The Food and Drug Administration is banning the sale of electronic cigarettes to minors as part of a broad set of regulations the agency finalized Wednesday.

With the rules that were more than two years in the making, the agency is expanding its authority over e-cigarettes, cigars and hookah tobacco, in much the same way it already regulates traditional cigarettes.

In addition to barring sales of tobacco products and e-cigarettes to people under age 18, the FDA would impose other restrictions, including:

• A prohibition on distribution of free samples
• A ban on selling e-cigarettes in vending machines unless they are in secure places that never admit young people
• A requirement that e-cigarettes carry warnings that they contain nicotine, which is addictive

The rules also require companies to get FDA approval for any products that were put on the market after Feb. 15, 2007. Also, e-cigarette makers will have to go back to the agency within two years for approval of the products they already sell.

E-cigarettes consist of plastic or metal tubes that contain a heating element that vaporizes a liquid solution containing nicotine.

The popularity of “vaping” has grown in recent years. The FDA says about 16 percent of high school students used e-cigarettes in 2015.

Some have welcomed the devices as an alternative to traditional cigarettes, whose dangers are well-known, and as an aid to help smokers quit.

In the U.K., for example, the Royal College of Physicians in April embraced e-cigarettes as a way to reduce smoking, which the group says is far more dangerous. “In the interests of public health it is important to promote the use of e-cigarettes,” the group said in a statement released April 28.

The industry trade group has pressed that point. E-cigarettes “provide smokers with a viable path to reducing their tobacco consumption and quitting altogether,” said Tony Abboud, national legislative director of the Vapor Technology Association, the trade group for e-cigarette makers.

Others fear the devices will addict nonsmokers to nicotine and eventually lead to more people smoking.

Health and Human Services Secretary Sylvia Burwell nodded to that concern in a statement released with the new rules that said use of e-cigarettes has risen as traditional smoking has declined. “All of this is creating a new generation of Americans who are at risk of addiction,” she said.

The FDA had previously attempted to regulate e-cigarettes, but that effort was thwarted in court.

Public health advocates such as the American Lung Association and the American Academy of Pediatrics welcomed the new rules.

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A study by researchers at Johns Hopkins Medicine says medical errors should rank as the third leading cause of death in the United States — and highlights how shortcomings in tracking vital statistics may hinder research and keep the problem out of the public eye.

The authors, led by Johns Hopkins surgeon Dr. Martin Makary, call for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death.

Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. On the CDC’s official list, that would rank just behind heart disease and cancer, which each took about 600,000 lives in 2014, and in front of respiratory disease, which caused about 150,000 deaths.

Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive.

But no one knows the exact toll taken by medical errors. In significant part, that’s because the coding system used by CDC to record death certificate data doesn’t capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says.

“You have this overappreciation and overestimate of things like cardiovascular disease, and a vast underrecognition of the place of medical care as the cause of death,” Makary said in an interview. “That informs all our national health priorities and our research grants.”

The study was published Tuesday in The BMJ, formerly the British Medical Journal.

Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates and that codes do capture them.

The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment. As a result, even if a doctor does list medical errors on a death certificate, they aren’t included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.

Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.

The Johns Hopkins authors said the inability to capture the full impact of medical errors results in a lack of public attention and a failure to invest in research. They called for adding a new question to death certificates specifically asking if a preventable complication of care contributed.

“While no method of investigating and documenting preventable harm is perfect,” the authors write, “some form of data collection of death due to medical error is needed to address the problem.”

Anderson, however, said it’s an “uncomfortable situation” for a doctor to report that a patient died from a medical error. Adding a check box to the death certificate won’t solve that problem, he said, and a better strategy is to educate doctors about the importance of reporting errors.

“This is a public health issue, and they need to report it for the sake of public health,” he said.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said her organization refers to patient harm as the third leading cause of death. Better tracking would improve funding and public recognition of the problem, she said.

“If you ask the public about patient safety most people don’t really know about it,” she said. “If you ask them the top causes of death, most people wouldn’t say ‘preventable harm.’ “

Dr. Eric Thomas, a professor of medicine at the University of Texas Houston Medical School whose research was cited in the Institute of Medicine’s landmark To Err is Human report, said existing estimates aren’t precise enough to support immediately listing errors as the third leading cause of death.

But collecting better cause-of-death data is a good idea, said Thomas, who agreed that medical errors are underreported.

“If we can clarify for the public and lawmakers how big a problem these errors are,” he said, “you would hope it would lead to more resources toward patient safety.”

Have you or a loved one been harmed during medical care? Join the discussion at ProPublica’s Patient Safety Facebook group or fill out the Patient Harm Questionnaire.

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At some hospitals, posters on the wall in the emergency department list the drugs that are in short supply or unavailable, along with recommended alternatives.

The low-tech visual aid can save time with critically ill patients, allowing doctors to focus on caring for them rather than doing research on the fly, said Dr. Jesse Pines, a professor of emergency medicine and director of the Office for Clinical Practice Innovation at the George Washington University School of Medicine and Health Sciences. He has studied the problems created by shortages.

The need for such workarounds probably won’t end anytime soon. According to a new study, shortages of many drugs that are essential in emergency care have increased in both number and duration in recent years even as shortages for drugs for non-acute or chronic care have eased somewhat. The shortages have persisted despite a federal law enacted in 2012 that gave the Food and Drug Administration regulatory powers to respond to drug shortages, the study found.

For this report, which was published in the May issue of Health Affairs, researchers analyzed drug shortage data between 2001 and 2014 from the University of Utah’s Drug Information Service, which contains all confirmed national drug shortages, according to the study.

They divided the drugs into acute and non-acute categories. Acute-care drugs were those used in the emergency department for many of the urgent and severe conditions handled there and include remedies such as pain medications, heart drugs, saline solution and electrolyte products.

Overall, the study found that 52 percent of the 1,929 shortages during the time period studied were for acute-care drugs. Following passage of the federal law in 2012, the number of active shortages of non-acute care drugs began to decline for the first time since 2004, but there was no corresponding dropoff in shortages of drugs that emergency departments and intensive care units rely on, the researchers reported.

Shortages of the drugs for emergency care lasted longer as well, the study found. Half of the shortages of drugs for acute care lasted longer than 242 days, compared with 173 days for non-acute care drugs.

Seventy percent of the drugs that were difficult to get were injectable drugs, which emergency departments rely on to a much greater degree than other types of providers. The most common acute-care drugs affected were those to fight infections, such as antibiotics; those that affect the central nervous system, including painkillers and sedatives; and the drugs that suppress or stimulate the autonomic nervous system, which controls heart and breathing rates.

When patients come to the emergency department who have been seriously injured and are having trouble breathing, for example, it’s often necessary to administer drugs that sedate them and cause their muscles to relax so that emergency personnel can insert a breathing tube in the windpipe.

“All of a sudden you have a life-critical procedure and you’re using your second-best drug or a drug you’re less familiar with,” said Dr. Arjun Venkatesh, an assistant professor of emergency medicine at Yale School of Medicine and a study co-author.

Venkatesh said his own experience with recurring shortages of such basic but critical medicines as saline solution while working in the emergency department at Yale-New Haven Hospital was the impetus for the study.

Patients are naturally often unaware of drug shortages in the emergency department, and there’s no data to show that substituting a preferred drug with one that a doctor is less comfortable with results in patient harm, experts say.

“But if you extrapolate this problem over 140 million emergency department visits annually, I don’t see how patients couldn’t have been harmed by [substitutions],” said Dr. Frederick Blum, an associate professor of emergency medicine at West Virginia University School of Medicine who is a former president of the American College of Emergency Physicians.

The Food and Drug Administration Safety and Innovation Act of 2012 contains provisions aimed at stemming these problems, including requiring reporting of shortages by drug manufacturers to the FDA and expediting inspections and reviews by the FDA of alternative products and manufacturing facilities.

“We need more,” Venkatesh said. “At the national level, they need to provide more support around generic injectables and antibiotics, the two areas that are ripe for improvement.”

The FDA continues to work closely with manufacturers to resolve shortages, said agency spokesman Christopher Kelly.

“In the past couple of years, numbers of new shortages have gone down and that’s largely due to increased notifications by manufacturers,” Kelly said in a statement. Injectable drugs “are particularly susceptible to shortages and can be difficult to solve.”

Changing the economics of these drugs could help, said George Washington’s Pines, noting that profit margins are thin and there’s not a lot of extra capacity in the system if one manufacturer stops producing a drug. The Health Affairs study suggests tax credits, rebates or temporary market exclusivity as potential strategies to improve the supply of generic injectables, among other things.

David Gaugh, senior vice president for sciences and regulatory affairs at the Generic Pharmaceutical Association, said drugmakers’ efforts have helped decrease the shortages but acknowledged more is needed. He called for continued communication between regulators and generic drug manufacturers on the issues and improvements in the drug review process. “The only way to mitigate current shortages and prevent future shortages from occurring is a collaborative effort,” he said.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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Need knee replacement surgery? It may be worthwhile to head for Tucson.

That’s because the average price for a knee replacement in the Arizona city is $21,976, about $38,000 less than it would in Sacramento, Calif. That’s according to a report issued Wednesday by the Health Care Cost Institute.

The report, called the National Chartbook on Health Care Prices, uses claims and payment data from three of the largest insurance companies in the U.S. to analyze how prices for procedures vary from state to state, and city to city.

The takeaway?

Health care prices are crazy.

“There doesn’t seem to be a systematic pattern with respect to what’s high and what’s low,” says David Newman, HCCI’s executive director. Newman is lead author of an article published Wednesday online in the journal Health Affairs that accompanied the release of the Chartbook.

The reports compare average state prices for 242 medical services — from primary doctor visits to coronary angioplasty to a foot x-ray — to the national average price for those services. It shows that states such as Minnesota and Wisconsin have higher than average prices while others, such as Florida and Maryland, were cheaper overall.

Arizona’s health care prices were generally cheaper, about 82 percent of the national average, while next door in New Mexico, care was more expensive, about 25 percent above average.

And prices vary within states, too.

If a Sacramento knee replacement patient doesn’t want to drive the 871 miles to Tuscon, he or she could drive south to Riverside, Calif., and pay $27,000 less. In Florida, the surgery costs $17,000 less in Miami than it does 180 miles north in Palm Bay.

“For every mile that a consumer drives south on I-95, they will save $100,” Newman says.

The HCCI data is some of the most detailed and complete information available on health care prices paid by private insurance companies. It includes payment data from Aetna, Humana, UnitedHealthCare. It doesn’t include claims information from The Blue Cross and Blue Shield Association, which is the largest health insurer in the country.

The price variations revealed by HCCI show that the health care market is not following traditional economic and market rules.

“The market just isn’t working,” says Zack Cooper, a professor of health policy and economics at Yale University.

Cooper says in the past, analysts believed that health care costs were rising because people were using too much health care. That analysis was based on Medicare data. However, Medicare pays the same across the country.

The new data show that private-insurance payments vary widely and states that have low Medicare spending, like Minnesota, often have higher prices in the private insurance market.

He says one major factor is the consolidation of hospitals, leading to a lack of competition.

“Where one large hospital dominates the markets, that hospital is able to get higher prices,” he says. “Hospitals have gotten increasingly powerful over time.”

The new data may give insurers and consumers better ammunition to shop around for lower prices or to negotiate better deals.

But that will require people taking a different approach to choosing health care.

People should be willing to travel farther for services, Cooper says. That would put powerful hospital systems in different cities in competition with one another, perhaps putting pressure on prices.

And there are limits on where competition can bloom in health care, says
Sarah Dash, president and co-CEO of the Alliance for Health Reform.

“A woman is going to go to the one OB/GYN that she goes to. She’s not going to run all over town trying to find the cheapest one necessarily,” Dash says.

“Where it’s shoppable, where it’s elective, where it’s not an emergency and where the price is knowable, then there are things that can be done,” she says.

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Only Human is a new podcast from WNYC Studios. Hosted by Mary Harris, Only Human tells stories we all can relate to. Because every body has a story. Subscribe to Only Human on iTunes or wherever you like to get your podcasts.

When Lee Herzenberg remembers the day her son Michael was born, she laughs and calls it a “cool birth.” Her obstetrician was a friend, and she describes it almost like a party — “a little bit painful, but that you forget very quickly.” Lee even got a kick out of the fact that a resident learned to do an episiotomy on her.

It was November 1961, and she was at the newly christened Palo Alto-Stanford Hospital Center; her husband, Len, was a biology professor on campus. Like most fathers at the time, he didn’t attend the birth, which meant he wasn’t there when Michael started turning blue.

The nurses whisked the newborn off to the nursery without telling Lee anything was wrong.

It was then that a doctor noticed the characteristic features of Down syndrome: floppy muscles, eyes that slanted upward. They got Michael breathing again, but doctors thought his prognosis was grim. They gave Michael just a few months to live. A daisy chain of physicians was called, and Lee says it was a pediatrics professor who told her husband what had happened. Then Len was dispatched to tell Lee.

She remembers the moment with uncharacteristic emotion. “We hugged each other, and it was a terrible conversation to realize that you’d lost the baby, but the baby was lost,” Lee says now. “We knew immediately what we’d do. We had already made the decision that it was not a good thing to take the baby home, and so we didn’t.”

In the 1960s — an era before neurodiversity movements and early intervention programs — many people still called people with Down syndrome “mongoloids.” Playwright Arthur Miller institutionalized his son, Daniel, in 1966. A few years later, an article in The Atlantic Monthly argued that “a Down’s is not a person.”

Lee and Len Herzenberg had seen friends struggle with the birth of a child with Down syndrome and had even gone with a colleague to an institution, where he dropped off his own infant daughter.

So, they decided Michael would never come home.

But Michael wasn’t absolutely lost to them. Michael’s birth sparked their search for a blood test that has revolutionized prenatal care in this country.

I made the mistake of telling one scientist I was reporting about “Len Herzenberg’s lab.” He corrected me instantly: “Len and Lee’s lab.” Because Lee Herzenberg was “leaning in” decades before Sheryl Sandberg coined the phrase. At 81, Lee, a professor of genetics, is still running the lab she and her husband founded more than 50 years ago. Len died in 2013.

The lab is a quirky place, even by Stanford standards. Lee rarely sits on chairs, preferring cushions on the floor. She’s often accompanied by her bichon frise, Gigi. Researchers can often be found working in this basement office well into the night.

But Lee Herzenberg isn’t just quirky. She is one of the few professors at Stanford — possibly the only one — never to have officially graduated from college. Instead, she trained by her husband’s side, auditing courses while he got his Ph.D. at Caltech (women weren’t allowed to attend at the time) and working at his labs at the Pasteur Institute in Paris and the National Institutes of Health.

And the science that’s been done here has changed the course of medicine.

The Herzenbergs are best known as the creators of the modern-day fluorescence-activated flow cytometer, or FACS. It was a machine born out of frustration: Len couldn’t stand squinting down a microscope looking at cells.

Before the FACS, a biologist peering at slides could feel like he was playing a really intense round of “Where’s Waldo,” staring at crowds of all kinds of cells, trying to pinpoint the exact ones he was looking for. Not only was it annoying — Len Herzenberg worried it wasn’t particularly scientific. He wanted a way to find and describe cells that didn’t rely on his worn-out eyes.

The FACS allows you to pour cells in, program the machine to find whatever it is you’re looking for, and then it will spit out a little tube of just those cells alone. And the FACS gives you all kinds of information, too: how big the cells are and how much DNA they have inside.

The FACS was used to diagnose AIDS because the technology can quickly and easily sort out T cells. The FACS was used to find the first stem cells. When Len Herzenberg died, one colleague told The New York Times that “without Len, tens of thousands of people now alive would not be.”

But in the 1970s, the Herzenbergs were still proving the value of this machine. That’s when they started thinking about using it to create a blood test for Down syndrome.

Len had seen research from Finland claiming it was possible to see a fetus’s cells in a mother’s blood. It was hard to believe. But he figured that FACS, with its nearly magical sorting capabilities, could figure it out. So he took on a medical student named Diana Bianchi as a research associate and made sorting out these cells her project.

If they could isolate these cells, he could learn a lot about the developing fetus, including whether the fetus had chromosomal abnormalities.

“They had a very personal reason for doing this, because of their son Michael,” Bianchi says now. “They wanted to have a test that could be offered to any pregnant woman — that would be noninvasive and would allow them to know if a child had Down syndrome. The first step, however, was to show that you could pull out fetal cells.”

Scientists now estimate that for every 200 billion cells in a mother’s bloodstream, about 10 of those are fetal cells. Bianchi was one of the first people to see them.

The New York Times quoted Len saying the work was a “first step” toward a blood test for Down syndrome for all pregnant women. But it would take 30 years for a practical test to become a reality.

As it turned out, Len’s FACS wasn’t the right tool for prenatal diagnosis. There weren’t very many fetal cells to be sorted, and if a pregnant woman already had children, scientists couldn’t be sure if the cells in her blood came from the current fetus or one of her older kids.

But in 2008, Len helped ensure the right tool was found.

A researcher named Stephen Quake had discovered a way to sequence chunks of fetal DNA floating in expectant mothers’ blood. As a member of the National Academy of Sciences, Len made sure the paper was published in the academy’s journal. Another researcher, Dennis Lo, confirmed Quake’s findings. Three years later, the tests were on the market.

Now, at just 10 weeks into a pregnancy, a whole range of things can be revealed with this test. Not just Down syndrome, but a host of other chromosomal abnormalities as well as the sex of the child to be.

Until this test, doctors had to rely on amniocentesis, an invasive procedure that involves inserting a needle in the womb to sample amniotic fluid, or biopsying the placenta, to tell them with any reliability whether a fetus had a chromosomal abnormality. These tests aren’t just uncomfortable; they come with a risk of miscarriage. By some estimates, in the past five years the number of these procedures performed in this country has plummeted by more than 50 percent.

To some parents, this knowledge can be alarming. Advocates in Ohio are trying to pass a law preventing abortions if Down syndrome is the reason (North Dakota and Indiana have already passed similar laws).

Lee Herzenberg is honest about what she would have done if she’d known early on in her pregnancy that Michael had Down syndrome.

“I’d say if I had the choice of not pushing Michael into this life — if I at that time would know I was carrying a Down syndrome child — I would have aborted the child,” she says. “I see no reason Michael has to live the life he leads. The fact that we’ve made it very happy for him or that he’s made it very happy for us — all of that is adapting to a situation, but I don’t think it’s fair or proper.”

But Lee is alarmed that these tests are now being used to determine the sex of unborn babies. She worries about parents choosing to abort girls.

Diana Bianchi, that medical student from the Herzenberg lab, is now a professor at Tufts, where she founded the Mother Infant Research Institute. She’s still working in prenatal testing. In fact, perfecting these tests has become her life’s work.

But her focus has shifted. Now that she can detect Down syndrome so early, she wants to treat it early, too — in the womb. Because finding this chromosomal abnormality at 10 weeks means there’s a window of opportunity: The brain changes associated with Down syndrome don’t occur until a month or so later. Theoretically, you could treat a fetus before some brain changes occur at all.

Bianchi’s work is still early. She’s experimenting with mice, giving them existing drugs in utero to see if she can forestall brain damage.

There’s an often-quoted statistic, that 90 percent of parents who find out that their fetus has Down syndrome will abort. But that statistic is from a study done in the United Kingdom. In the U.S., far fewer women terminate.

“We have to unpack this connection between prenatal testing and abortion,” she says. “We have good data to suggest that approximately 40 plus percent of women who know their fetus has Down syndrome continue their pregnancy. There are many women who speak very highly of the fact that this allows them to prepare.”

The Down syndrome baby who kicked off the search for this blood test is now a 54-year-old man. He lives in a squat house in Redwood City, Calif., just a 30-minute drive from his birth mother’s home.

For years, Michael lived with a local woman named Barbara Jennings, who raised a number of children with developmental challenges. The Herzenbergs’ pediatrician helped them find her when Michael was a newborn. The Herzenbergs would visit Michael every month or so, but they never felt they should bring him home. When Barbara died, Michael moved to this group home.

It’s hard to know how much Michael understands when I speak to him, though he has learned to read and use a cellphone. And he’s stubborn. A lot like his mother, actually. “Michael has the hardest head in the whole world,” says Janet Thomas, the caretaker who runs this house. “He does whatever he wants to do. He does not care whatever you say. He’s going to do whatever it is he wants to do — that’s Michael.”

I asked Lee if she ever regretted not raising Michael, and she said no. “It was a decision that was selfish, if you like, because we had things we wanted to do. In retrospect, a lot of things would never have gotten done. There would be no FACS had we decided to do this. Because it would have been a very intensive kind of upbringing.”

As for Michael, he clearly loves his mother, no matter what she decided. In Michael’s room, there are photos on almost every surface, with snapshots of his biological and adopted families. In the corner is a huge poster of his father, celebrating when he won the Kyoto Prize for his contributions to biotechnology. And deep in one album, there’s a picture of Len and Lee together. The caption reads: “Michael’s Other Mom + Dad.”

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To wrap up our series on public health in Baltimore, Audie Cornish met up with Baltimore City Health Commissioner Leana Wen in Freddie Gray’s neighborhood of Sandtown-Winchester. The health department recently opened a new outpost of its violence prevention program Safe Streets there, employing ex-offenders to mediate conflicts before they erupt in violence.

Wen spoke about pushing a public health agenda in a city that has long struggled with poverty, violence and addiction. She also talked about what she, as an emergency physician, has learned in her first stint in government. Here are interview highlights, edited for length and clarity.

On her goal to make Baltimore a model for the country

We have gotten significant national recognition for some of our programs, including our programs to respond to the opioid overdose epidemic. I had the opportunity to testify in front of the U.S. Senate and House and was invited to speak with President Obama about Baltimore’s work. I do believe that because of the way we’ve focused on addiction as a disease, that that’s changing the conversation in our city and actually, is leading the way around the country. People are beginning to see Baltimore not as [the HBO drama] The Wire and heroin overdose but actually as a model for recovery and resilience.

On what she wants to tackle next

The unrest [after Freddie Gray] paradoxically opened the door for us to address trauma, which is a natural segue to talk about mental health and the bigger picture of emotional well-being. People finally felt like they could talk about the trauma they’ve experienced for so many years. It’s the trauma of police brutality. It’s the trauma of discriminatory practices. It’s the trauma even of being poor. We now want to convene a citywide group to address this issue, which is very difficult because ultimately, the trauma work has to be done at the community level.

On her optimism, despite the challenges Baltimore faces

I’m not blind to the problems that exist. But I also realize these problems have been in the making for decades. We’re not going to be able to make a huge difference overnight. But there are things we can do along the way to demonstrate to our community that we hear you, and this is what we do in the meantime. We cannot solve the issue of addiction overnight, but we can reduce overdose deaths, and we have passed a Good Samaritan law [to protect people who help overdose victims] and we are introducing programs where individuals caught with drugs are not going to be incarcerated but actually, are going to be offered drug treatment. So we’re showing that things can be done, and that we’re taking small steps. And actually, our community gets it. If we just came to the community and said we’re going to solve all of our crime problems overnight, they’re not going to buy it. But if we say we know the success of Safe Streets, it’s been demonstrated in four sites across our city, now we’re going to open a fifth site in Sandtown, you can feel the energy and the optimism. And maybe that’s why I’m so optimistic.

On what she’s learned from the job since she began in January 2015

I was never in the political world, and I’m not from Baltimore. So coming here, everyone was new. It’s been a really steep learning curve.

The things I’ve learned over the year have been a lot about myself, and who I am as a manager, who I am with navigating complicated politics and situations, but also what motivates me. And I’ve learned that I like a fight. I don’t want to be in a situation where things are going well. I don’t feel like I have anything to do in that case. In the ER, it’s the patient dying in front of me. It’s someone who is gravely ill, and my fight is the fight to save their life.

I see the same thing in Baltimore. There are so many problems. There are so many fights I can have every single day. It’s the fight to get health on every agenda, to change legislation, to change public perception and mindset, to reduce stigma, to introduce new programs in a time of severe fiscal constraints. I like a fight, and I’m good at it, and that is what motivates me.

I’m learning now just how powerful that voice can be — to say, I’m not here as a politician. I’m here as a doctor and as a scientist. I’m here to give voice to all these issues that we’ve seen that are unfair — housing politics, policing policies, drug policies. And I’m saying from a health perspective how these policies have destroyed our community, and this is what we’re doing about it now.

Dr. Leana Wen has been a contributor to Shots since 2013. You can read her account of why she decided to become Baltimore’s health commissioner here.

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Stacey McHoul left jail last summer with a history of heroin use and depression and only a few days of medicine to treat them. When the pills ran out she started thinking about hurting herself.

“Once the meds start coming out of my system, in the past, it’s always caused me to relapse,” she said. “I start self-medicating and trying to stop the crazy thoughts in my head.”

Jail officials gave her neither prescription refills nor a Medicaid card to pay for them, she said. Within days she was back on heroin — her preferred self-medication — and sleeping in abandoned homes around Baltimore’s run-down Sandtown-Winchester neighborhood.

Thousands of people leave incarceration every year without access to the coverage and care they’re entitled to, jeopardizing their own health and sometimes the public’s.

Advocates for ex-convicts held high hopes for the Affordable Care Act’s Medicaid expansion that promised to deliver insurance to previously excluded single adults starting in 2014, including almost everybody released from prisons and jails.

Many former inmates are mentally ill or struggle with drug abuse, diabetes or HIV and hepatitis C infection. Most return to poor communities such as West Baltimore’s Sandtown, which exploded in violence a year ago after Freddie Gray died from injuries sustained in police custody.

But Maryland’s prison agency, which three years ago said it was “well positioned” to enroll released inmates in Medicaid, is signing up fewer than a tenth of those who leave prisons and jails every year, according to state data. Few other states that have expanded Medicaid under the health law are doing any better, specialists say.

Officials of the Maryland Department of Public Safety and Correctional Services say they do the best they can with limited resources, enrolling the most severely ill in Medicaid while letting most ex-inmates fend for themselves.

“We are battling, every one of us,” to maximize coverage, said prison medical director Dr. Sharon Baucom, pointing to efforts to train sign-up specialists, get Medicaid insurance for hospitalized inmates and share information on mentally ill inmates with other agencies.

“There are handoffs that could be improved,” she said. “With the resources that we currently have, and the process that we have in place, we could do more — and we just need some more help.”

Coverage under Medicaid was seen as an unprecedented chance to transform care for ex-inmates by connecting them to treatment, reducing emergency room visits, controlling disease and putting them on a path to rehabilitation.

As many as 90 percent of people leaving prisons and jails are eligible for Medicaid in states such as Maryland that expanded the federally supported program for low-income residents under the health act, experts estimate. The law gave states the option of extending Medicaid coverage to all low-income adults under 65, not just the children, pregnant women and disabled adults who were mainly included before.

Sickest Inmates Are First In Line

Some 12,000 of Maryland’s 21,000 prison inmates are designated at any given time as chronically ill with behavioral problems, diabetes, HIV, asthma, high blood pressure and other conditions, according to prison officials. But given limited means and the already tall order of connecting emerging prisoners with transportation, shelter and employment, the system must focus on enrolling the very sickest, Baucom said.

“It’s a shame to have to make that call,” she said.

Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.

“People frequently ran out of their medications and did not have access to the care they needed,” said Stewart, an associate professor at the Johns Hopkins University medical school.

McHoul, 40, spent two short stays last year in Baltimore’s Women’s Detention Center. The first time the facility released her without Medicaid coverage. Shortly afterwards she landed in a hospital with an inflamed esophagus. She got out after a second jail stay in August without knowing the hospital had enrolled her in Medicaid between incarcerations, she said.

At neither time did she have more than two weeks’ supply of any medication, including Depakote, a mood stabilizer, she said. For some prescriptions there was less than a week’s store.

“It was whatever was left in the blister pack,” said McHoul, who’s now in a Baltimore drug treatment program. “It’s like, ‘Here’s your supply. Sign this that we gave them to you. See you later.'”

State policy is to give exiting prisoners 30 days’ worth of medicine. But a court ordered McHoul released shortly after she was arrested the second time, which didn’t give the jail enough time to prepare medications, said a corrections spokesman.

A Burden For Emergency Departments

There are many Stacey McHouls.

“Maybe somebody needs prescription services and they’re not enrolled and they don’t know where to go,” said Traci Kodeck, interim CEO of HealthCare Access Maryland, a nonprofit that connects consumers to coverage and has worked with the prison system. “Absolutely it happens. Many of them will end up in the emergency departments if we don’t attempt to connect them to services prior to release.”

Mark Pruitt, 46, was released from a Baltimore facility in October with no Medicaid card and a craving for heroin, which he said he had used before he was incarcerated for a parole violation.

He desperately wanted to enter a drug treatment program, but signing up for Medicaid to pay for it was going to take weeks — far longer than he could wait.

“I knew what I wanted. I wanted help,” he said. “I really wanted help. But it’s a struggle when you’re broke — no money, no insurance, feeling defeated. Where do you turn?”

If administrators at a Baltimore recovery facility hadn’t gotten him enrolled in Medicaid, he said, “I think I’d be dead.”

From January 2014, when the Medicaid expansion took effect, through March of this year, Maryland released almost 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.

But the corrections department said it enrolled only 1,337 released inmates in Medicaid from the beginning of 2014 through late March. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)

Many ex-prisoners are enrolled only when they experience a crisis and end up in an emergency room — the kind of expensive care health officials are trying to reduce. The law requires hospitals to treat emergency cases regardless of insurance coverage. They can retroactively sign those patients for Medicaid.

‘They Don’t Want To Do The Paperwork’

Monique Wright, 35, got out of Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spine curvature. Without Medicaid coverage or a primary care doctor, she said she had to seek emergency care at Johns Hopkins Bayview Medical Center.

“It’s the paperwork” that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. “They don’t want to do the paperwork. They don’t have the staff to do the paperwork.”

Advocates wonder why the corrections system is so poor at enrolling what, they often point out, is “literally a captive audience.”

“They’ve had them housed for the past 10, 15 years,” said a frustrated Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. “What’s so hard about it?”

Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card doesn’t arrive until after they’re out. Computer problems slowed signups in late 2014.

One mistake made by Maryland and most other states is not considering inmates for Medicaid until their release dates approach, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process.

“It’s a bad way to do it because you’re getting a very small number” of enrollees by waiting, she said. A better alternative is to enroll inmates when they are booked, as Chicago’s Cook County Jail has demonstrated, she said. Those incarcerated are generally ineligible for Medicaid, but putting them in the system when they enter makes it easier to trigger coverage when they leave, she added.

Ex-Inmates Struggle To Get Medicaid Without Help

If it’s hard for the prison system to enroll inmates, it’s even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don’t bother.

For most leaving incarceration, “it’s up to you to go there, make sure you get your health insurance,” said Jamal McCoy, 21, who was living with family in West Baltimore on home detention before he was released. “Most people don’t go. Some people take it easy when they get home.”

Those who try often find that lack of identification is the first challenge. To prevent fraud, Maryland and other states require Medicaid applicants to show verified Social Security numbers.

But jails frequently lose inmate IDs, say prisoners and enrollment officials. Those locked up for years are non-persons for much of the system, with no credit records or driver’s licenses.

That can mean delays of many weeks when released prisoners are especially vulnerable. Gaps in coverage and care of even a few days after fragile patients leave the corrections health system can make the difference between life and death.

“If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now,” said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. “You can’t wait two weeks because you may drop dead.”

Compared with the rest of the population, ex-prisoners in Washington state were a dozen times more likely to die in the first two weeks after release, according to research by Dr. Ingrid Binswanger, lead researcher for Kaiser Permanente Colorado’s Institute for Health Research. Drug overdose, cardiovascular disease, homicide and suicide were the leading causes of death.

“It’s very important to manage that transition, to make sure people have continuity of care,” she said. (Kaiser Permanente has no relationship with Kaiser Health News.)

Yet in some cases the prison system has stymied outside groups trying to arrange inmates’ coverage. Stewart’s group repeatedly sought permission — “continuously, for about three years,” she said — to meet vulnerable prisoners inside the facility to get an early start on enrollment and post-release appointments. It never happened.

Baucom blamed the problem on “competing priorities” and staff turnover.

Acceptance into Medicaid by the state isn’t the end of the story. Released inmates then must enroll in a private managed care organization hired by Maryland to provide coverage. That can take weeks longer.

Even when insured, ex-inmates face the same barriers to care experienced by other low-income Baltimoreans — or worse.

Many prison inmates are infected with hepatitis C, which can cause liver damage or cancer over time. But the high cost of curing the disease has prompted Maryland’s and other Medicaid programs to limit access to treatment to those whose livers are already compromised.

“I guess I got to wait until damage is done to my liver,” said William Carter, 50, adding that prison officials initiated Medicaid enrollment when he got out last year.

Released prisoners often have no idea that some Medicaid managed-care contractors allow them to use only certain doctors and pharmacies.

“So a patient goes to Walgreens or wherever to fill something and it’s like, ‘That’ll be $150,'” because he should have gone somewhere else, said Stewart. “They don’t understand what the problem was.”

Even checking all the right boxes sometimes isn’t enough for ex-inmates, who bear the double stigma of poverty and a criminal history.

One released prisoner got an appointment to renew his mental health prescription with a facility in Carroll County, Maryland — his home — that also accepted his Medicaid card, said Baucom. After the clinic learned he had a prison record it cancelled the visit.

“It’s not enough to have a card,” Baucom said. “You’ve got to have access.”

Neighborhoods are at risk when former inmates with chronic illness return.

“You really need to think about this as a public health issue,” said Scott Nolen, director of drug treatment programs for the Open Society Institute–Baltimore, a nonprofit that works on criminal justice policy. “There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care.”

In few places is the burden greater than Sandtown-Winchester. Gray, 25, died of spinal injuries that prosecutors filing manslaughter and assault charges blamed on police who arrested him.

The Justice Policy Institute, a nonprofit, called Sandtown “ground zero for the use of incarceration” in Baltimore last year, estimating that nearly one resident in 30 is in prison.

At the same time, three West Baltimore ZIP codes including Sandtown showed the highest rates of HIV infection in Maryland in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.

The corrections department could use more computers, release planners and other enrollment resources, Baucom said.

“If you do the checkoff list, we’ve checked off everything we can do,” she said, noting efforts not only to increase enrollment capacity but cooperation with the Maryland motor vehicle agency to get inmates state IDs.

Jesse Jannetta, a specialist at the Urban Institute in prisoner re-entry, believes Maryland’s low signup rate “is not unusual” in other states. A study published in Health Affairs found prisons and jails nationwide had enrolled 112,520 people in Medicaid from late 2013 up to January 2015, although the authors believe the actual figure was higher.

Federal and state prisons released 636,000 people in 2014, according to the Justice Department. Millions more are estimated to cycle through jails each year.

Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates anytime soon.

“It’s fair to say we’re just at the tip of the iceberg” in prisoner enrollment, said Johns Hopkins’ Barry, a co-author of the Health Affairs study. “Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don’t have any of these types of programs in place.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

This story came from a partnership with The Baltimore Sun and Capital News Service, which is run by the University of Maryland’s Philip Merrill College of Journalism. KHN reporter Shefali Luthra and CNS reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed.

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