Wednesday, December 20, 2017

No Sweeteners Added To Tax Bill To Spread Use Of Health Savings Accounts

By Michelle Andrews
Kaiser Health News

The following article, originally published by Kaiser Health News, answers reader questions about the impact the tax bill could have on health insurance plans.

The ongoing uncertainty about congressional changes to the health law — and their impact on insurance and the online marketplaces — continues to raise questions among consumers. Here are answers to recent queries.

Q: Does the GOP tax bill affect health savings accounts?

At this time, there are no changes aimed specifically at HSAs. These are savings accounts linked to high-deductible plans and exempt from tax liability.
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Congressional Republicans have been very interested in expanding the use of these tax-free accounts, and bills to repeal and replace the Affordable Care Act last summer included provisions to increase the maximum amount people could contribute to them or to allow people to use them to pay their health insurance premiums, among other things.  The GOP promotes the plans as a way to help consumers play a larger role in controlling their health spending and says that the tax advantages help people afford care.

The GOP tax legislation doesn’t incorporate any of those changes, said Roy Ramthun, president of HSA Consulting Services.

Some analysts say it’s still possible that HSA changes could be attached to other pieces of legislation, such as a spending bill or a bill to extend the Children’s Health Insurance Program.

“The GOP would like to get some of these HSA expansion provisions into one of these bills,” said Dorian Smith, a partner at human resources consultant Mercer.

Q: Republicans are seeking to repeal the individual mandate as part of the tax bill. Would that go into effect next year? 

Probably not. The joint bill that House and Senate negotiators have agreed to doesn’t repeal the ACA’s requirement that most people have health insurance, called the individual mandate. But it does repeal the penalty for not having coverage. That change wouldn’t take effect until 2019, however.

So, assuming the bill is enacted, most people will face a penalty if they don’t have health insurance next year of the greater of 2.5 percent of household income or $695 per adult.

Many people, however, qualify for one of several exemptions to the mandate. Those include people who have suffered a hardship like eviction or bankruptcy and those whose earnings are low enough that health insurance is considered unaffordable.

In 2017, health insurance is considered unaffordable if the cheapest comprehensive coverage you can find would cost more than 8.16 percent of your household income.
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“Because premiums have gone up so high in 2017 and 2018, there will be more people who qualify for the affordability exemption,” said Timothy Jost, a professor emeritus of law at Washington and Lee University in Virginia who is an expert on health law.

If you’re pondering whether to “go bare” next year, it’s worth noting that the Internal Revenue Service won’t accept electronically filed returns unless you indicate whether you had coverage, an exemption or will pay the penalty.

Q: None of the marketplace plans in my area offer out-of-state coverage or any coverage for non-network providers. Why would an insurer limit what’s offered in that way?

Plans with broad provider networks have been steadily shrinking. Nearly three-quarters of plans sold on the ACA’s marketplaces in 2018 have restrictive networks, according to an analysis by the consulting firm Avalere Health. The percentage of such plans has steadily increased since 2015, when it was 54 percent, the analysis found.

Health maintenance organization (HMO) plans and exclusive provider organization (EPO) plans were categorized as restrictive because they typically have relatively fewer providers and don’t provide coverage for out-of-network care. Preferred provider organization (PPO) and point-of-service plans, on the other hand, were considered less restrictive because they generally have broader networks of providers and offer some out-of-network coverage.

The reason plans with restrictive networks are proliferating is because they help reduce costs, said Chris Sloan, a senior manager at Avalere.

“One of the ways to do that is to have a narrower network,” he said.

But there may be an upside for consumers. “It’s not just reducing costs for the sake of costs, it’s also to slow the premium growth,” he said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Tuesday, December 19, 2017

Don’t Let Influenza Interrupt Your Holiday Merriment

Influenza got a jump-start on Santa Claus this year — the deadly illness already is infecting Texans across the state, according to the Texas Department of State Health Services (DSHS). Texas physicians and DSHS want to remind everyone to protect themselves and their loved ones this holiday season by getting a flu shot. It’s not too late.

“Getting the flu vaccine is the most important thing you can do right now to help protect yourself from influenza,” said Dr. Jennifer Shuford, DSHS infectious disease medical officer. Vaccination is especially important for older adults, infants, pregnant women, and people with chronic health conditions because they are at greater risk of developing serious complications from the flu. Everyone 6 months of age and older should get a flu shot. To schedule a flu shot, contact your physician or visit texasflu.org.

In addition to the flu shot, DSHS and physicians say Texans can help prevent the spread of flu by washing their hands, covering coughs and sneezes, and staying home when they are sick.

Monday, December 11, 2017

Big Tobacco Finally Telling the Truth About Its Products

By Sid Roberts, MD
Lufkin Radiation Oncologist

This blog post was originally published Dec. 10 at the Lufkin Daily News and on the Angelina Radiation Oncology Associates blog.

There was some big, big news recently you probably haven’t heard. After years of legal wrangling, the tobacco industry not only has been found guilty of fraud, conspiracy, and racketeering, but also has been ordered to run television and newspaper ads admitting the truth it fought so hard to suppress for decades.

Let’s go back to the beginning. It was more than 50 years ago, in 1964, when Luther Terry, the ninth surgeon general of the United States, issued a landmark report linking smoking to lung cancer and a host of other diseases. Since that time, Big Tobacco lied, deceived, and in every way engaged in a no-holds-barred battle against every attempt to regulate or curtail the sale of tobacco products. In the meantime, tens of millions of U.S. citizens have died prematurely from tobacco use.

In 1999, the Department of Justice took on Philip Morris and other tobacco giants under the Racketeer Influenced and Corrupt Organizations Act, alleging the tobacco companies had engaged in a decades-long conspiracy to (1) mislead the public about the risks of smoking; (2) mislead the public about the danger of secondhand smoke; (3) misrepresent the addictiveness of nicotine; (4) manipulate the nicotine delivery of cigarettes; (5) deceptively market cigarettes characterized as “light” or “low-tar,” while knowing those cigarettes were at least as hazardous as full-flavored cigarettes; (6) target the youth market; and (7) not produce safer cigarettes.

Seven years later, in 2006, Federal District Court Judge Judy Kessler ruled that Philip Morris and other tobacco companies engaged in fraud, conspiracy, and racketeering — all to deliberately deceive the American public about the health risks of smoking and secondhand smoke. Her ruling noted that Big Tobacco had “marketed and sold their lethal product with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy or social costs that success exacted.” Judge Kessler ordered that these companies admit their guilt publicly by running newspaper and television ads detailing their deception.

It took 11 more years — and a lengthy appeal process — for Big Tobacco to finally agree to any sort of public mea culpa about the health effects of smoking and its role in addicting hundreds of millions of people. Its watered-down admissions of guilt (known in legal parlance as “corrective statements”) will appear in about 50 newspapers and for a year on major television networks.

One startlingly honest (and obvious) fact that must be publicized is that Altria, R.J. Reynolds Tobacco, Lorillard, and Philip Morris USA intentionally designed cigarettes to make them more addictive.

Think about that. At a time when we rightly are criticizing pharmaceutical companies for how they market pain medications (which actually have a therapeutic use), we still give a pass to the companies that market the most addictive, useless, and deadly product around.

At least Big Tobacco now must admit publicly that “more people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes and alcohol combined.”

Other statements you may see: “Many smokers switch to low-tar and light cigarettes rather than quitting because they think low-tar and light cigarettes are less harmful. They are not,” and “There is no safe level of exposure to secondhand smoke.” Sadly, we have known all of this for years; decades, even.


(One of the court-ordered ads warning of the dangers of tobacco.)

These ads started on Nov. 26, but I have yet to see one myself. I wonder if anyone who needs to see them will see them. Major newspapers and even television are not the way our vulnerable youth consume media these days. I am sure Big Tobacco is counting on that.

In the meantime, tobacco sales continue at a brisk pace. A Wall Street Journal article in April of this year noted that revenues for U.S. tobacco companies hit $117 billion in 2016, up from $78 billion in 2001, despite lawsuits, rising taxes, and declining smoking rates. Americans spent more than $90 billion on cigarettes in retail stores last year.

Stores that sell tobacco products today are complicit in the very deception that Big Tobacco is guilty of. The retail markup of tobacco products, according to the Wall Street Journal, is 17 percent, higher than that on groceries. No wonder grocery and convenience store chains put tobacco products front and center in their stores — or even out in front of their stores. Easy money. Dirty money.

The conservative/libertarian argument about supply and demand and “personal choice” is, pardon the pun, smoke and mirrors when people are knowingly addicted to the product in question. Cigarettes are not sugar water. I don’t mind companies making a profit — even obscene profits — as long as it isn’t by addicting us and killing us.

If nothing else comes from this mea culpa — these “corrective statements” — I hope tobacco and related products become so regulated and taxed that not only is it not possible to become addicted, but also it is too expensive for our youth to even consider starting. Nothing short of a world without tobacco will do. Perhaps that is a pipe dream, but our kids are worth it.

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin. He can be reached at sroberts@memorialhealth.org. Previous columns may be found at https://www.angelinaradiation.com/blog 

Friday, December 8, 2017

Old Medications a Potential Health Threat

Expired or unused prescription medications are a common sight in the medicine cabinet of a typical American home, but public health experts say leftover medications are an increasing health risk. A December Texas Medicine magazine article says patients who hold on to old prescription drugs might not understand the risk they pose for poisoning and misuse, but getting rid of old medications poses challenges too. The danger of keeping old medicine, or its improper disposal, is complex. If not disposed of correctly, medicine thrown in the trash or flushed down the toilet can eventually enter local waterways and hurt the environment. Yet teens and adults can abuse or misuse easily accessible medications in the home, experts say.

"Our medicine cabinets are the number one source of medications for teens to experiment [with] or abuse," said Jeanie Jaramillo-Stametz, PharmD, an assistant professor of pharmacy practice at Texas Tech University Health Sciences Center-Amarillo. "And there's a misperception by teens that it's better and safer to abuse a prescription medication than it is illicit drugs ― marijuana, heroin, cocaine ― when really these can be just as dangerous. Even regular non-narcotic prescriptions and over-the-counter medications can be abused and cause harm."

Old, unused prescriptions are a factor in the national opioid crisis. According to the 2013 National Survey on Drug Use and Health, 53 percent of people obtained opioids for nonmedical use from a friend or relative, 10.6 percent bought them from a friend or relative, and 4 percent stole them from someone they knew.

To confuse matters, in some cases, experts still advise flushing drugs away. For example, the Food and Drug Administration (FDA) says people should flush opioids like fentanyl because the drugs depress breathing in children who accidentally touch them.

Some participants in the health care system contribute to the problem of too many leftover drugs. Laredo gastroenterologist Sunny Wong, MD, who has worked with the Texas Medical Association (TMA) on effective ways to dispose of unused medicines, says many health insurance policies force patients to buy more medications than they need or know what to do with.

Pharmacist Dr. Jaramillo-Stametz agrees. "A lot of this is driven by the insurance industry," she said. "The physicians are doing what they can, and they're trying to provide their patient with the appropriate medication at the best rate that the patient would like. [The patients] want the $10 copay for a 90-day supply; they don't want the $10 copay for a 30-day supply. ... It's very difficult for [physicians] to manage all that and find a compromise where the patient will be happy without creating the problem of over-dispensing and accumulation."

"The cost of health care is going up," Dr. Wong said. "And one of the problems is the amount of drugs being given out ― whether they are used or not."

Federal and state agencies recommend disposing of medications at drop-off sites. But, currently, there is no all-inclusive program in Texas or at the national level that allow people to dispose of old medications at their convenience. There are some local options to drop off unused medicine across the state, including medication clean-out events Dr. Jaramillo-Stametz organizes in west Texas, but many Texans still do not have consistent options for safe drug disposal. Wong says disposing of old medications should be as easy as dropping mail in the mailbox. "The ideal situation for practices and patients is to [follow] the concept of a toner cartridge being shipped back to the manufacturer at no cost to the consumer," he said.

Dr. Jaramillo-Stametz says the best thing physicians can do now is educate themselves on ways to minimize the problem. "The physicians are doing what they can, and they're trying to provide their patient with the appropriate medication at the best rate that the patient would like. It's very difficult for [physicians] to manage all that and find a compromise where the patient will be happy without creating the problem of over-dispensing and accumulation."

Resources for Safe Drug Disposal:

Texas Medicine lists searchable websites to locate safe medicine disposal and drug take-back programs across Texas. In addition, local city and county government websites may also provide information on safe drug disposal.

To search local disposal sites, visit:



Tuesday, December 5, 2017

States — And 9M Kids — ‘In A Bind’ As Congress Dawdles On CHIP Funding

By Ashley Lopez, KUT and Selena Simmons-Duffin, NPR

Last week, Colorado became the first state to notify families that children who receive health insurance through the Children’s Health Insurance Program are in danger of losing their coverage.

Nearly 9 million children are insured through CHIP, which covers mostly working-class families. The program has bipartisan support in both the House and Senate, but Congress let federal funding for CHIP expire in September.

The National Governors Association weighed in Wednesday, urging Congress to reauthorize the program this year because states are starting to run out of money.

In Virginia, Linda Nablo, an official with the Department of Medical Assistance Services, is drafting a letter for parents of the 66,000 Virginia children enrolled in CHIP.

“We’ve never had to do this before,” she said. “How do you write the very best letter saying, ‘Your child might lose coverage, but it’s not certain yet. But in the meantime, these are some things you need to think about’?”

Children may be able to enroll in Medicaid, get added to a family plan on the Affordable Care Act’s health exchange or be put on an employer health plan. But the options vary by state and could turn out to be very expensive.

If Congress reauthorizes CHIP funding, states are in the clear. But they can’t bank on it yet, and states have to prepare to shut down if the funding doesn’t come through. Virginia would have to do so on Jan. 31.

“We’re essentially doing everything we would need to shut down the program at the end of January,” Nablo said. “We’ve got a work group going with all the different components of this agency, and there are many.”

For example, they will need to reprogram their enrollment systems, inform pediatricians and hospitals, and train staff to deal with an onslaught of confused families.

Joan Alker, who runs the Georgetown University Center for Children and Families, said most states need to give families 30 days’ notice.

“But [state officials] are hearing rumors that Congress might get this done in the next couple of weeks, and they don’t want to scare families,” she said. “States are really in a bind here. It’s very tough to know what to do.”

Colorado was the first to send out a notice, and other states are close behind. There are a handful that are starting to run out of money in December, Alker said, such as Oregon, Minnesota and the District of Columbia.

The exact deadline for when CHIP funding runs out in each state is tricky to calculate, because the amount of money each has depends on how fast a state spends it — and how much stopgap help the federal government gives them.

Some states are getting creative. Oregon just announced it will spend state money to keep CHIP running, said Alker, “and they’re assuming that Congress will pass it and they’re get reimbursed retroactively. That’s what they’re hoping.”

Texas is set to run out of CHIP funds a lot sooner than was expected just a few months ago. And there’s a big reason for that: Hurricane Harvey, said Laura Guerra-Cardus with the Children’s Defense Fund in Austin.

“Natural disasters are often a way that individuals that never had to rely on programs like Medicaid and CHIP need them for the first time,” she said.

Guerra-Cardus said that after Harvey a lot of new families enrolled in CHIP and that there was also a higher demand for services. “When there is such a traumatic event, health care needs also rise. There’s been a lot of post-traumatic stress in children,” she said.

And to help those families out, Texas officials also waived fees they usually have to pay to join CHIP. So, lately there’s been less money coming in and more money going out. Like Virginia, without reauthorization, Texas would have to shutter CHIP by the end of January.

For Amy Ellis in Alpine, Texas, that’s something she’s dreading. “Losing a lot of sleep,” she said. “Still losing a lot of sleep.”

Ellis has an 8-year-old daughter who has been on CHIP since she was born. The girl has asthma and allergies, Ellis said, and health insurance is really important because her family doesn’t make a lot of money. Her daughter’s allergy medicine is expensive.

Ellis lives in rural West Texas, nearly four hours southeast of El Paso and “three hours from the closest city,” she said.

The isolation means that Ellis doesn’t have many options other than CHIP, she said. One would be enrolling her daughter in the insurance plan she and her husband have through the Affordable Care Act marketplace, but Ellis said that would be expensive.

“It would cost $300 to $400 a month for us to add her to our plan, which would be a huge chunk of our income,” she said. “That’s our grocery money and our gas money.”

A lot of families in Texas could find themselves in the same situation if Congress doesn’t act soon, said Guerra-Cardus. “Kids with chronic or special health care needs, this is going to turn their lives absolutely upside down.”

Roughly 450,000 children are covered by CHIP in Texas. Officials say they are asking the federal government to give them money that will keep CHIP alive through February.

But because officials must give families 30 days’ notice if the program will end, families in Texas could get letters right around Christmas that say their children are losing their health insurance.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s All Things Considered, currently on an exchange with Washington, D.C. member station WAMU.

Friday, December 1, 2017

PrEP Can Prevent the Spread of HIV

By M. Brett Cooper, MD
Houston Pediatrician/Adolescent Medicine Fellow

39,513. That is the estimated number of new HIV diagnoses in the United States in 2015, ac-cording to the Centers for Disease Control and Prevention (CDC). Although the number of new diagnoses fell nine percent from 2010-2014, certain populations remain most at risk, particularly men who have sex with men and IV drug users. These two groups together accounted for three-quarters (76 percent) of new diagnoses in 2015. With advances in HIV care, these numbers can be reduced even further. One of these medical advances is HIV pre-exposure prophylaxis (PrEP). PrEP is an oral medication taken once daily to prevent HIV infection. Truvada® is currently the only FDA-approved medication for use in patients aged 18 and older. When used in combination with other risk-reduction measures, PrEP can be more than 90 percent effective at reducing the risk of HIV infection when taken daily as prescribed. Both patients and physicians can help in-crease awareness and use of PrEP hopefully to achieve the goal of “Getting to Zero” new infec-tions. Here are some tips for patients and physicians.

Patients:
Even if your physician does not discuss your sexual history with you, empower yourself to speak up. If you frequently engage in condomless vaginal or anal sex and/or have sex under the influ-ence of drugs or alcohol, ask your physician about PrEP. PrEP may also be a good option for you if you are in a sexual relationship with a partner who is HIV positive. Ensure that you are tested for HIV and other sexually transmitted infections at least once per year. If you are concerned about the cost of PrEP, or you do not have insurance, do not worry. The manufacturer of the medication has a patient-assistance program that may make the medication free, depending on your income.

Physicians and other health care providers:
The CDC has developed a guide for clinicians to help them identify which patients would be good candidates to screen for PrEP. In order to identify at-risk patients, physicians should take a sexual history for every patient at least once per year. This includes what sites are used for inter-course, the gender of one’s partners, whether condoms are used, and whether intercourse takes place under the influence of substances. Admittedly, this can be an uncomfortable topic for many physicians to discuss. However, your patients may be just as uncomfortable initiating this conver-sation with you. In addition, all sexually active patients should receive an HIV screening test at least once per year, including adolescents. For those patients who screen negative and are at risk, providers can discuss PrEP and other risk reduction measures. For patients who screen positive, they should be promptly referred for treatment.

As we celebrate the 30th World AIDS Day today, let us not forget those patients whose lives were claimed by HIV/AIDS. PrEP and other HIV risk-reduction methods can bring us ever clos-er to the goal of zero new infections. Prompt identification of those who are HIV positive and referral to treatment can bring their viral loads (the amount of HIV in a person’s blood) to unde-tectable levels, effectively giving those patients no risk of transmitting the virus to others. With physicians and patients working together, we will one day be able to raise an AIDS-free genera-tion.

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