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You Can Buy Insulin Without A Prescription, But Should You?

Carmen Smith now gets the insulin she needs via her doctor's prescription. When she lacked health insurance, buying a version of the medicine over the counter was cheaper, she says. But it was hard to get the dose right.
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Carmen Smith now gets the insulin she needs via her doctor’s prescription. When she lacked health insurance, buying a version of the medicine over the counter was cheaper, she says. But it was hard to get the dose right. Lynn Ischay for NPR hide caption

toggle caption Lynn Ischay for NPR

As anyone with diabetes can tell you, managing the disease with insulin usually means regular checkups at the doctor’s office to fine-tune the dosage, monitor blood-sugar levels and check for complications.

But here’s a little known fact: Some forms of insulin can be bought without a prescription.

Carmen Smith did that for six years when she didn’t have health insurance and didn’t have a primary care doctor. She bought her insulin without a prescription at Wal-Mart.

“It’s not like we go in our trench coat and a top hat, saying, ‘Uh I need the insulin,’ ” says Smith, who lives in Cleveland. “The clerks usually don’t know it’s a big secret. They’ll just go, ‘Do we sell over-the-counter insulin?’ “

Once the pharmacist says yes, the clerk just goes to get it, Smith says. “And you purchase it and go about your business.”

But it’s still a pretty uncommon purchase.

Smith keeps the tools for controlling her diabetes in this kit, which contains metformin, syringes, fast-acting insulin for daytime use and slow-release for overnight.

Smith keeps the tools for controlling her diabetes in this kit, which contains metformin, syringes, fast-acting insulin for daytime use and slow-release for overnight. Lynn Ischay for NPR hide caption

toggle caption Lynn Ischay for NPR

Smith didn’t learn from a doctor that she could buy insulin that way. In fact, many doctors don’t know it’s possible. When she no longer had insurance to help pay for doctors’ appointments or medicine, Smith happened to ask at Wal-Mart if she could get vials of the medicine without a prescription. To figure out the dose, she just used the same amount a doctor had given her years before.

It was a way to survive, she says, but no way to live. It was horrible when she didn’t get the size of the dose or the timing quite right.

“It’s a quick high and then, it’s a down,” Smith says. “The down part is, you feel icky. You feel lifeless. You feel pain. And the cramps are so intense — till you can’t walk, you can’t sit, you can’t stand.”

Smith says her guesswork put her in the emergency room a handful of times over the years.

The availability of insulin over the counter presents a real conundrum. As Smith’s experience shows, without training or guidance from a health care provider, it can be dangerous for a patient to guess at the best dosage and timing from version to version of insulin. On the other hand, being able to afford and easily buy some when she needed it may have saved her life.

There are two types of human insulin available over the counter; one made by Eli Lilly and the other by Novo Nordisk. These versions of the medicine are older, and take longer to metabolize than some of the newer, prescription versions; they were created in the early 1980s, and the prices range from more than $200 a vial to as little as $25, depending on where you buy them.

Dr. Jorge Calles, an endocrinologist at MetroHealth, Cleveland’s public hospital, is alarmed to think that some people are self-medicating with any sort of insulin.

“It’s a very serious situation if they are selling it over the counter — without any control with a prescription, specifically,” Calles says.

According to the medical consulting firm IMS Health, about 15 percent of people who buy insulin in the growing U.S. diabetes market purchase it over the counter without a prescription.

The U.S. Food and Drug Administration declined multiple requests by NPR for an interview on this topic. But, in an email, an FDA representative said that the versions of insulin now available over the counter were approved for sale that way because they are based on a less concentrated, older formulation, “that did not require a licensed medical practitioner’s supervision for safe use.”

The broader availability of this form of insulin allows patients with diabetes to obtain it “quickly in urgent situations, without delays,” the FDA says, and is intended to increase patient safety.

Still, some people with diabetes, as well as some doctors, doubt that the benefits of that greater availability outweigh the risks, especially for patients who switch from one type of insulin to another without telling their doctor.

“This is not something that should be done without the help of a professional,” says David Kliff, who has Type 1 diabetes and writes the Diabetic Investors blog. Kliff has followed and written about the expanding business of diabetes for years.

FDA officials are “basically sticking their heads in the sand” on this issue, Kliff says, and making a lot of assumptions.

“They look at insulin as a drug,” he says, “and say, ‘There’s this enormous body of evidence that shows that the drug is safe.’ But, you know, there’s a little asterisk at the end there. What the little asterisk basically says is: ‘You know, that’s assuming that the patient is trained on it.’ “

When asked about safety concerns, the FDA told NPR that the agency welcomes more research into the safety of over-the-counter insulin.

One state does require prescriptions for all insulin. Dr. Kevin Burke, a health officer for Clark County, Ind., led the effort to require prescriptions in his state.

“I didn’t realize that insulin was over the counter in Indiana until two of my patients, who were in good control, suddenly had increased glucoses,” Burke says. He asked them if they had changed their diet, lost weight, altered their workout routines. They had not.

“They both admitted that they had decided to switch to over-the-counter insulin,” Burke says, “which was different from what I had prescribed.”

Over time, taking the wrong dosages destroys your body, Burke says. Poorly managed diabetes is the cause of a host of complications, such as high blood pressure, kidney disease, nerve damage, loss of eyesight and stroke.

Burke says he took his concerns to the American Medical Association. But the national doctor’s association told him there are no data showing that the drug’s over-the counter availability is a public health hazard. In fact, the AMA’s board noted, getting insulin without a doctor’s prescription may be an important way for some insulin-dependent patients to get access to the medicine they need.

Dr. Todd Hobbs is chief medical officer of Novo Nordisk in North America, which makes Novolin, one of the two versions of insulin sold over the counter. His company partners with Wal-Mart to sell its version under the brand name ReliOn. (Wal-Mart declined to be interviewed for this story.)

Hobbs says Novo Nordisk’s version of insulin is for people who don’t have insurance, or who have to pay a lot for their other prescriptions — “people who just, for whatever reason, have fallen through the cracks and either don’t have insurance coverage at the time or are without coverage.”

With ever-rising copays and premiums, he says, many patients are turning to nonprescription insulin because it’s cheaper and all they can afford.

“But we hope to try to help them to not have to do that,” Hobbs says.

“We clearly think the newer versions are more close to what the body would do on its own,” he says. The prescription versions are better and safer, he agrees, because they make it easier for patients to avoid wild fluctuations in blood sugar.

Carmen Smith doesn’t blame the insulin she was taking for her emergency room visits.

“Insulin is not the problem,” she says. “It is getting the insulin that is the problem. Once I got connected with my physician, life as a diabetic got a lot less complicated for me.”

Smith is now on Medicaid. She has a doctor — and a prescription for one of the newer generations of insulin.

This story is part of NPR’s reporting partnership with WCPN ideastream and Kaiser Health News.

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Today in Movie Culture: 'Star Wars: Episode VI – Return of the Jedi' Edition

Here are a bunch of little bites to satisfy your hunger for Star Wars movie culture:

We’re counting down the days to the release of Star Wars: The Force Awakens by devoting a week’s worth of movie culture roundups to the seven live-action installments of the Star Wars Saga, continuing today with the third installment (sixth episode), Return of the Jedi, and further in release order through next Thursday.

See More Star Wars Movie Culture:

Star Wars: Episode IV – A New Hope
Star Wars: Episode V – The Empire Strikes Back

Classic Trailer of the Day:

The first teaser for the second Star Wars sequel arrived in 1982 with a different title: Revenge of the Jedi. Watch the preview below, and check out the redone version with the final title here.

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Alterations of the Day:

Return of the Jedi has arguably the most controversial changes from its original form to the 1997 Special Edition on onward post-prequels. Here is a video showing every change between 1983 and 2011:

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Alternative Movie Poster of the Day:

Tim Anderson’s design for a Return of the Jedi poster is one of the best minimal yet representative fan-made works there is:

Film Analysis of the Day:

Earthling Cinema takes a humorous approach to analyzing the plot of Return of the Jedi from the point of view of aliens from our future:

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Scene Analysis of the Day:

Film Theorists examines the final duel between Luke Skywalker and Darth Vader with focus on its story beats — or “screenwriting mind tricks”:

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Movie Mashup of the Day:

Years before Disney bought Lucasfilm and Star Wars, fan artist Francesco Francavilla gave us this crossover between Winnie the Pooh and the Ewoks:

Movie Trivia of the Day:

ScreenCrush tests your knowledge of Return of the Jedi with the following 15 facts:

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Vintage Image of the Day:

“Are you kidding me with this outfit?” Carrie Fisher seems to be asking of George Lucas, who seems to be replying, to his audience, “You’re welcome.”

Cosplay of the Day:

Speaking of the slave Leia costume, it’s now a huge part of cosplay, but the best Return of the Jedi costume of all time is this Rancor, which made its debut at Comic-Con last summer:

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Movie Takedown of the Day:

How It Should Have Ended took on a few of Return of the Jedi‘s plot holes, including that big one where the Empire didn’t make sure the second Death Star couldn’t be easily destroyed, too.

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Atlanta Is Setting Its Storied Neighborhood Bar — In High Resolution

Secret Service personnel man the roof of Manuel's Tavern in Atlanta, where President Barack Obama had an interview on March 10.
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Secret Service personnel man the roof of Manuel’s Tavern in Atlanta, where President Barack Obama had an interview on March 10. Brendan Smialowski/AFP/Getty Images hide caption

toggle caption Brendan Smialowski/AFP/Getty Images

Exploring the maze-like layout of Manuel’s Tavern is like walking through a museum. And, like museums, the bar is up for its first facelift since it opened nearly 60 years ago, meaning it will close down for several months.

“Not much in this room has changed at all since 1956,” says Brian Maloof, the youngest son of the bar’s original owner.

Brian Maloof took over Manuel’s Tavern after his father, Manuel Maloof, a well-known Atlanta Democrat, died in 2004. Now he’s leading it through a challenging time.

In the narrow room where the tavern started, he points to a nude painting on the wall.

“The artist that painted that picture, that’s his wife,” he says. “He would pay off his bar tabs by leaving us paintings.”

Above the bar stools, Maloof points out a dozen or so plaques that belong to regulars who once took those seats as regulars.

He then gestures to a doorway behind the bar, to an urn. The four urns here, all the photos, posters and other mementos put up by staff and customers will have to come down.

“The renovation has been a very scary thing,” Maloof says.

“Essentially all the people that love this place, know this place, I’m rearranging their furniture in their home. I mean, they think of this place as their home,” he says.

Many people have called him, worried their contributions will be lost, or even just moved.

So when Georgia State University lecturer, Ruth Dusseault approached him about preserving it all digitally, he was relieved.

In a back room at the tavern, Dusseault uses a special camera to take high resolution images.

“The idea really started, because I’m also a resident of the neighborhood and every time I’ve come here, I’ve walked around and looked at all the images,” she says.

Her idea turned into a project that involves professors, artists and students, who are digitally archiving hundreds of objects and the stories behind them, explain Dusseault and Emory University’s Michael Page.

“The end result will be an interactive website, where the public can move around inside of Manuel’s,” says Dusseult.

“And as they see pictures on the walls, they can click on it, and then they get a high resolution photograph of the image but they can also click and get user stories or the story about, you know, the John F. Kennedy photo or Jimmy Carter, just some of the rich history that’s on the walls of Manuel’s,” Page says.

Sure, the objects in the archive speak to the bar’s role as a Democratic hangout, but also as a cop bar, a hub for professors and a meeting place for journalists.

Sitting in a booth, eating lunch is Andy Klubock. In a rapidly-changing city, he says, the tavern’s images are a view into the past.

“I’ve been coming here since ’77,” he says. “I could probably tell you how each picture is there. It’s a great sense of history here in Atlanta.”

Manuel’s Tavern will still be different after the renovation. But now, at least, Brian Maloof says he can make sure all the objects go back to their original place.

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Alabama Running Back Derrick Henry Wins Heisman Trophy

Running back Derrick Henry of the Alabama Crimson Tide speaks after being named the 81st Heisman Memorial Trophy Award winner Saturday in New York City.

Running back Derrick Henry of the Alabama Crimson Tide speaks after being named the 81st Heisman Memorial Trophy Award winner Saturday in New York City. Kelly Kline/Getty Images hide caption

toggle caption Kelly Kline/Getty Images

Alabama running back Derrick Henry has taken home this year’s Heisman Trophy.

Henry led the nation in rushing yards and rushing attempts, among other noteworthy stats, the Heisman Web site notes:

“The 6-3, 242-pounder from Yulee, Fla., set an SEC single-season-record in 2015 with 1,986 rushing yards. He also tied the conference mark for rushing touchdowns with 23.”

In one game against Auburn, Henry notched 46 carries for 271 yards — a career best in both, the Heisman site says.

The award site shared a video of Henry’s highlights from that game:

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YouTube

Although Alabama is a college football powerhouse, Henry is only the second Crimson Tide player to win a Heisman. The first was Mark Ingram, in 2009; Ingram was also the most recent running back to win the trophy.

Henry’s margin of victory was narrower than recent Heisman winners’, the Associated Press notes, but the contest wasn’t quite a squeaker. The Crimson Tide star had 1,892 points — 293 more points than second-place finisher Christian McCaffrey, a Stanford running back with the NCAA record for all-purpose yards in a season.

Clemson quarterback Deshaun Watson came in third.

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Today in Movie Culture: 'Star Wars: Episode V – The Empire Strikes Back' Edition

Here are a bunch of little bites to satisfy your hunger for Star Wars movie culture:

We’re counting down the days to the release of Star Wars: The Force Awakens by devoting a week’s worth of movie culture roundups to the seven live-action installments of the Star Wars Saga, continuing today with the second episode, The Empire Strikes Back, and further in release order through next Thursday.

See More Star Wars Movie Culture:

Star Wars: Episode IV – A New Hope

Classic Trailer of the Day:

The first trailer for The Empire Strikes Back arrived in 1979, promoting a sequel that would hit theaters the following summer. Watch it below.

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Movie Remake of the Day:

With approval of Lucasfilm, 480 fans got to contribute to this shot-for-shot remake of The Empire Strikes Back, each taking on a different scene in a different style:

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Sweded Scene of the Day:

Watch a homemade re-creation of the Hoth battle from The Empire Strikes Back, complete with a capella score:

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Alternative Movie Poster of the Day:

Some of the most well-known Mondo posters for any movie are Olly Moss’s Star Wars triptych. Below is the design for The Empire Strikes Back, which cleverly uses Cloud City to form part of Boba Fett’s helmet. See the other two here.

Movie Parody of the Day:

How It Should Have Ended took on The Empire Strikes Back five years ago, focusing on the iconic reveal that Darth Vader is Luke Skywalker’s father:

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Movie Scene Remix:

This re-edit of a brief moment from The Empire Strikes Back turns Darth Vader into an even bigger jerk:

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Cosplay of the Day:

By the time The Empire Strikes Back rolled into theaters, fans were already attending conventions in costume. But this duo dressed as Princess Leia (Bespin outfit) and Yoda must have seen the sequel before attending Westercon in the summer of 1980.

Movie Trivia of the Day:

Think you’re a master of Star Wars trivia? Then knew everything in the following video of The Empire Strikes Back facts you did:

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Vintage Image of the Day:

Kermit the Frog and Miss Piggy visit the set of The Empire Strikes Back in 1979 to meet their new Muppet friend, Yoda. Also in the photo are Yoda puppeteers Frank Oz and Kathryn Mullen, Muppets creator Jim Henson, Empire director Irvin Kershner and producer Gary Kurtz.

Movie Takedown of the Day:

Everyone thinks The Empire Strikes Back is not only the greatest Star Wars movie but one of the best movies of all time. So, here’s CinemaSins with everything wrong with the sequel:

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and

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Post-Bankruptcy, A Booming Detroit Is Still Fragile

Detroit, after having billions of dollars of debt erased through bankruptcy, has emerged with a razor-thin financial cushion.
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Detroit, after having billions of dollars of debt erased through bankruptcy, has emerged with a razor-thin financial cushion. Laura McDermott/Bloomberg via Getty Images hide caption

toggle caption Laura McDermott/Bloomberg via Getty Images

It’s been a year since Detroit emerged from the nation’s largest-ever municipal bankruptcy. The city has made strides in improving services, is enjoying a construction boom and, unencumbered by the billions of dollars of debt erased through bankruptcy, just gave the underpaid police force a raise before their contract is up.

“I want to get the bankruptcy behind us. We have to move this forward. It’s no longer the Motor City like it used to be. It’s no longer Motown. But we can write a new history,” said Mark Young, head of one of the city’s police unions, at a recent news conference about the police force raise.

Nevertheless, Detroit is walking a financial tightrope.

Detroit emerged from bankruptcy with a razor-thin financial cushion, where even being a few million dollars off in its billion-dollar general fund budget could trigger another fiscal collapse. Detroit Mayor Mike Duggan says even with the state having final say, the city is still making substantial progress.

“We have almost 90 percent of the lights in this city replaced. We have a full contingent of buses and the ambulances are arriving within eight or nine minutes, which is the national standard.”

But some financial analysts say Detroit’s bankruptcy has made the national bond markets leery of loaning money to any municipality.

Stephen Spencer represented Detroit’s major bondholders. He testified at a recent U.S. Senate hearing that the bankruptcy court allowed Detroit to pay far more of what it owed to city retirees than to bondholders.

“Detroit wasn’t a bankruptcy. It was a stick up,” Spencer said.

Yet even those who Spencer claims received preferential treatment say they don’t feel favored at all.

Fear Of Two Cities

Some city retirees lost a portion of their monthly pension payments, all the savings the city had invested for them and their health care benefits. Now retirees like Sheila Baker say they’re paying five times more for health insurance while the city’s downtown is booming with new construction.

“All of a sudden you got money in your pocket? They knew what they were doing,” she says. “You know, it’s all just a racket — literally — and they waited till we were older to do this to us? It is just unbelievable to me.”

New development is erupting downtown. There’s a new hockey arena complex and a new light rail line.

Construction continues on Orleans Landing, a housing development along the Detroit riverfront. A year after its exit from bankruptcy, new development is booming downtown.

Construction continues on Orleans Landing, a housing development along the Detroit riverfront. A year after its exit from bankruptcy, new development is booming downtown. Carlos Osorio/AP hide caption

toggle caption Carlos Osorio/AP

Trying to walk through a maze of construction at a downtown park, Detroiter Paul Garrison calls the efforts a godsend.

“Bankruptcy, in my perspective and opinion, was 10 years overdue. But fortunately it did finally take place,” he says, “and so the money the city is bringing in will not have to all go to debt.”

But only a few blocks away, at Detroit’s major transit center, bus rider James Jordan says he’s yet to see the new development touch the city’s outer-lying neighborhoods.

“OK, they’re opening a Nike shop. But you never hear about a new housing development or a new grocery store being built in the heart of the neighborhood.”

For their part, business leaders say Detroit cannot survive by becoming, in essence, two cities: one of haves and one of have nots.

Detroit-based businessman and auto racing legend Roger Penske is helping redevelop the city’s downtown. He says Detroit’s success depends on making it a city people want to live in.

“I’m gonna be sure it’s not two cities,” Penske says.

City officials are tearing down tens of thousands of blighted buildings and offering cut-rate prices to those who will move in and fix up salvageable homes. But Detroit still needs more jobs and a better school system.

If efforts to make those improvements fail, Detroit’s fragile financial forecast could again falter.

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Best of the Week: Golden Globe Nominations, New 'X-Men' and 'Teenage Mutant Ninja Turtles' Trailers and More

The Important News

Marvel Madness: Doctor Strange dropped some beautiful concept art. Cate Blanchett is joining the MCU for Thor: Ragnarok.

Star Wars Mania: Fans were assured Jar Jar Binks will not be in Star Wars: The Force Awakens. George Lucas briefly reviewed Star Wars: The Force Awakens. Carrie Fisher’s daughter honors her heritage in Star Wars: The Force Awakens. J.J. Abrams wants Ava DuVernay to direct a Star Wars movie.

Casting Net: Josh Hutcherson joined James Franco’s The Disaster Artist. Bill Murray will play a dog in Wes Anderson’s next stop-motion film. Idris Elba might play the Gunslinger in The Dark Tower series.

Franchise Fever: Lionsgate is seriously considering Hunger Games prequels. Will Smith might return as Deadshot in a solo Batman movie.

Sequelitis: Trainspotting 2 is finally due in 2017. Quentin Tarantino teased Kill Bill Vol. 3 again.

Remake Report: Sofia Boutella might play the monster in The Mummy.

Box Office: Krampus is a holiday horror hit.

Reel TV: Abigail Breslin will star in a TV musical remake of Dirty Dancing.

Festival Fare: The 2016 Sundance Film Festival announced its big premieres.

Awards Seasoning: The SAG Awards nominations were announced. And the Golden Globes nominations were announced.

Celebrating the Classics: The Shining and other classic movies are returning to theaters in 2016.

The Videos and Geek Stuff

New Movie Trailers: X-Men: Apocalypse, The BFG, Teenage Mutant Ninja Turtles: Out of the Shadows, The Legend of Tarzan, Godzilla: Resurgence, Kubo and the Two Strings, The Brothers Grimsby, Mojave and Crouching Tiger, Hidden Dragon: Sword of Destiny.

Movie Clips: Indigenous.

Behind the Scenes: Scouts Guide to the Zombie Apocalypse.

Watch: A video counting down the 25 best movies of 2015.

See: What President Obama picked as his favorite movie of 2015.

Learn: Which Star Wars: The Force Awakens character was cast as a different genre than intended. And why Bill Nye likes Star Trek better than Star Wars.

See: A roundup of fun stuff related to the original Star Wars.

Watch: Fans react to The Phantom Menace back in 1999.

See: How NASA already has TIE Fighters and droids like those in Star Wars.

Watch: Michael B. Jordan gets completely knocked out shooting Creed.

See: How you can live like a Hobbit.

Watch: A musical mashup remix of Christmas movies.

See: The best new movie posters of the week. And a Nightcrawler (X-Men) Mondo poster. And a poster that brings Spaceballs into the Star Wars: The Force Awakens festivities.

Our Features

Comic Book Movie Guide: We break down the rumors about the next Batman movie.

Geek Movie Guide: What movie geeks need to see, read and buy this month.

Movie List: Movies that taught us that the ocean sucks.

Movie Memories: We remember when Johnny Depp first got weird for Edward Scissorhands. And we remember when Master and Commander: Far Side of the World became the best seafaring movie ever.

Adaptation Guide: See which of today’s most popular books are being turned into movies.

Home Viewing: Here’s our guide to everything hitting VOD this week. And here’s our guide to the best indie and foreign films on DVD and Blu-ray this month.

and

MORE FROM AROUND THE WEB:

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Industrial Giants DuPont, Dow Chemical Announce $130 Billion Merger

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Two of America’s oldest and most important industrial companies are tying the knot. DuPont and Dow Chemical plan to merge in a $130 billion deal that would create an agricultural and chemicals powerhouse. If the deal is approved, the new company would be split into three separate businesses — agriculture, materials and specialty products.

Transcript

KELLY MCEVERS, HOST:

Two giants of American industry say they are merging in a deal worth $130 billion. NPR’s Jim Zarroli reports that Dow Chemical and DuPont have both been under intense pressure from shareholders to do something about sagging profits.

JIM ZARROLI, BYLINE: The new company will be called Dow DuPont. Within the next couple of years, it will be broken up into three separate companies for agriculture, material science and specialty products. Officials are hoping the new companies will be leaner and more focused. Emilie Feldman is an assistant professor of management at the Wharton School.

EMILIE FELDMAN: Right now you have these big, sprawling companies that are doing lots of different things not very well, and so they’re going to slim themselves down and each do things well that they can focus on.

ZARROLI: Dow and DuPont are both venerable names in American industry. Dow introduced Saran Wrap and Ziploc Bags. DuPont invented Teflon for cookware and Kevlar for bulletproof vests. But the companies have been hard-hit by the slowdown in global growth and the drop in commodity prices. Both have fallen under intense pressure from shareholder activists who wanted to see them broken up and reorganized. DuPont CEO Edward Breen, who will keep the same title in the new company, says the deal announced today will be much better for shareholders.

(SOUNDBITE OF ARCHIVED RECORDING)

EDWARD BREEN: I mean, we looked at every possibility, analyzed every one financially. There’s nothing that financially compares to the value creation for a DuPont shareholder.

ZARROLI: Breen spoke on CNBC. Like all big mergers, this one will have to be approved by regulators who will decide whether it hurts competition. Company officials say they’re not expecting a lot of problems. While Dow and DuPont are the two biggest U.S. chemical companies, they are in a global market and face plenty of foreign competition. They also don’t tend to compete in many of their biggest product lines. Still, federal regulators have been more skeptical of big mergers lately, and this one is likely to face a lot of scrutiny. Jim Zarroli, NPR News, New York.

Copyright © 2015 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by a contractor for NPR, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of NPR’s programming is the audio.

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California Expands Substance Abuse Treatment For Low-Income Residents

After years fighting a heroin addiction, Danny Montgomery, 33, is receiving inpatient treatment that is being paid for by Los Angeles County.

After years fighting a heroin addiction, Danny Montgomery, 33, is receiving inpatient treatment that is being paid for by Los Angeles County. Anna Gorman/KHN hide caption

toggle caption Anna Gorman/KHN

California is overhauling its substance abuse treatment system for low-income people, embarking on a massive experiment to create a smoother path for addicts from detox through recovery.

The state is the first to receive federal permission to revamp drug and alcohol treatment for beneficiaries of Medicaid, known as Medi-Cal in California. Through what’s known as a drug waiver, state officials will have new spending flexibility as they try to help people get sober and reduce social and financial costs of people with substance abuse disorders.

Under the waiver, the state plans to expand treatment services, including inpatient care, case management, recovery services and added medication. Beginning next year, drug treatment centers will be able to get reimbursed for providing this much wider range of options to people on Medi-Cal.

Only a small fraction of low-income Californians with substance abuse disorders receive treatment, largely because of restrictions on what Medicaid will pay for.

“This was a long time coming,” said Keith Lewis, executive director of Horizon Services, which provides treatment in San Mateo, Santa Clara and Alameda counties. “It’s a win/win for people with substance use issues and their families … and for the people providing those services.”

The changes, which will be phased in starting next year, stem in part from the Affordable Care Act, which required that substance abuse treatment be covered for people newly insured through Medicaid or insurance exchanges. The health law allowed states to expand Medicaid to cover millions more people.

Drug rehabilitation providers say the changes will give addicts a better chance at getting — and staying — clean. But they fear the state won’t raise the traditionally low Medi-Cal reimbursement rates for treatment, making it harder to provide services and produce the outcomes California is hoping for.

Lewis, of Horizon Services, said that under the waiver he expects drug treatment services to be higher quality and the workforce better trained. But he said that “Medi-Cal rates, which have always been too low, have to go up.”

California’s Medi-Cal drug treatment program currently costs about $180 million annually, paid through a combination of state and federal funds. There aren’t any estimates for costs under the new approach. But the idea is that the changes will help health care expenses overall by enabling more people to get sober and healthier so they stop rotating through treatment centers, jails and hospitals.

Nearly 14 percent of Medicaid recipients are believed to have a substance abuse disorder, according to the National Survey on Drug Use and Health.

The five-year pilot project in California was approved by the federal Centers for Medicare & Medicaid Services in August. Under the waiver, counties will approve treatment for Medi-Cal patients based on medical necessity and criteria established by the American Society of Addiction Medicine.

The Tarzana Treatment Centers in Los Angeles County provide outpatient and inpatient care for substance use disorders.

The Tarzana Treatment Centers in Los Angeles County provide outpatient and inpatient care for substance use disorders. Anna Gorman/KHN hide caption

toggle caption Anna Gorman/KHN

Current federal rules limit drug treatment centers’ ability to get reimbursed under Medicaid for residential care. Clinics with more than 16 beds essentially cannot get paid, except for treating pregnant and postpartum women. That restriction will be dropped for California under the waiver.

As a result, Medi-Cal beneficiaries will be able to access up to two 90-day residential stays each year, with the possibility of one 30-day extension if providers determine that it is medically necessary. Certain populations, including those in the criminal justice system, can get approval for longer stays.

The waiver is also designed to provide better coordination between physical, mental health and substance abuse services,” according to John Connolly, deputy director of substance abuse prevention and control for the Los Angeles County Department of Public Health. That along with more access could result in fewer emergency room visits and hospitalizations, he said.

That’s potentially good news for people like Caitlin Knoles, a resident of Orange County who says she gets turned down for treatment of her methamphetamine addiction every time she tells residential centers she’s on Medi-Cal. She has ended up in the hospital more than once because of her addiction.

“It’s hard,” Knoles said. “I can’t get help.”

The only way she can reliably get clean now is in jail, she says.

“It’d be nice to have a job and have my family back and just be normal,” said Knoles, 24, as she sat outside a liquor store in Laguna Hills.

For the first time, substance abuse disorders will be treated like a disease rather than a short-term illness, said Marlies Perez, chief of the substance use disorder compliance division for the state Department of Health Care Services. “Even though we know it’s a chronic condition, we have treated it acutely,” she said.

Much depends, however, on reimbursement rates, which are still being negotiated. Clinic officials say they need higher rates to expand services and handle the anticipated influx of clients, many of whom will be seeking rehab for the first time.

“There is a cost to raising the bar on treatment,” said Albert Senella, president of the California Association of Alcohol and Drug Program Executives. “If the rates aren’t adequate … we are not going to be able to effectively meet the [new requirements] and the needs of the population.”

Senella, who is also CEO of Tarzana Treatment Centers in Tarzana, Calif., said many clinics across the state don’t have money to prepare for the overhaul, which will require improving technology and adding and training staff. For now, no plans are in place to provide counties or clinics with startup funds.

Eli Veitzer, interim CEO of Prototypes, which provides treatment services in Los Angeles, Orange and Ventura counties, said the waiver provides an “incredible opportunity” to transform care.

But in addition to fears about rates, Veitzer said he is also worried that 90 days of residential treatment won’t be enough for many people. Someone may be able to stem their addiction in three months but will still need more time in a treatment facility to prepare for life outside.

“If their ability to function independently in the community is not addressed, they are likely to relapse,” he said.

Danny Montgomery, a 33-year-old patient at Tarzana Treatment Centers, said he needed more than a few months to get clean after nearly a decade on heroin. The addiction, which he estimated cost him up to $100 a day, caused him to lose his job and nearly lose his family.

“The whole thing is a process,” said Montgomery, who lives in the San Fernando Valley. “You get the substance removed from your body, but you have to retrain your mind.” Montgomery said he tried to get a bed in a residential treatment center but couldn’t find one that would take Medi-Cal.

He tried to get clean on his own but it never lasted. Months after beginning his search, Montgomery was finally able to get a spot at Tarzana. He said Los Angeles County is paying for his stay, which began in May.

As worried as they are about reimbursements, clinic operators said a big advantage of the new approach is that it could help stabilize their funding. Providers now depend largely on counties to pay for residential treatment for low-income residents.

“You always suffered the vagaries of the budget cycle,” said Vitka Eisen, CEO of HealthRIGHT 360, which provides drug treatment in the Bay Area.

The waiver also means increased oversight of treatment centers.

Last year, a state audit found widespread fraud and questionable billing among Medi-Cal drug treatment providers. The audit followed reports by the Center for Investigative Reporting that clinics were billing for fake clients.

The new system will include more levels of accountability, Perez says, including more stringent requirements for clinics and more local control over contracting.

Knoles, who is addicted to methamphetamine, said she hopes that more people like her will be able to get treatment.

“I’ve had a lot of friends die from addiction,” she said. “Imagine if they’d gotten the help they wanted and needed. Things would have been different.”

Anna Gorman is a reporter with Kaiser Health News, a nonprofit news organization covering health care policy and politics. A version of this story appeared on KQED’s State of Health blog.

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Appeals Court Lets FanDuel, DraftKings Operate In N.Y. — For Now

A New York state appeals court is temporarily allowing daily fantasy sports sites FanDuel and DraftKings to continue operating in the state, blocking a lower court’s ruling to bar the websites that was handed down earlier in the day.

The order allows the companies to continue business while the issue is fully considered, at least through next month, the Associated Press reports.

State Attorney General Eric Schneiderman filed an enforcement action in New York State Supreme Court on Nov. 17, seeking a preliminary injunction against the fantasy sites that allow players to compete against each other for money.

Friday morning, Supreme Court Justice Manuel J. Mendez barred DraftKings and FanDuel from “accepting entry fees, wagers or bets from New York consumers in regards to any competition, game or contest” on the websites.

The attorney general’s motion had cited New York’s ban on bookmaking and other forms of sports gambling that have stood since 1894.

“So-called Daily Fantasy Sports (‘DFS’) wagers fit squarely in both these definitions,” Schneiderman’s memorandum reads, “though by meeting just one of the two definitions DFS would be considered gambling. DFS is nothing more than a rebranding of sports betting. It is plainly illegal.”

Update at 11:20 a.m. ET: DraftKings ‘Disappointed’

David Boies, counsel to DraftKings, has issued a statement about the injunction:

“We are disappointed with the Court’s decision, and will immediately file an emergency notice of appeal in order to preserve the status quo.

“Daily Fantasy Sports contests have been played legally by New Yorkers for the past seven years and we believe this status quo should be maintained while the litigation plays out.”

Original post continues:

Federal and congressional authorities have also been looking at the sites’ business model to see if it runs afoul of U.S. gambling laws.

In addition to those challenges, the sites also face a legal threat from NFL players. From our post on that development in October:

“Washington wide receiver Pierre Garcon has filed a class-action lawsuit on behalf of NFL players against the daily fantasy sports site FanDuel, alleging it misuses players’ names and likenesses without proper licensing or permission.”

Earlier in that same month, DraftKings and FanDuel moved to reassure their customers, after questions emerged about whether an employee of one site used inside information to win thousands of dollars on the other site.

As the Two-Way reported:

“Daily fantasy sites such as FanDuel and Draft Kings offer customers the chance to assemble a fantasy team roster (with a salary cap) that they then pit against other contenders. Some games are free to enter; others require buy-ins that range from $3 to $20 and up, with first-place payouts that top $1 million.”

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