Study: Even Low-Level Air Pollution Kills the Elderly

Action Points

  • Long-term exposure to airborne fine particulate matter (PM2.5) and ozone was associated with an increased risk of death among Medicare beneficiaries, even when exposure levels were below national air quality standards.
  • Note that there was no appreciable level below which mortality risk tapered off, and thus no “safe” level of PM2.5.

Long-term exposure to airborne fine particulate matter (PM2.5) and ozone was associated with an increased risk of death among Medicare beneficiaries, even for exposures below National Ambient Air Quality Standards, reported researchers.

Analysis of more than 60 million Medicare beneficiaries found that each increase in PM2.5 of 10 µg/m3 was associated with a 7.3% increase in all-cause mortality (95% CI 7.1%-7.5%), reported Qian Di, MS, of Harvard University, and colleagues in the New England Journal of Medicine.

“If we could reduce PM2.5 level by just 1 µg/m3 nationwide, we could save about 12,000 lives just among people above 65 years old. The health benefit could be even larger in the overall population,” Di told MedPage Today.

“There was no appreciable level below which mortality risk tapered off, and thus no ‘safe’ level of PM2.5. More importantly, we found significant harmful effects of air pollution below the current National Ambient Air Quality Standards for PM2.5.”

Writing in an accompanying editorial, titled “Air Pollution Still Kills,” Rebecca E. Berger, MD, of Massachusetts General Hospital in Boston, and colleagues said, “Owing to the large size of the cohort, [the researchers] were able to perform robust subgroup analyses and identified greater risks of death associated with air pollutants among blacks and Medicaid-eligible populations; moreover, these groups were more likely to be exposed to higher pollutant levels.

“The findings stress the need for tighter regulation of air-pollutant levels, including the imposition of stricter limits on levels of PM2.5.”

Di and colleagues constructed an open cohort of 60,925,443 Medicare beneficiaries in the continental U.S. with 460,310,521 person-years of follow-up. The team analyzed 2002-2012 data from the Medicare beneficiary denominator file from the Centers for Medicare and Medicaid Services on all beneficiaries age 65 and older with all-cause mortality as the outcome. This included the date of death (up to Dec. 31, 2012), age at year of Medicare entry, year of entry, sex, race, ZIP code of residence, and Medicaid eligibility (a proxy for low socioeconomic status).

Annual averages of fine particulate matter PM2.5 and ozone were estimated according to the ZIP code of residence for each enrollee via previously validated prediction models.

Using a two-pollutant Cox proportional-hazards model that controlled for demographic characteristics, Medicaid eligibility, and area-level covariates, the researchers estimated the risk of death associated with exposure to increases of 10 μg per cubic meter for PM2.5 and 10 parts per billion (ppb) for ozone.

Annual average PM2.5 concentrations across the U.S. ranged from 6.21 to 15.64 μg per cubic meter (fifth and 95th percentiles, respectively), and the warm-season average ozone concentrations ranged from 36.27 to 55.86 ppb (fifth and 95th percentiles, respectively). The highest PM2.5 concentrations were in California and the eastern and southeastern U.S., while the Mountain region and California had the highest ozone concentrations.

For each 1 ppb increase in ozone, the associated mortality rate increase was about 1.1% (95% CI 1.0-1.2), Di et al reported. Similarly, a reduction in ozone level of just 1 ppb nationwide could save 1,900 elderly lives each year, the team wrote.

The researchers also noted that males, blacks, and Medicaid-eligible participants had higher risk estimates associated with PM2.5 exposure compared with the national average. Notably among blacks, the effect estimate for PM2.5 was three times that of the overall population.

“The message is clear,” Di explained in an email: “Air pollution kills people, even below current National Ambient Air Quality Standards. Current air quality standard is not stringent enough to protect human health. We need to strengthen, not weaken, EPA air pollution standards. We need to increase, not reduce the EPA research funding.”

Berger and colleagues agreed, noting in the editorial that despite compelling data such as this study, “the Trump administration is moving headlong in the opposite direction. Trump’s proposed budget includes crippling cuts to the EPA, including cuts in funding for both federal and state enforcement of regulations. The increased air pollution that would result from loosening current restrictions would have devastating effects on public health.”

The study was supported by grants from the Health Effects Institute, the National Institutes of Health, the National Cancer Institute, and the Environmental Protection Agency.

Di and co-authors reported having no potential conflicts of interest.

2017-06-28T17:00:00-0400

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Chronic Opioid Use ‘Substantial’ in Older RA Patients

Action Points

  • There is substantial use of opioids in an older rheumatoid arthritis (RA) population despite societal concerns regarding potential over-prescribing in recent years.
  • Note that this pattern of opioid use among RA patients was similar to that found in a study of older Medicare patients that was not focused on RA.

Despite mounting concerns that opioids are being overprescribed, their use among older patients with rheumatoid arthritis (RA) — although slightly declining — remains substantial, investigators have determined.

Researchers led by Jeffrey R. Curtis, MD, director of the Arthritis Clinical Intervention Program at the University of Alabama at Birmingham reported that based on 2006-2014 Medicare data, regular opioid use in older RA patients peaked in 2010, and then began a slight decline. However, as of 2014, 40% of RA patients were using prescribed opioids regularly.

The results of the study appear online in Arthritis & Rheumatology.

Curtis and his colleagues identified 70,929 RA patients (mean age 67.4) who met the eligibility requirements for a time-trend analysis of opioid use from 2006 to 2014. Regular opioid use was defined as having three or more filled prescriptions (written by any physician) or one or more prescriptions filled for a 90-day supply during a calendar year.

The researchers found that regular opioid use among these patients increased slowly — but significantly — from 2006 to 2010, and has since slowly declined. In 2006 the most common opioids were in medications that combined acetaminophen with hydrocodone or propoxyphene. The FDA announced its intent to remove propoxyphene from the market in 2010, a date that coincides with the start of a gentle decline in opioid use. However, the researchers pointed out that the withdrawal of propoxyphene from the market had a limited impact on total opioid use since the use of hydrocodone and tramadol increased commensurately in 2011.

Curtis and his colleagues noted that this pattern of opioid use among RA patients was similar to that found in a study of older Medicare patients that was not focused on RA. That study found a general increase in opioid prescriptions from 2007 to 2012, reaching a peak in 2011 and then declining in 2012.

The team also performed a second analysis that used 2014 data only and focused on identifying the degree of variability of opioid use that could be attributed to physicians’ prescribing patterns.

This analysis classified patients as regular opioid users (as defined for the time trend analysis), non-users (no filled prescriptions in 2014), or intermittent users.

In this part of the study, researchers identified 240,750 RA Medicare patients. Of these, 97,859 patients (41%) were determined to be regular users. 40% were non-users, and 19% were intermittent users.

Regular users were younger (mean age of 67), mostly female (almost 80%), and more likely to be black (12%) compared with non-users and intermittent users.

Curtis et al found a “substantial” variability among rheumatologists in the proportion of their patients who received opioids (ranging from none to 93%). However, when adjusted for patient characteristics such as disease activity and severity, other painful conditions such as metastatic cancer or back pain, as well as conditions where use of opioids is considered controversial or contraindicated (such as fibromyalgia, anxiety, and depression), affiliation with a particular radiologist was associated with a 25% greater or lesser likelihood that a patient would be a regular opioid user.

The researchers pointed out that while a large database study such as this “cannot directly assess whether the individual decisions made for each patient reflected the optimum balance of risk and benefit [of opioid use], as recommended by the CDC and others,” the findings “raise concerns” about inappropriate prescribing decisions.

For example, the team continued, there is no evidence that long-term use of opioids is helpful for fibromyalgia, while the CDC considers depression and anxiety to be factors associated with an increased risk of misuse of opioids.

Yet, “these three characteristics were independently associated with opioid receipt. Even if none of these conditions were construed as strict contraindications, the positive association we found invites a concern that some patients likely received opioids when other interventions may have been more appropriate.”

Curtis and his colleagues concluded that while their results suggest that the use of opioids in older RA populations appears to be substantial, rheumatologists caring for these patients face a dilemma “precisely because the options for care of pain remain problematic.”

The findings, the authors suggest, “reinforce parallel needs for individualized care and increased efforts to develop new and effective pain interventions for patients with rheumatoid arthritis.”

Curtis reported having no relevant disclosures.

Three co-authors noted financial relationships with Abbott, Amgen, AstraZeneca, Bayer, BMS, Merck, Novartis, Pfizer, Roche/Genentech, and UCB.

2017-06-28T14:30:00-0400

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Drop In Sudden Cardiac Arrests Linked To Obamacare

If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.

“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.

A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.

The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15, after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.

Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.

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Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest], because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.

The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.

“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t,you might let it go for a while,” said Chugh.

Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.

J. Michael McWilliams of the Department of Health Care Policy at Harvard Medical School, who was not involved in the study, questioned the large reduction in cardiac arrests seen in the study, saying it “seems too good to be true.”

Still, he said assessing the effects of health insurance on clinical outcomes like cardiac arrest is notoriously difficult, and there is good evidence that health insurance improves access to care and diagnosis of important conditions.

“I think when we focus on the lack of consensus evidence on the effects of coverage on hard outcomes like mortality, and use that as an argument against covering the uninsured, I think we let perfect be the enemy of good,” McWilliams said.

James Frank (Courtesy of James Frank)

Take James Frank, 64, of Lancaster, Calif., who was uninsured several years ago when he first started experiencing the symptoms of heart disease.

“I couldn’t catch my breath, I was wheezing,” Frank recalled. “I felt like I had like a chest cold. My feet were tingling. I was getting the sweats.” In 2013, Frank had a heart attack and was taken to the emergency room.

He signed up for coverage under Covered California, the state’s health insurance exchange, which opened in 2013 for coverage that began in January 2014. His doctor put him on a statin and blood pressure medication to prevent another heart attack, and he started watching his weight religiously.

Frank was quick to add that the coverage he gained under the ACA has not been perfect — his premium and deductibles are high, and he thinks that Congress should repair it. Still, he believes the health law saved his life. “I had the same heart attack that killed my mother,” he said. “Had it not been for Obamacare, I probably would have had another one.”

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

Tags: Chronic Disease Care, Medicaid Expansion, Oregon, Study

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Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill

California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.

The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.

“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”

Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.

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California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.

The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.

In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.

The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.

“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”

The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.

Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/KHN)

GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.

The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.

Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.

Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.

State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.

“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”

The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.

The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.

In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.

Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.

California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.

Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.

The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.

“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”

During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”

Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.

“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”

Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.

“Without insurance, I’m not going to have access to my medication,” he said.

Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.

“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”

Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.

Ana Ibarra contributed to this report.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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Vectura signs deal with Novartis for generic U.S. lung therapy

Vectura Group Plc said on Wednesday it has signed an exclusive deal with Sandoz AG, a unit of Swiss drugmaker Novartis, to develop a generic copy of an existing combined lung therapy for the U.S. market.

British drugmaker Vectura has been trying to build a specialized lung drug business since it merged with Skypeharma last year and said it would prioritize three to five generic projects each year.

However, the firm hasn’t had it easy, following delays in its generic drug with Hikma coming onto the market, a royalties row with GSK, and delays in Novartis launching its Ultibro inhaler in the U.S.

“This program represents the first partnered collaboration of this series of projects and offers substantial potential for future value creation,” Chief Executive James Ward-Lilley said in a statement issued after trading hours.

Vectura, which hopes to get a foothold in the $40 billion global respiratory market, said the deal could result in payouts of $10 million if the drug achieves some development milestones.

The company also said it would develop the therapy’s formula and manufacture clinical batches to use in pilot studies, while Sandoz would head the drug’s clinical development, manufacturing and commercialization.

The therapy, which is expected to seek regulatory approval and then be launched in the early to mid-2020, is an inhaled combination treatment for asthma and chronic obstructive pulmonary disease.

(Reporting by Esha Vaish in Bengaluru; Edited by Martina D’Couto)


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Analysis: Mitch McConnell Plans To Hide Trumpcare’s Pain Until After Midterms

Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal Obamacare.

Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.

Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:

2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.

2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.

2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.

2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.

2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.

McConnell insists everything about the bill has been aboveboard and transparent.

“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.

But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)

Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.

One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President Donald Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.

On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.

The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.

In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.

Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.

Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.

A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.

“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”

Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.

“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”

Democrats said McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.

“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the health care system,” Fallon said.

Sen. Patty Murray (D-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.

“Sen. McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”

Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.

Categories: 2018 Elections, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

Tags: Legislation, U.S. Congress

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House Seeks To Cap Malpractice Awards As Part Of Health Care Update

Last week, a jury awarded a Pennsylvania man $620,000 for pain and suffering in a medical malpractice lawsuit he filed against a surgeon who mistakenly removed his healthy testicle, leaving the painful, atrophied one intact.

However, if a bill before the House of Representatives passes, the maximum he would be able to receive for such “non-economic” damages would be $250,000.

Non-economic damages cover losses that are hard to put a dollar amount on such as suffering, loss of a limb, pain, and loss of companionship. In addition, medical malpractice awards may include monetary damages to cover medical costs and loss of future wages. Sometimes punitive damages may be awarded as well as punishment for reckless or other harmful behavior.

The bill is part of a package of proposed reforms that supplement the American Health Care Act, the House measure to replace the Affordable Care Act that was narrowly approved in May. The Trump administration pledged to support the tort reform legislation.

Passage is far from certain. Groups across the political spectrum oppose the measure. Patients advocates say it would be unfair to seriously injured people whose lives are changed forever because of medical negligence. Many conservatives don’t embrace it either because it would impose federal standards on tort law, an area where states have traditionally determined the rules.

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The Congressional Budget Office estimated that the bill would lower health care costs by reducing medical liability insurance premiums and the use of health care services by providers worried about being sued. This would lead to lower spending on federal health care programs and lower medical insurance liability premiums. The effect would be to reduce deficits by nearly $50 billion over 10 years.

Supporters say caps on medical malpractice awards discourage frivolous lawsuits and reduce the cost of health care because providers no longer need to practice defensive medicine.

Yet research shows that costs from medical liability make up just 2 to 2.5 percent of total health care spending.

About half of states have a cap of some sort on non-economic damages in medical malpractice cases, according to Joanne Doroshow, executive director of the Center for Justice and Democracy, a consumer advocacy organization for civil justice issues.

Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.

The case of the Pennsylvania man’s surgery is a “never event,” one that experts on patient safety say should never occur. Since that state doesn’t have a cap on non-economic damages, if the House bill had been in effect, it would limit the amount that the jury could award the patient to $250,000. The patient, Steven Hanes, 54, also was awarded $250,000 in punitive damages.

Hanes declined to be interviewed, but his attorney, Braden Lepisto, said his client was shocked to learn of the proposed cap. “He felt that the $250,000 cap was ridiculous because that amount would not compensate him for what he has gone through and will go through moving forward,” Lepisto said in an email. He added, “The reality is that there are many individuals who are injured from medical negligence who do not have ‘economic loss’ as defined by the law. Nonetheless, their lives are altered from the pain and suffering, loss of life’s pleasures, and the emotional effects of the injuries.”

The House bill would also come into play in Florida, where earlier this month the state Supreme Court struck down caps on non-economic damages in medical negligence cases because the court ruled they violate the equal protection clause of the state constitution. The House bill would supersede the state court decision and impose the cap in Florida cases.

Although the damages cap is noteworthy, other elements of the House bill also trouble consumer advocates. For example, it would establish a three-year statute of limitations following an injury for consumers to bring a lawsuit, or a one-year limit from the date that the consumer discovers or should have discovered an injury.

“Because it’s [worded as] whichever comes first, for all intents and purposes it’s one year,” said Doroshow. “That is a drastic change. Almost no state has a statute of limitations that severe.”

The bill would also set limits on the amounts that lawyers can recover in contingency fees from consumer judgments. This seemingly consumer-friendly provision could actually harm patients, said Doroshow.

Medical malpractice cases are complex and expensive to bring, she noted. “If you have a law that caps the ability of the attorney to recover from the judgment, they’ll think twice before taking a case,” Doroshow said. “It hurts the patient’s ability to have a competent attorney or any attorney at all.”

Meanwhile, some supporters of tort reform say the House bill goes about it the wrong way.

“The federal government doesn’t really have a legitimate role to play here,” said Dr. Jeffrey Singer, a general surgeon in Phoenix who is an adjunct scholar at the libertarian Cato Institute, located in Washington, D.C.

Conservatives might be relying too much on the idea of tort reform to bring down health care costs, he said.

“It’s become almost a part of the canon of people who align themselves with the market-oriented conservative reforms school,” he said. “But it should be done at the state level and we’re fooling ourselves if we think that it’ll be the magic bullet.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Health Care Costs, Health Industry, Insuring Your Health, Public Health

Tags: Legislation, Medical Errors, U.S. Congress

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California to list herbicide as cancer-causing; Monsanto vows fight

By Karl Plume

Glyphosate, an herbicide and the active ingredient in Monsanto Co’s popular Roundup weed killer, will be added to California’s list of chemicals known to cause cancer effective July 7, the state’s Office of Environmental Health Hazard Assessment (OEHHA) said on Monday.

Monsanto vowed to continue its legal fight against the designation, required under a state law known as Proposition 65, and called the decision “unwarranted on the basis of science and the law.”

The listing is the latest legal setback for the seeds and chemicals company, which has faced increasing litigation over glyphosate since the World Health Organization’s International Agency for Research on Cancer said that it is “probably carcinogenic” in a controversial ruling in 2015.

Earlier this month, Reuters reported that the scientist leading the IARC’s review knew of fresh data showing no link between glyphosate and cancer. But he never mentioned it, and the agency did not take the information into account because it had yet to be published in a scientific journal. The IARC classed glyphosate as a “probable carcinogen,”  the only major health regulator to do so.

Dicamba, a weed killer designed for use with Monsanto’s next generation of biotech crops, is under scrutiny in Arkansas after the state’s plant board voted last week to ban the chemical.

OEHHA said the designation of glyphosate under Proposition 65 will proceed following an unsuccessful attempt by Monsanto to block the listing in trial court and after requests for stay were denied by a state appellate court and the California’s Supreme Court.

Monsanto’s appeal of the trial court’s ruling is pending.

“This is not the final step in the process, and it has no bearing on the merits of the case. We will continue to aggressively challenge this improper decision,” Scott Partridge, Monsanto’s vice president of global strategy, said.

Listing glyphosate as a known carcinogen under California’s Proposition 65 would require companies selling the chemical in the state to add warning labels to packaging. Warnings would also be required if glyphosate is being sprayed at levels deemed unsafe by regulators.

Users of the chemical include landscapers, golf courses, orchards, vineyards and farms.

Monsanto and other glyphosate producers would have roughly a year from the listing date to re-label products or remove them from store shelves if further legal challenges are lost.

Monsanto has not calculated the cost of any re-labeling effort and does not break out glyphosate sales data by state, Partridge said.

Environmental groups cheered OEHHA’s move to list the chemical.

“California’s decision makes it the national leader in protecting people from cancer-causing pesticides,” said Nathan Donley, a senior scientist at the Center for Biological Diversity.

(Reporting by Karl Plume in Chicago; Editing by David Gregorio)


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Facing revolt on healthcare bill, Senate Republicans delay vote

By Susan Cornwell and Richard Cowan
| WASHINGTON

Facing a potentially disastrous defeat by members of his own party, U.S. Senate Majority Leader Mitch McConnell decided on Tuesday to delay a vote on healthcare legislation in order to get more support from Republican senators.

President Donald Trump summoned all 52 Republican senators to the White House on Tuesday afternoon to discuss how to proceed.

McConnell had been pushing for a vote ahead of the July 4 recess that starts at the end of the week. The legislation would advance a repeal of major elements of Obamacare and replace it with a new federal healthcare program.

The delay showed McConnell and Trump have failed so far to attract enough votes amid a solid block of Democratic opposition and attacks from both moderate and conservative Republican senators.

McConnell, who has a razor-thin majority in the Senate, told reporters that Republican leaders were still working to get the 50 votes to pass the bill, adding that the White House was anxious to help write legislation that could pass the Senate.

While the House of Representatives narrowly passed a measure last month to replace Obamacare, the Senate version stalled on Tuesday as a small but potentially crippling group of senators held out.

Moderate senators worried that millions of people would lose their insurance. Conservatives said the bill does not do enough to erase Democratic former President Barack Obama’s signature domestic legislation.

U.S. stock prices fell on Tuesday after the decision to postpone the vote. U.S. stocks have rallied this year on hopes for tax reform, deregulation and changes to the health sector. Markets are beginning to doubt whether the Trump administration can fulfill its promises.

By early afternoon the benchmark S&P 500 index was down 0.5 percent and the Dow Jones industrial average was off 0.2 percent.

“The market likes certainty and now there’s uncertainty. What is this going to look like when this gets out of the next iteration?,” said Peter Costa, president of trading firm Empire Executions Inc.

The bill’s prospects were not helped by an analysis by the nonpartisan Congressional Budget Office on Monday saying the measure would cause 22 million Americans to lose medical insurance over the next decade even as it reduced the federal deficit by $321 billion over the next decade.

The report prompted Senator Susan Collins, a key moderate vote, to say she could not support moving forward on the bill as it stands.

At least four conservative Republican senators said they were still opposed after the CBO analysis.

Passing the measure would hand Trump a legislative win as he seeks to shift attention after weeks of questions over Russia’s role in last year’s U.S. presidential election.

‘ROOT AND BRANCH’

McConnell has promised since 2010 that Republicans, who view Obamacare as a costly government intrusion, would destroy the law “root and branch” if they controlled Congress and the White House. Their electoral victories in 2014 and 2016 were directly tied to that promise, they say.

Republicans worry that failure to deliver will tell voters that they are unable to govern effectively in the run-up to next year’s congressional elections.

If the Senate passes a bill, it will either have to be approved by the House, which passed its own version last month, or the two chambers would reconcile their differences in a conference committee. Otherwise, the House could pass a new version and bounce it back to the Senate.

Democrats remained united in opposition, blasting the Senate bill as a tax break for the wealthy.

(Additional reporting by Yasmeen Abulateb, Amanda Becker, Eric Walsh, Susan Heavey and Tim Ahmann; Writing by Richard Cowan and Frances Kerry; Editing by Jeffrey Benkoe)


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