political downsides for Republicans. One senior Democratic aide summed it up succinctly.

“We suffered for a few cycles over health care, but at least we had people who could talk about it who were helped,” the aide said. “They won’t have that.”

Still, the GOP remains committed to trying to fulfill the pledge they’ve made for seven years, and even vulnerable senators like Flake were not giving up.

“We’ve still got a long way to go, I think,” Flake said. “In some ways, we’re going around in circles, but I think we’re getting closer on some elements.”

Flake said the lawmakers were sending various amendments that contain those elements to the CBO and expected to have numbers back next week while the Senate is on recess. Those numbers will be crucial.

“We’re just trying to get to 50 votes,” Rounds said. “We’ve got a lot of work to do yet. We just want to make it the best we can.”

Categories: Insurance, Medicaid, Repeal And Replace Watch, The Health Law

Tags: Opioids, U.S. Congress

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Men Wrote The Senate Health Care Bill. This Woman Could Stop It.

As Majority Leader Mitch McConnell (R-Ky.) tries to negotiate his way to a health bill that can win at least 50 Republican votes, there is one woman in the Senate who could stop the bill cold.

She isn’t even a senator.

Elizabeth MacDonough is the Senate’s parliamentarian, the first woman to hold that post, which involves advising senators on the chamber’s byzantine rules and procedures. She alone can decide what pieces of the emerging Senate overhaul of the Affordable Care Act can be included under the budget reconciliation process senators are using. That process allows them to pass the measure with a simple majority vote rather than needing the usual 60.

In theory at least, she could reject the very deals McConnell is trying to cut.

By all accounts, MacDonough, who has spent almost her entire career working for the Senate and was appointed to her position in 2012, is scrupulously fair and trusted by both major parties.

“Elizabeth is great,” said Rodney Whitlock, a former Republican staffer on the Senate Finance Committee who has argued tricky legislative points before her numerous times. Democrats agree. “She’s a straight shooter and an honest broker,” said Bill Dauster, a longtime Democratic staff director for the Budget Committee.

It’s good that both sides like her, because if the Senate bill comes to the floor, MacDonough may have to make some tough decisions that will make one side or the other very unhappy.

MacDonough, along with her assistant parliamentarians, are charged with deciding which pieces of the bill violate the rules of budget reconciliation, in particular the “Byrd Rule,” named for its author, the late Sen. Robert Byrd (D-W.Va.). That rule requires that everything in the bill pertain directly to the federal budget. The idea is to prevent senators from loading up the budget bill, which gets fast-track consideration, with unrelated items that belong in the regular, slower Senate process.

The judgments mostly involve parts of the bill that opponents argue don’t add to or subtract from federal spending, or whose budget impact is “merely incidental” to the purpose of the policy. Outside observers say the parts of the Senate measure that are vulnerable under this rule include provisions that would defund Planned Parenthood and those affecting the rules for private insurance plans.

Generally, the “Byrd bath,” as it’s called on Capitol Hill, involves a string of meetings between Senate committee staff and the parliamentarian.

(Photo courtesy of the U.S. Senate)

“The Democrats go in, the Republicans go in, then both of them go in together,” said Dauster. Each side argues whether certain language should or should not be allowed in the bill.

The parliamentarian’s office in the Capitol “is actually a small room,” said Whitlock. “And when they are ready to have you in, you’re standing around and all the assembled in the room have at it.”

MacDonough does not make her rulings immediately after the arguments. “She has, of late, gotten back to people by email” with her decisions, said Dauster.

That has not always been the case. In the past, said Bill Hoagland, a longtime GOP staff director for the Senate Budget Committee, after making their arguments “we would wait until we went to the floor and [a senator] would raise a point of order” against some specific language, and senators and staff would learn the parliamentarian’s decision only then.

MacDonough’s ruling may prompt the bill’s authors to delete language before the bill comes to the Senate floor. Or they may opt to let the drama may play out in front of the C-SPAN cameras. Any senator can raise a point of order against a specific provision claiming it violates the Byrd Rule. It takes 60 votes to overcome such a point of order.

But what if Senate leaders opt not to accept MacDonough’s decision?

“That’s what scares the heck out of me,” said Hoagland. Under the Senate’s rules, the senator who is acting as the presiding officer during the debate does not have to take the parliamentarian’s advice. But if he or she rules against what the parliamentarian has advised, “I would argue that you have basically destroyed the Byrd Rule and you’ve destroyed the purpose of reconciliation at that point,” he said.

That’s because it would allow the majority party, which controls the Senate, to effectively include any provisions it wants in the fast-track budget bill with only a simple majority.

“It’s another way to go nuclear,” said Dauster, referring to efforts to end the Senate filibuster, which requires 60 votes to break.

Will that happen? It depends how MacDonough rules. And how badly the Republicans want their health bill to pass.

Categories: Insurance, Repeal And Replace Watch, The Health Law

Tags: Legislation, U.S. Congress

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Popular Heartburn Meds Don’t Raise Alzheimer’s Risk: Study

News Picture: Popular Heartburn Meds Don't Raise Alzheimer's Risk: Study

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WEDNESDAY, June 28, 2017 (HealthDay News) — Drugs used to treat acid reflux and ulcers don’t appear to boost the risk of dementia, as has been previously suspected, new research suggests.

The study focused on widely used proton pump inhibitors (PPIs) drugs — medicines such as Prevacid, Prilosec and Nexium. Previous studies have suggested the drugs may increase the risk of dementia and Alzheimer’s disease in people aged 75 and older.

PPIs are used to treat digestive problems like reflux disease by reducing the body’s production of acid.

Researchers from Emory University in Atlanta analyzed a National Alzheimer’s Coordinating Center database for the study. The data, compiled from 2005 to 2015, included close to 10,500 Americans, aged 50 or older, with normal brain function or mild thinking difficulties.

Eight percent always used PPIs, and 18 percent sometimes did. Users were older than non-users.

Researchers found those who used PPIs were at a lower risk of a decline in thinking skills.

“The results of this study do not confirm recent reports that the use of PPIs is linked to greater risk of dementia and Alzheimer’s disease,” wrote the researchers led by Felicia Goldstein of the department of neurology at Emory’s School of Medicine, in Atlanta.

But those who used PPIs were also more likely to use anticholinergic medicines that have been linked to thinking difficulties. Those medications are used to treat incontinence, depression and sleep problems and include diphenhydramine (Benadryl).

The study found PPI users were more likely to have suffered from heart disease, depression, diabetes, high blood pressure, stroke or the mini-strokes known as transient ischemic attacks (TIAs).

The study was published recently in the Journal of the American Geriatrics Society.

— Randy Dotinga

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SOURCES: American Geriatrics Society, press release, June 22, 2017; Journal of the American Geriatrics Society, May 2017

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Manage your chronic conditions with connected care

Wayne is in his early 70s, and has diabetes and a history of high blood pressure. He was overwhelmed trying to manage both conditions at the same time. His doctor told him that Medicare includes chronic care management services to better manage his health conditions. Now, a health care professional helps Wayne keep track of his medical history, medications, and all the doctors he sees.

Like Wayne, about two-thirds of people with Medicare have 2 or more chronic conditions. In fact, about a third of people with Medicare have 4 or more chronic conditions. If you live with 2 or more chronic conditions—like arthritis, asthma, depression, diabetes, osteoporosis and high blood pressure that have lasted, or are expected to last, at least a year—Medicare may pay for a health care provider’s help to manage those conditions.

Chronic care management may include:

  • At least 20 minutes a month of chronic care management services
  • Personalized help from a dedicated health care professional, like a doctor, nurse or physician’s assistant, who will work with you to create a care plan based on your needs and goals
  • Care coordinated between your doctor, pharmacy, specialists, testing centers, hospitals, and other services
  • Phone check-ins between visits to keep you on track
  • Emergency access to a health care professional, 24 hours a day, 7 days a week
  • Expert help with setting and meeting your health goals

You may have to pay a monthly copayment for chronic care management services. If you have supplemental insurance or Medicaid, they may help pay the monthly costs.

Wayne now feels reassured knowing he can make contact with a health care professional regardless of the time of day or day of week, and has his high blood pressure and diabetes under control. Get the connected care you need—talk to your doctor or health care professional to see if you’re eligible for chronic care management, and watch our video to learn more about what’s covered. Health care professionals and community partners can learn more by visiting the Connected Care page at go.cms.gov/ccm.

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Safe Under The ACA, Patients With Preexisting Conditions Now Fear Bias

Cheasanee Huette, a 20-year-old college student in Northern California, is worried. Two years ago, knowing she was protected by the Affordable Care Act’s guarantees of coverage for preexisting conditions, she decided to find out if she carried the same genetic mutation that eventually killed her mother.

She tested positive for one of the cancer-related mutations referred to as Lynch syndrome.

Now, as congressional Republicans advance proposals to overhaul the health law’s consumer protections, she frets that her future health insurance and employment options will be defined by that test — and that the mutation documented in her medical records and related screenings could rule out individual insurance coverage.

“Once I move to my own health care plan, I’m concerned about who is going to be willing to cover me and how much will that cost,” said Huette, who now has coverage under her father’s policy.

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With the protections of Obamacare in place, physicians in recent years have urged patients to be screened for a variety of diseases and predisposition to illness, feeling confident it would not affect their future insurability. Being predisposed to an illness — such as carrying BRCA gene mutations associated with breast and ovarian cancer — does not mean a patient will come down with the illness. And it may allow them to take steps to prevent its development.

But the results recorded on patients’ charts could haunt them, experts say.

Dr. Kenneth Lin, associate professor of family medicine at Georgetown University School of Medicine in Washington, D.C., said that doctors might become reluctant to screen for widespread conditions such as prediabetes. The Centers for Disease Control and Prevention and the American Medical Association have urged primary care doctors to screen patients at risk for the condition with a blood test. It is one of the screening tests covered under the ACA at no-cost to those patients.

Lisa Salberg, chief executive officer of the Hypertrophic Cardiomyopathy Association, received a heart transplant in February. She was given her old heart back, frozen and in a plastic bag, so she could use it as a tool to teach people about hypertrophic cardiomyopathy. “We finally got to a place where people understood the value [of genetic testing],” she said. “Now, because we’re turning health care on its head, people are becoming more paranoid again.” (Sarah Vrablik/Speckle Photography)

If the changes being proposed by the GOP become law, Lin wrote in an email, “you can bet that I’ll be even more reluctant to test patients or record the diagnosis of prediabetes in their charts.” Such a notation might mean hundreds of dollars a month more in premiums for individuals in some states under the new bill, according to Lin.

It is a concern expressed by many patient-advocacy groups, who say members could be penalized or face the possible loss of the guarantee of coverage.

Huette is sharing her story publicly, since — come what may — her genetic mutation is already on the record — her medical record.

But genetics experts and patient advocates worry that people are already shying away from testing as the health law’s future becomes more uncertain. Their underlying concern: What if a positive result is added to their medical record, along with related screening and other preventive procedures that might further flag them to future insurers?

There have been “panicked expressions of concern,” said Lisa Schlager, vice president of community affairs and public policy at the nonprofit group Facing Our Risk of Cancer Empowered (FORCE). “Somebody who had cancer even saying, ‘I don’t want my daughter to test now.’ Or ‘I’m going to be dropped from my insurance because I have the BRCA mutation.’ There’s a lot of fear.”

These fears, which come in an era of accelerating genetics-driven medicine, rest upon whether a gap that was closed by the ACA will be reopened.

A law passed in 2008, the Genetic Information Nondiscrimination Act (GINA), bans health insurance discrimination if someone tests positive for a mutation. But that protection stops once the mutation causes “manifest disease,” jargon for a diagnosable health condition.

That means “when you become symptomatic,” although it’s not clear how severe the symptoms must be to constitute having the disease, said Mark Rothstein, an attorney and bioethicist at the University of Louisville School of Medicine in Kentucky, who has written extensively about GINA.

The ACA, passed two years later, closed that gap by barring health insurance discrimination based on preexisting conditions, Rothstein said.

On paper, the legislation unveiled by Senate Majority Leader Mitch McConnell (R-Ky.) last week wouldn’t permit higher rates to be charged to people with preexisting conditions, but health policy analysts said it could effectively exclude such patients from coverage because it allows states to offer insurance that carved out coverage for certain maladies. The bill that passed the House last month has a provision that allows states to waive preexisting protections for people buying their own insurance if they have a gap in coverage of 63 days or longer during the prior year.

A genetic predilection for a certain disease is “not black-and-white,” said Dr. Robert Green, a medical geneticist who directs the Genomes2People (G2P) Research Program at Brigham and Women’s Hospital and Harvard Medical School in Boston. Once someone tests positive for a mutation, the recommended screening to catch disease at an earlier point could over time identify clinical or laboratory data “that are suggestive, but not definitive,” he said.

Green was involved with a study published this week in the Annals of Internal Medicine, which found that even seemingly healthy individuals can carry — unbeknownst to them — mutations for rare diseases. Of the 50 healthy patients who agreed to undergo whole-genome sequencing, 11 tested positive. Subsequently, two of the 11 were found to have related symptoms; the rest showed no signs of disease.

Lisa Salberg, chief executive officer of the Hypertrophic Cardiomyopathy Association, has cardiomyopathy, a condition that can make the walls of the heart thick and rigid. She was recovering from a heart transplant earlier this year when her phone and social media accounts blew up over the preexisting waivers in the House bill. “We finally got to a place where people understood the value [of genetic testing],” she said. “Now, because we’re turning health care on its head, people are becoming more paranoid again.”

When members of a Lynch syndrome-related social media group were asked about their views on testing, with assurance of no direct attribution without prior consent, slightly more than two dozen men and women responded.

Nearly all of those who posted said they were delaying action for themselves or suggesting that family members, and particularly children, should hold off. (Lynch syndrome refers to a cluster of mutations that can boost the risk of a wide range of cancers, particularly colon and rectal.)

Huette was the only one who agreed to speak for attribution.

She had witnessed the impact that worries about insurance coverage before the ACA had on patients. Her mother, a veterinarian, had wanted to run her own practice but instead took a federal government job for the guarantee of health insurance. She died at age 57 in 2011 of pancreatic cancer, one of six malignancies she had been diagnosed with over the years.

Huette said she doesn’t regret getting tested. Without that result, Huette pointed out, how was she going to persuade a doctor to give her a colonoscopy in her 20s? She added: “Ultimately, my health is more important than my bank account.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

Tags: Cancer, Preexisting Conditions, Preventive Services

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Insect Venom Shortage Stings Allergy Sufferers This Summer

As summer begins, signaling peak time for insect stings, allergists across the U.S. are warning of a shortage of a little-known but crucial product — honeybee, hornet and wasp venom extracts used in shots that prevent life-threatening reactions.

Supplies of the extracts — which are made from venom gathered by hand from millions of individual insects — have been scarce since October. That’s when one of two manufacturers in the U.S. shut down production after contamination problems. Doctors say they hope the situation will be resolved, but that’s not likely before next year. For now, they’re rationing doses for patients who need them most.

“It’s going to be a rough summer,” said Dr. David Golden, an allergy expert and associate professor of medicine at Johns Hopkins University.

Golden estimates he’s seen a 25 to 35 percent drop in the supply of venom extracts aimed at preventing dozens, perhaps hundreds, of deaths in the U.S. each year. Between 1 and 3 percent of the country’s adult population — up to 7.4 million people — may have systemic reactions to insect stings, and a smaller proportion have life-threatening responses, experts say.

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

Most of those vulnerable people carry portable epinephrine — often EpiPens — to quickly counteract symptoms. But a smaller number use what’s known as venom immunotherapy, or VIT, to dramatically reduce the risk of reactions. The treatment, authorized for nearly 40 years, injects small doses of venom under the skin to reduce sensitivity to the allergens that can trigger dangerous symptoms.

“It’s one of the few things that allergists do that actually save lives,” said Dr. Stephen Tilles, a Seattle allergist who is president of the American College of Allergy, Asthma and Immunology (ACAAI). “It’s about 98 percent effective.”

The shortage started last fall, when ALK Laboratories of Denmark shut down production of six types of venom proteins — honeybee, wasp, white-faced hornet, yellow hornet, yellow jacket and “mixed vespid,” a cocktail of venoms.

The move followed a 2016  letter from the Food and Drug Administration citing problems with microbiological contamination. ALK officials didn’t respond to requests for comment.

That left only Jubilant HollisterStier, a Spokane, Wash., company that also produces venom extracts. HollisterStier ramped up manufacturing, Golden said, but the firm couldn’t supply enough venom extract fast enough to avoid a shortage. Firm officials declined to comment.

“Most allergists are having to seriously limit what they use,” Golden said. “We’re trying to stretch the venom that we have.”

This spring, Golden and colleagues issued recommended guidelines for rationing venom during the shortage. They called for spacing out doses at longer intervals, cutting maintenance doses, minimizing venom waste — and stopping treatment for patients at lowest risk for severe reactions.

So far, the plan appears to have worked, said Dr. Sandra Hong, an allergist with the Cleveland Clinic. Most patients do fine with shots at longer intervals; instead of every four weeks, they get them every three months. And after three to five years of treatment, many can be weaned from the venom with no ill effects.

“With all the things the allergists have done, it has decreased the shortage,” Hong said.

There have been a few reports of allergists who couldn’t get supplies of venom, and patients who couldn’t get the product, which costs about $70 for induction doses and about $20 for each maintenance dose. So far, there are no known cases of adverse events in patients who couldn’t get shots. There’s also no sign of the skyrocketing drug prices that have occurred with other products in short supply.

Still, allergists worked to ensure that patients at the highest risk weren’t harmed. That includes people like Ciro DeMarco, 58, a retired machinist from Moxee, Wash.

DeMarco nearly died in 1983 after he was stung by a honeybee while riding a motorcycle near a river in rural eastern Washington.

“I started feeling real strange,” he recalled. “I stopped the motorcycle and sat down. All of a sudden, I had no sight and I was almost unconscious.”

He lived in fear of another sting until about 10 years ago, when he learned about VIT. Now he gets regular venom shots every three months and takes over-the-counter allergy medications before he climbs onto his Harley-Davidson. He’s relieved that the shortage hasn’t affected his supply.

“Every spring I worry about it,” he said. “But I’m not going to quit riding just in case I get stung.”

ALK Laboratories may resume production soon and the shortage could be eased in coming months. Once the supply question is resolved, Golden said, he hopes to tackle a larger issue: lack of VIT awareness among people who’ve had a bad reaction to an insect sting.

“No more than 10 percent of the affected people have sought medical attention,” he said. “Problem No. 1 is that many people, including doctors, don’t know venom immunotherapy exists.”

Categories: Public Health

Tags: Preventive Services

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