Former Rep. John Dingell, the Michigan Democrat who holds the record as the longest-serving member of the U.S. House, died Thursday night in Michigan. He was 92.

And while his name was not familiar to many, his impact on the nation, and on health care in particular, was immense.

For more than 16 years Dingell led the powerful House Energy and Commerce Committee, which is responsible for overseeing the Medicare and Medicaid programs, the U.S. Public Health Service, the Food and Drug Administration and the National Institutes of Health.

Dingell served in the House for nearly 60 years. As a young legislator, he presided over the House during the vote to approve Medicare in 1965.

As a tribute to his father, who served before him and who introduced the first congressional legislation to establish national health insurance during the New Deal, Dingell introduced his own national health insurance bill at the start of every Congress.

And when the House passed what would become the Affordable Care Act in 2009, leaders named the legislation after him. Dingell sat by the side of President Barack Obama when he signed the bill into law in 2010.

Dingell was “a beloved pillar of the Congress and one of the greatest legislators in American history,” said a statement from House Speaker Nancy Pelosi. “Yet, among the vast array of historic legislative achievements, few hold greater meaning than his tireless commitment to the health of the American people.”

He was not always nice. Dingell had a quick temper and a ferocious demeanor when he was displeased, which was often. Witnesses who testified before him could feel his wrath, as could Republican opponents and even other committee Democrats. And he was fiercely protective of his committee’s territory.

In 1993, during the effort by President Bill Clinton to pass major health reform, as the heads of the three main committees that oversee health issues argued over which would lead the effort, Dingell famously proclaimed of his panel, “We have health.”

Dingell and his health subcommittee chairman, California Democrat Henry Waxman, fought endlessly over energy and environmental issues. Waxman, who represented an area that included western Los Angeles, was one of the House’s most active environmentalists. Dingell represented the powerful auto industry in southeastern Michigan and opposed many efforts to require safety equipment and fuel and emission standards.

In 2008, Waxman ousted Dingell from the chairmanship of the full committee.

But the two were of the same mind on most health issues, and together during the 1980s and early 1990s they expanded the Medicaid program, reshaped Medicare and modernized the FDA, NIH and the Centers for Disease Control and Prevention.

“It was always a relief for me to know that when he and I met with the Senate in conference, we were talking from the same page, believed in the same things, and we were going to fight together,” Waxman said in 2009.

Dingell was succeeded in his seat by his wife, Rep. Debbie Dingell, herself a former auto industry lobbyist.

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Many vaccines and some medicines, such as insulin, have to be delivered by injection. That’s a pain, both for patients and for health care providers. But two groups of researchers are trying to put some of these medications in pill form to avoid the needle.

One team of scientists, from MIT’s Koch Institute for Integrative Cancer Research and Harvard’s Brigham and Women’s Hospital, developed a system to deliver insulin that actually still uses a needle — but is so small you can swallow it and the injection doesn’t hurt.

They built a pea-size device containing a spring that ejects a tiny dart of solid insulin into the wall of the stomach, says gastroenterologist Carlo Giovanni Traverso, an associate physician at Brigham and Women’s Hospital.

“We chose the stomach as the site of delivery because we recognized that the stomach is a thick and robust part of the GI tract,” Traverso says.

Once the device gets into the stomach, the humidity there allows the spring to launch the insulin dart.

So far so good, but Traverso says there was a problem the team had to overcome: “How do we get these devices to self-orient such that the end that is doing the injecting part is in direct contact with a tissue?”

To get it to roll into the right position all on its own, they turned to nature.

“Leopard tortoises happened to have evolved a way of doing this,” Traverso says. The shape of the tortoise shell helps the turtle flip over if it happens to wind up on its back.

And there was another source of inspiration: Weebles, those egg-shape toys that wobble but don’t fall down.

As the researchers report in the journal Science, they’ve tested the device on pigs, and it can deliver a therapeutic dose of insulin provided the pig has an empty stomach.

Traverso and his colleagues have been working with the global health care company Novo Nordisk to ready the device for human testing. He has received consulting fees from the company and is a co-inventor on patent applications describing oral biologic delivery. Traverso hopes their device will be ready for human tests in a few years.

On the other side of the U.S., nanoengineer Ronnie Fang of the University of California, San Diego and his colleagues have a different delivery system. Theirs is a kind of ingestible microrocket, about the size of a grain of sand, that is designed to zip past the stomach and into the small intestine.

“It actually propels [itself] using bubbles in a reaction of magnesium with biological fluids,” Fang says.

The rocket has a coating that protects its payload from the acidic and enzyme-filled environment of the stomach. Once the rocket enters the small intestine, the change in acidity causes the coating to dissolve and lets the rocket stick to the intestinal wall to release its payload, in this case a vaccine protein.

Much like Traverso’s design was inspired by the shape of a tortoise shell, the bubble-propelled microrocket travels like a bacterium.

“If you had bacteria invade your gut, they’re not just going to be sitting around statically, they’re going to be swimming around, and they’re going to make it to the intestinal wall,” Fang says.

As Fang and his colleagues report in Nano Letters, their delivery system works in mice, but human testing is probably many years off.

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In Texas, a growing number of patients are turning to a little-known state mediation program to deal with unexpected hospital bills.

The bills in question often arrive in patients’ mailboxes with shocking balances that run into the tens or even hundreds of thousands of dollars.

When patients, through no fault of their own, are treated outside their insurers’ network of hospitals, the result can be a surprise bill. Other times, insurers won’t agree to pay what the hospital charges, and the patient is on the hook for the balance.

The Texas Department of Insurance’s mediation program can intervene when Texans complain about an unexpected bill — often after an emergency in which a patient rushed for treatment at an out-of-network hospital.

Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

Since then, more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, however, it received 4,445 bills, more than double the 2,063 bills received in 2017.

Even after the changes, the mediation program could be a lot more robust and is likely addressing only a fraction of these problematic bills, consumer advocates say.

The road to a surprise medical bill

Brad Buckingham says he had to deal with a surprise medical bill after a bicycle accident in 2016.

Buckingham sent his bill to Kaiser Health News and NPR’s Bill of the Month portal last year.

The Austin, Texas, dentist says he was on a ride with friends in December 2016 when he crossed some train tracks at an angle to avoid a pileup. His wheel slipped out from under him, and he landed hard on his left hip.

“All I could do was scream,” he says. “I couldn’t even make words.”

His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David’s South Austin Medical Center.

“I specifically remember I gave them my health insurance information in the ambulance,” he says. “And they put me in the ER, and from the ER they took my insurance information again.”

Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David’s was out of his plan’s network, but no one told him that — at first.

Buckingham had broken his hip, and doctors took him into surgery the same day.

“They held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge,” he says.

A few weeks later, Buckingham got a bill that said he owed $71,543.

The total bill eventually came to $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only $3,812.

Buckingham says he thought it was a mistake. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.

Both the hospital and insurer insisted payment was his responsibility.

“I’m sitting there thinking to myself that there is no way – there is no way — this is right,” he says.

Baylor Scott & White says it couldn’t discuss Buckingham’s bill “due to confidentiality requirements.”

After Buckingham gave St. David’s permission to discuss his case with the media, the hospital released a statement saying his bill was actually the amount he owed from his deductible and coinsurance — not a balance bill.

The hospital also said the bill was so large because of his “high deductible plan.”

Those plans “may be attractive to some people because they cost less, though they place more financial responsibility on the patient,” the statement from St. David’s said.

Buckingham says his policy had a deductible of $5,000 for in-network care and $10,000 for out-of-network care. He says he still doesn’t know how his bill got to be so high.

Buckingham didn’t know about the state’s mediation program. But even if he had known, he wasn’t eligible for the program at the time. His bike accident and the billing dispute with the hospital happened months before the Texas Legislature decided to expand the pool of eligible patients. So he hired his own lawyer to help him negotiate with the hospital.

Buckingham says he now owes a couple of thousand dollars to St. David’s, but he remains frustrated by the experience.

“You know, whenever I tell my story to anybody, they kind of agree — like, ‘Oh my gosh, this is ridiculous,’ ” he says. “But then when you talk to the people that have any control over it, it’s the exact opposite. It’s: ‘You owe it; we don’t.’ “

‘A total roll of the dice’

A surprise bill can happen to anyone who makes an urgent trip to the nearest emergency room.

“It’s a total roll of the dice,” says Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. She has been looking into balance billing for years. “The medical emergency that’s going to send you to the hospital where you could get a surprise bill — is that emergency room going to be in or out of network?”

Pogue says the Texas Department of Insurance’s mediation process forces an insurance company and the hospital or medical provider to negotiate a fair price for services. She says 90 percent of the time those negotiations happen over the phone.

There are two big reasons the number of bills sent for mediation more than doubled from 2017 to 2018, Pogue says.

“One is just increased awareness,” she says. “There is constant media attention now to surprise medical bills because the stories are so shocking, right? We see them covered more, so people are more aware that when they get one, they could do something about it.”

The second reason is that in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.

Can’t wish it away

Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David’s South Austin Medical Center after she landed in the emergency room last March.

The marathon runner said she woke up one Saturday for an early run and wasn’t feeling well.

“All of a sudden the whole room started spinning. … I started sweating, sweating like buckets,” she says. “It was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out.”

Shapiro’s boyfriend heard her hit the bathroom floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David’s because it was the closest hospital.

Shapiro says she was taken care of in a few hours. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a dramatic change in her blood pressure that was likely due to a spell of hypoglycemia, or low blood sugar.

Two months later, a bill for $6,720 came in the mail.

Like many teachers in Austin, Shapiro gets her health insurance from Aetna.

In a statement, the insurer said Austin school district employees are supposed to use the Seton Accountable Care network, comprising several Catholic hospitals in the area. St. David’s parent company, the for-profit hospital chain HCA, doesn’t participate in that network.

“Unfortunately, HCA is not currently accepting payments through Aetna’s [contracted payment] program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit,” Aetna wrote in a statement.

Shapiro says she had heard of other Austin Independent School District employees dealing with high hospital bills. In fact, Shapiro reached out to KUT after hearing the story of Drew Calver, an Austin high school teacher who was balance billed for nearly $109,000 by St. David’s after a heart attack. Calver’s story was part of Kaiser Health News and NPR’s Bill of the Month series last year.

Shapiro says that in her case, Aetna told her not to pay what the hospital was charging her. She says she was told to pay only her deductible ($1,275), which she did right away. But St. David’s kept sending her bills for the remaining balance, which was more than $5,000.

“I guess I just thought that it was going to go away,” Shapiro says.

But it didn’t. For a public school teacher, $5,000 would have been a huge blow to her budget, she says.

Shapiro applied for financial assistance, but St. David’s told her she didn’t qualify. She says she felt like she was out of options — until a friend told her about the state’s mediation program.

After she contacted the program, a state mediator set up a scheduled call with Aetna and St. David’s. But before it took place, a KUT reporter asked St. David’s for a comment on the situation. Shortly afterward, Shapiro says, St. David’s told her she no longer owed anything.

St. David’s later told KUT that Shapiro had “already satisfied her financial obligation.” It also denied that she was balance billed to begin with.

Shapiro says the whole experience has been exhausting. “It’s just very frustrating because this has been very time-consuming,” she says.

More work to do

The Center for Public Policy Priorities’ Pogue has been arguing that the state needs to find more ways to get involved.

She says the current mediation process is pretty good, but not enough people know it’s an option.

“Because first, the instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she says.

And even if people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer, Pogue adds.

But when people use the program, it tends to work by saving patients money.

In fiscal year 2018, the initial complaints amounted to $9.7 million worth of medical bills, according to the state insurance agency. After mediation, the final charges had been negotiated down to $1.3 million.

Pogue says mediation is helpful, but it still puts a big burden on the patient, who may be confused. “Why didn’t this happen in the first place?” Pogue says. “How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?”

The ideal solution to surprise medical bills would remove consumers from this confusing web altogether, she says.

Pogue points out that states like New York, California and Florida have systems that make things easier for consumers. She thinks Texas should do that too.

In 2015, New York became the first state to pass a law aimed at protecting patients from surprise medical bills from out-of-network hospitals. The Emergency Medical Services and Surprise Bills Law holds consumers harmless if they are treated by an out-of-network doctor at a participating hospital, among other things.

In 2016, Florida lawmakers passed legislation protecting consumers from receiving surprise medical bills “from doctors and hospitals that don’t have a contract with the patient’s insurance plan,” the Miami Herald reported.

And in 2017, California passed a law shielding patients from balance billing. The law kicks in if someone visits an in-network provider, including a hospital, imaging center or lab, according to the San Francisco Chronicle. Under the law, patients “will be responsible only for [their] in-network share of the cost, even if [they are] seen by an out-of-network provider,” the Chronicle reported.

In the meantime, Pogue says, more Texans should take advantage of what’s already in place in the state.

The number of people who seek mediation is “tiny compared to the number of people who get surprise bills,” she says, “so there is a ton of work to be done.”

This story is part of NPR’s reporting partnership with KUT and Kaiser Health News. You can follow Ashley Lopez on Twitter: @AshLopezRadio.

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Ashoor Rasho has spent more than half his life alone in a prison cell in Illinois — 22 to 24 hours a day. The cell was so narrow he could reach his arms out and touch both walls at once.

“It was pretty broke down — the whole system, the way they treated us,” says the 43-year-old Rasho, who has been diagnosed with several mental health conditions, including severe depression, schizophrenia and borderline personality disorder.

Rasho says little things would trigger him, and he’d react violently. Although he’d been sentenced to prison initially for robbery and burglary, his sentence was extended over and over for assaults on prison staff.

“Even if they would label us schizophrenic or bipolar, we would still be considered behavioral problems,” Rasho says. “So the only best thing for them to do was keep us isolated. Or they heavily medicate you.”

He spent most of his 26-year prison sentence in restrictive housing, or solitary confinement, where he had hallucinations, engaged in self-mutilation and tried to kill himself.

In 2007, Rasho and 12,000 other inmates with mental illness sued the Illinois Department of Corrections, alleging that the agency punishes inmates with mental illness instead of properly treating them.

A settlement was reached in 2016, when the state agreed to revamp mental health care and provide better treatment.

But a federal judge has ruled that care remains “grossly insufficient” and “extremely poor.” The agency has not hired enough mental health staff to provide care to everyone who needs it, and inmates with mental illness suffer as they continue to wait for long-overdue treatment.

Punishment, not treatment

Dr. Stuart Grassian is a psychiatrist who spent 25 years at Harvard studying how the conditions in solitary confinement cause harm — especially for people who are mentally ill.

“You’re looking at the population of a state psychiatric hospital,” says Grassian, who has met hundreds of inmates like Rasho who have served long sentences in extreme isolation.

“They’re not the worst of the worst,” Grassian says. “They’re the sickest of the sick; the wretched of the Earth. Maybe they weren’t even that bad before they got in, and they just get worse and worse. It’s a tragedy — absolutely immoral — to see that happen to people.”

Inadequate treatment of mentally ill prisoners is a problem across the U.S. When psychiatric institutions began closing down in the 1950s, they weren’t replaced with mental health services in the community. So, many people with mental illness have scrapes with the law, and end up in prisons that are ill-equipped to treat them.

According to federal data on state and federal prisons from 2011 to 2012, nearly 40 percent of inmates reported having been told by a mental health professional that they had a mental health disorder.

Yet among those who met the threshold for having serious psychological distress at the time of the survey, only about half were receiving treatment — medication, counseling, or both — for their illness. And they were more likely to be written up or charged with verbal or physical assault against correctional staff or other inmates than prisoners without an indicator of a mental health problem.

Correctional facilities in the U.S. are considered the largest provider of mental health services. Yet many prison systems are facing fiscal crises and struggle to provide constitutionally adequate treatment, even after lawsuits lead to court mandates for access to mental health care.

The problem is particularly bad in Illinois, which has long ranked near last in terms of the amount of money it spends on health care for inmates, according to the Pew Charitable Trusts.

And when prison inmates don’t receive the mental health care they need, they’re more likely to cycle in and out of the criminal justice system.

Alan Mills, one of the attorneys representing inmates in the 2007 class-action lawsuit, has made numerous visits to Illinois prison facilities in recent years.

“When you walk through these galleries, you get overwhelmed by the pain and suffering that you see in front of you,” says Mills, director of the Uptown People’s Law Center in Chicago.

An obvious problem

Even state officials acknowledge the prison system has not done well for inmates with mental illness.

“Corrections in Illinois was a little slow to recognize we are the mental health system for Illinois,” says John Baldwin, who directs the state’s corrections department. “Whether we want to be or not, we are; and we have to start acting like it.”

Baldwin says since he took over in 2015, the department has hired more mental health staff and provided training to all employees on how to engage with people who are mentally ill.

Most inmates now spend at least eight hours a week out of their cell and see a therapist once a month.

And about 765 of the inmates who are most ill have been transferred to new residential treatment facilities — where they are finally receiving appropriate care, Baldwin says.

But Mills points out: That’s a small fraction of the 12,000 who are mentally ill.

“And for the vast majority of those, not a lot has changed,” Mills says. “They simply aren’t getting the kind of treatment they need in order to improve their situation at all.”

A sign of progress

The Joliet Treatment Center in the southwest suburbs of Chicago doesn’t look like a typical prison facility.

Half a dozen single-story buildings — called dorms — surround a big grassy area. Walking paths connect the dorms.

“I always refer to it as the quad,” Warden Andrea Tack says, as she takes me on a tour. “It reminds me of some of the college campuses that have [a] big center lawn area and then all the classrooms surround it.”

But, unlike a college campus, this facility is surrounded by two layers of barbed wire fencing.

A few years ago, Illinois spent $17 million to convert what used to be a youth detention center at Joliet into a mental health treatment facility for inmates with serious mental illness.

The dining hall is at the center of the quad; the gym is just to the east, and a building to the south houses a library, medical clinic and classrooms where inmates take GED courses and receive job training.

Tack says the inmates here spend about 30 hours a week out of their cell in various activities, according to their individual treatment plans.

She says she’s seen inmates who’ve been transferred to the Joliet facility make huge strides over the past year.

People who were attempting to hang themselves and acting out aggressively, “now, they’re out and about in the community — going to classes, going to meals, interacting with others,” Tack says. “Some are serving as mentors for other residents.”

Mills says he, too, has seen this transformation in some inmates.

“And it’s a difficult transition,” he says, “because you’ve been treated in a place where you’re continually traumatized, and then you get to a place where actually people care about you.”

It takes time, Mills says, for many to learn that they can trust and receive help, instead of acting out aggressively the way they’ve been conditioned to do for so many years.

‘Culture of abuse’

The atmosphere at the Joliet center stands in stark contrast to the experience at some of the state’s other prisons, such as Pontiac Correctional Center, located about 60 miles south of Joliet.

There, inmates with mental illness are often kept isolated and are lucky to get even one hour of mental health treatment a month, says Dr. Pablo Stewart, a psychiatrist. He was appointed by the federal court to oversee the settlement in the lawsuit.

In his most recent report, Stewart singled out the prison at Pontiac for having a “culture of abuse and retaliation” against mentally ill inmates.

“Almost everyone at the mental health unit at Pontiac should be at Joliet,” Stewart says.

If they were getting that same level of mental health care, Stewart says, they wouldn’t have as many behavior issues.

The Pontiac prison has a high concentration of inmates with behavior problems; the most challenging inmates are transferred there from prison facilities across the state.

And the facility lacks the necessary mental health staff to provide treatment to everyone who needs it.

As a result, Stewart says, many mentally ill inmates are isolated from the rest of the prison population, with little or no meaningful social interaction. The conditions cause them to deteriorate, he says, making them more prone to acting out.

Mentally ill prisoners isolated this way “end up throwing feces or urine at staff; end up exposing themselves [or] masturbating in front of female staff,” Stewart says.

Inmates with untreated mental illness also often get into fights with other inmates and prison staff.

Stewart says the workers themselves are traumatized from their job, and that can make them prone to retaliate. Based on interviews with both inmates and staff, Stewart says he’s absolutely convinced that some staff members abuse inmates at Pontiac.

Asked about those abuse allegations, a spokesperson for the corrections department, Lindsey Hess, writes in an email that the agency takes allegations of excessive force seriously and investigates them.

In an interview prior to the latest court monitor’s report, Baldwin said he would “be surprised” if inmates with mental illness were being abused today.

“We take swift action to refer [any reports of abuse] we get to the state police or the state’s attorney,” he said. “We will not tolerate that.”

As for prison staff who may be traumatized by their job, Hess says the agency has implemented several initiatives in recent years to improve the mental, physical and emotional well-being of employees.

These include peer support groups for staff, access to professional counselors and a recurring class — called “From Corrections Fatigue to Fulfillment” — that teaches staff members about the psychological dynamics of working in the field of corrections.

Stewart says Joliet is one Illinois facility that is finally providing inmates with adequate mental health treatment. That should be the norm everywhere, he says. But it’s not.

“That’s the standard of care that’s required,” Stewart says.

A lingering problem

When I interviewed Rasho last May, he’d been out of prison for more than a year. But his many years spent in solitary confinement still haunt him.

“I don’t sleep right,” he told me. “Any little thing triggers something in me.”

Last fall, Rasho was arrested again, so he’s now back in the prison system.

Mills says the situation in Illinois shows that lawsuits don’t always solve the problems — at least not right away.

“A court order is great, but it’s a piece of paper,” he says. “It’s not actually treatment.”

The orders from U.S. District Judge Michael Mihm continue.

Days before Christmas, he ordered Illinois’ prison agency to correct widespread deficiencies. He gave the agency until March to hire enough mental health staff to provide adequate care to all inmates who need it.

This story was produced by Side Effects Public Media, a news collaborative covering public health. Christine Herman is a recipient of the 2018-2019 Rosalynn Carter Fellowships for Mental Health Journalism. Follow her on Twitter: @CTHerman.

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The first nine months of 2013 started off as a banner year for the Sackler family, owners of the pharmaceutical company that produces OxyContin, the addictive opioid pain medication. Purdue Pharma paid the family $400 million from its profits during that time, claims a lawsuit filed by the Massachusetts attorney general.

However, when profits dropped in the fourth quarter, the family allegedly supported the company’s intense push to increase sales representatives’ visits to doctors and other prescribers.

Purdue had hired a consulting firm to help reps target “high-prescribing” doctors, including several in Massachusetts. One physician in a town south of Boston wrote an additional 167 prescriptions for OxyContin after sales representatives increased their visits, according to the latest version of the lawsuit filed Thursday in Suffolk County Superior Court in Boston.

The lawsuit claims Purdue paid members of the Sackler family more than $4 billion between 2008 and 2016. Eight members of the family who served on the board or as executives as well as several directors and officers with Purdue are named in the lawsuit. This is the first lawsuit among hundreds of others that were previously filed across the country to charge the Sacklers with profiting from the harm and death of people taking the company’s opioids.

WBUR along with several other media outlets sued Purdue Pharma to force the release of previously redacted information that was filed in the Massachusetts Superior Court case. When a judge ordered the records to be released with few, if any, redactions this week, Purdue filed two appeals and lost.

Read the documents here or below:

The complaint filed by Massachusetts Attorney General Maura Healey says that former Purdue Pharma CEO Richard Sackler allegedly suggested the family sell the company or, if they weren’t able to find a buyer, to milk the drugmaker’s profits and “distribute more free cash flow” to themselves.

That was in 2008, one year after Purdue pleaded guilty to a felony and agreed to stop misrepresenting the addictive potential of its highly profitable painkiller, OxyContin.

The complaint says the Sacklers voted to pay themselves $250 million at a board meeting in June 2008. Another payment in September totaled $199 million.

The company continued to receive complaints about OxyContin similar to those that led to the 2007 guilty plea, according to unredacted documents filed in the case.

While the company settled lawsuits in 2009 totaling $2.7 million brought by family members of those who had been harmed by OxyContin throughout the country, the company amped up its marketing of the drug to physicians by spending $121.6 million on sales reps for the coming year. The Sacklers paid themselves $335 million that year.

The lawsuit claims Sackler family members directed efforts to boost sales. An attorney for the family and other board directors is challenging the authority to make that claim in Massachusetts. A motion on jurisdiction in the case hasn’t been heard. That attorney hasn’t responded to a request for comment on the most recent allegations.

Purdue Pharma, in a statement, said the complaint filed by Healey is “part of a continuing effort to single out Purdue, blame it for the entire opioid crisis, and try the case in the court of public opinion rather than the justice system.”

Purdue went on to charge Healey with attempting to “vilify” Purdue in a complaint “riddled with demonstrably inaccurate allegations.” Purdue said it has more than 65 initiatives aimed at reducing the misuse of prescription opioids. The company says Healey fails to acknowledge that most opioid overdose deaths currently are the result of fentanyl.

Purdue fought the release of many sections of the 274-page complaint. Attorneys for the company said at a hearing on Jan. 25 that they had agreed to release much more information in Massachusetts than has been cleared by a judge overseeing hundreds of cases consolidated in Ohio. Purdue filed both state and federal appeals this week to block release of the compensation figures and other information about Purdue’s plan to expand into drugs to treat opioid addiction.

The attorney general’s complaint says that in a ploy to distance themselves from the emerging statistics and studies that showed OxyContin’s addictive characteristics, the Sacklers approved public marketing plans that labeled people hurt by opioids as “junkies” and “criminals.”

Richard Sackler allegedly wrote that Purdue should “hammer” them in every way possible.

While Purdue Pharma publicly denied its opioids were addictive, internally company officials were acknowledging it and devising a plan to profit off them even more, the complaint states.

Kathe Sackler, a board member, pitched Project Tango, a secret plan to grow Purdue beyond providing painkillers by also providing a drug, Suboxone, to treat those addicted.

“Addictive opioids and opioid addiction are ‘naturally linked,’ ” she allegedly wrote in September 2014.

According to the lawsuit, Purdue staff wrote: “It is an attractive market. Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”

They predicted that 40-60 percent of the patients buying Suboxone for the first time would relapse and have to take it again, which meant more revenue.

Purdue never went through with it, but Healey contends this and other internal documents show the family’s greed and disregard for the welfare of patients.

A version of this story first ran on WBUR’s CommonHealth. You can follow @mbebinger on Twitter.

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“Medicare-for-all,” once widely considered a fringe proposal for providing health care in the U.S., is getting more popular. Several Democratic presidential hopefuls are getting behind the idea.

Sen. Kamala Harris, D-Calif., endorsed the approach Monday in a CNN town hall-style event, saying her aim would be to eliminate all private insurance.

“Who of us has not had that situation, where you’ve got to wait for approval and the doctor says, well, ‘I don’t know if your insurance company is going to cover this,’ ” Harris said. “Let’s eliminate all of that. Let’s move on.”

Harris was a co-sponsor of a 2017 bill written by Sen. Bernie Sanders, I-Vt., that would have created a national, single-payer health system, eliminating the private insurance system.

Sens. Elizabeth Warren, D-Mass., and Kirsten Gillibrand, D-N.Y., both presidential hopefuls, also co-sponsored the Sanders bill.

Everyone would get a Medicare card and doctors would have to sign annual agreements to participate.

The major questions the candidates face is how the government would pay for it.

Total spending on health care in the U.S. was about $3.5 trillion in 2017 and is forecast to rise to $5.7 trillion in 2026, according to the Department of Health and Human Services.

The federal government already pays for a lot of that through Medicare, Medicaid, military health care and the Department of Veterans Affairs. Much of the rest is through employer health insurance plans and individual health insurance and payments by patients.

Sanders laid out several options to pay for his proposal, including increasing taxes on employers who would no longer be paying insurance premiums; increasing individual income taxes; and boosting taxes on the wealthy.

Harris didn’t say, in the town hall-style meeting, how she would pay for the program. And her Senate office didn’t respond to an email asking whether she has a funding proposal.

Warren has proposed a 2 percent tax on the wealth of an individual that’s above $50 million and 3 percent on wealth of more than $1 billion.

The mechanism for paying for “Medicare-for-all” can make the politics muddy.

A recent poll by the Kaiser Family Foundation suggests that 56 percent of people in the U.S. like the idea overall.

But when people heard more details, those numbers changed.

When the question included the idea that “Medicare-for-all” would guarantee health insurance as a right, its support rose to 71 percent. But when it said people would have to pay more taxes, the popularity plummeted to 37 percent.

That dynamic has created an opening for potential centrist candidates to stake out a middle road.

Howard Schultz, the former CEO of Starbucks, who has said he is considering a presidential run, told CBS reporters that Harris’ proposal to eliminate the health insurance industry is “not American.” He also called proposed tax increases on the wealthy “punitive.”

Mike Bloomberg, the former mayor of New York and founder of Bloomberg LP, who is also considering a run, said in New Hampshire Tuesday that he, too, opposed the idea.

“To replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time,” he told workers at a factory he was visiting.

Bloomberg has said he supports opening Medicare to people who don’t have coverage through their employers.

The health insurance industry is already gearing up to oppose any “Medicare-for-all” proposals, according to The Intercept, an investigative news website.

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Matt Gleason had skipped getting a flu shot for more than a decade.

But after suffering a nasty bout of the virus last winter, he decided to get vaccinated at his Charlotte, N.C., workplace in October. “It was super easy and free,” said Gleason, 39, a sales operations analyst.

That is, until Gleason fainted five minutes after getting the shot. Though he came to quickly and had a history of fainting, his colleagues called 911. And when the paramedics sat him up, he began vomiting. That symptom worried him enough to agree to go to the hospital in an ambulance.

He spent the next eight hours at a nearby hospital — mostly in the emergency room waiting area. He had one consult with a doctor via teleconference as he was getting an electrocardiogram. He was feeling much better by the time he saw an in-person doctor, who ordered blood and urine tests and a chest X-ray.

All the tests to rule out a heart attack or other serious condition were negative, and Gleason was sent home at 10:30 p.m.

And then the bill came.

The patient: Matt Gleason, who works for Flexential, an information technology firm in Charlotte. He is married with two children.

Total bill: $4,692 for all the hospital care, including $2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83 for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer, Blue Cross and Blue Shield of North Carolina, negotiated discounts for the in-network hospital and reduced those costs to $3,711. Gleason is responsible for that entire amount because he had a $4,000 annual deductible. (The ambulance company and the ER doctor billed Gleason separately for their services, each about $1,300, but his out-of-pocket charge for each was $250 under his insurance.)

Service provider: Atrium Health Pineville (formerly called Carolinas HealthCare System-Pineville), a 235-bed nonprofit hospital in Charlotte and one of more than 40 hospitals owned by Atrium.

Medical service: On Oct. 4, Gleason was taken by ambulance to Atrium Health Pineville’s emergency room to be evaluated after briefly passing out and vomiting following a flu shot. He was given several tests, mostly to check for a heart attack.

What gives: Fainting after getting the flu vaccine or other shots is a well-described phenomenon in the medical literature. But once 911 is summoned, you could be facing an ER work-up. And in the U.S., that usually means big money.

The biggest part of Gleason’s bill — $2,961 — was the general ER fee. Atrium coded Gleason’s ER visit as a Level 5 — the second-highest and second-most expensive — on a 6-point scale. It is one step below the code for someone who has a gunshot wound or major injuries from a car accident. Gleason was told by the hospital that his admission was a Level 5 because he received at least three medical tests.

Gleason argued he should have paid a lower-level ER fee, considering his relatively mild symptoms and how he spent most of the eight hours in the ER waiting area.

The American Hospital Association, the American College of Emergency Physicians and other health groups devised criteria in 2000 to bring some uniformity to emergency room billing. The different levels reflect the varying amount of resources (equipment and supplies) the hospital uses for the particular ER level. Level 1 represents the lowest level of ER facility fees, while ER Level 6, or critical care, is the highest. Many hospitals have adopted the voluntary guidelines.

David McKenzie, reimbursement director at the American College of Emergency Physicians, said the guidelines were set up to help hospitals charge appropriately. Asked if hospitals have an incentive to perform extra tests to get patients to a higher-cost billing code, McKenzie said: “It’s not a perfect system. Hospitals have an incentive to do a CT exam, and taxi drivers have an incentive to take the long way home.”

The guidelines don’t determine the prices hospitals set for each ER level. Hospitals are free to set whatever prices they want as long as their system is consistent among patients, he said.

He said the multiple tests on Gleason suggest the hospital was worried he could be seriously ill. But he questioned why Gleason was told to stay in the ER waiting area for several hours if that was the case. It’s also not clear if Gleason’s history of fainting and overall good health was considered.

Blue Cross and Blue Shield of North Carolina said in a statement that the hospital “appears to have billed Gleason appropriately.” It noted the hospital reduced its costs by about $980 because of the insurer’s negotiated rates. But the insurer said it has no way to reduce the general ER admission fee.

“We work hard to negotiate discounts that reduce costs for our members, but costs are still far too high,” the insurer said. “This forces consumers to pay more out of pocket and drives up premiums.”

Gleason in fighting his bill actually got the hospital to send him its entire “chargemaster” price list for every code — a 250-page, double-sided document on paper. He was charged several hundred dollars more than the listed price for his Level 5 ER visit.

“In this specific example, the price of admission to the ER was more than $2,960. That was on top of more than $1,000 for the medical procedures actually performed. We won’t significantly bring down health care costs until we address the high prices like these,” BCBS-NC said in the statement.

John Hennessy, chief business development officer for WellRithms, a consulting firm that reviews bills for large employers, said the hospital charges are significantly higher than what Medicare pays in the Charlotte area, but those are the prices Gleason’s insurer has negotiated. “Seeing billed charges well in excess of what Medicare pays is nothing unusual,” Hennessy said.

He said the insurer most likely agreed to the higher charges to make sure it had the large hospital system in its network. Atrium is the biggest health system in North Carolina.

He said the coding “makes sense” because it meets the guidelines — even if that meant a nearly $4,000 bill for Gleason.

“The hospital has every right to collect it regardless if you or I think it’s a fair price,” he said.

Resolution: After Gleason appealed, Atrium Health reviewed the bill but didn’t make any changes. “I understand you may be frustrated with the cost of your visit; however, based on these findings, we are not able to make any adjustments to your account,” Josh Crawford, nurse manager for the hospital’s emergency department, wrote to Gleason on Nov. 15.

Atrium Health, in a statement to KHN and NPR, defended its care and charges as “appropriate.”

“The symptoms Mr. Gleason presented with could have been any number of things — some of them fatal,” the hospital said.

“Atrium Health has set criteria which determines at what level an [emergency department] visit is charged. In Mr. Gleason’s case, there were several variables that made this a Level 5 visit, including arriving by ambulance and three or more different departmental diagnostic tests.”

Gleason said the $3,700 hospital bill won’t bankrupt his family. “What it does is wipe out our savings,” he added.

The takeaway: Gleason, understandably, says he’s reluctant to get a flu shot in the future. But that’s not the best response. It’s important to know that fainting is a known reaction to shots and some people seem particularly prone. It’s best to sit or lie down when you get the vaccine, and wait five to 10 minutes before jumping up and returning to business.

Be aware, if you — or someone else — calls 911 for a health emergency, you are very likely to be taken to the hospital. You probably won’t have a choice of which one. And a hospital trip may not even be needed, so think before you call: “How do I feel?”

The medical professional who administered the shot might have suggested that calling 911 wasn’t a smart or needed response for a known side effect of a vaccine injection in a young person.

The emergency room is the most expensive place to seek care.

In hindsight, Gleason might have gone to an urgent care facility or called his primary care doctor, who could have evaluated him and run some tests at much lower prices, if needed.

But employers, hospitals and doctors regularly tell patients if they need immediate care to go to the ER, and hospitals often tout short waiting times in their ERs.

With high deductibles becoming more common, consumers need to be aware that a single trip to the hospital, especially an ER, could cost them thousands of dollars — even for symptoms that turn out to be nothing serious.

Alex Olgin of WFAE and Elisabeth Rosenthal of Kaiser Health News contributed contributed to the audio version of this story.

Do you have an exorbitant or baffling medical bill? Please share it with us and and tell us about your experience here.

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As U.S. immigration enforcement becomes stricter under the Trump administration, more immigrant families are cutting ties with health care services and other critical government programs, according to child advocates who work with these families.

In Texas, researchers studying the issue say it’s a major reason why more children are going without health insurance.

Ana, who lives in Central Texas with her husband and two children, has been increasingly hesitant to seek help from the government. In particular, she’s worried about getting help for her 9-year-old daughter, Sara, who was diagnosed with autism a few years ago.

Ana entered the country without documentation about 10 years ago, which is why NPR has agreed not to use her last name. Both her children were born in the U.S. and have been covered by Medicaid for years. But ever since President Trump took office, Ana has only been using the program for basics — such as checkups and vaccinations for the kids.

This decision to forgo care comes at a cost. Managing Sara’s behavior has been challenging, even after the diagnosis brought some clarity about what was going on. Sara acts out and has tantrums, sometimes in public places. Ana finds it difficult to soothe her daughter, and it’s become more awkward as Sara grows.

“To other people, Sara just seems spoiled or a brat,” Ana says.

After the diagnosis, Ana felt unsure about her next steps. She eventually went to a nonprofit in Austin that guides and supports parents whose children have disabilities. It’s called Vela (“candle” in Spanish).

At Vela, Ana learned about a range of services Sara could get access to via her Medicaid plan — including therapy to help the child communicate better.

However, the thought of asking for more government services for her daughter increased Ana’s anxiety. “I am looking for groups who are not associated with the government,” Ana explains.

Ana is in the middle of the long, expensive legal process of applying for permanent resident status, known informally as a “green card.” Recently, the Trump administration announced that it may tighten part of this process – the “public charge” assessment. The assessment scrutinizes how many government services a green card applicant currently uses — or might use later in life. If a person uses many government services, they could pose a net financial burden on the federal budget — or so goes the rationale. The government’s algorithms are complex, but “public charge” is part of the determination for who gets a green card and who doesn’t.

The rule change proposed by the Trump administration — which may not come to pass — has already led many applicants, or would-be applicants, to be wary of all government services, even those that wouldn’t affect their applications.

“I am afraid they will not give me a legal resident status,” Ana says.

Her husband already has a green card, and the couple is determined to not jeopardize Ana’s ongoing application. So they have decided — just to be safe — to avoid seeking any more help from the government. That’s even though their daughter, who is a citizen, needs more therapy than she’s getting right now.

“I feel bad that I have to do that,” Ana says.

She says she would love to treat her daughter’s autism, but has decided that there is nothing more important than getting that green card, in order to keep the family together in the U.S.

“I’m running into families that, when it’s time for re-enrollment or reapplication, they are pausing and they are questioning if they should,” says Nadine Rueb, a clinical social worker dealing with Ana’s case at Vela.

Reub says a range of fears are behind immigrants avoidance of government services. Some are staying under the radar to avoid immediate deportation. Others are more like Ana — they just want to be in the best position possible to finally get permanent legal status and move on with their lives.

“The climate of fear is so pervasive at this point, and there is so much misinformation out there,” says Cheasty Anderson, a Senior Policy Associate with the Children’s Defense Fund in Texas.

Anderson thinks the parents’ fears have led to an uptick in children going without health coverage in Texas.

A recent study from Georgetown University’s Center for Children and Families found that one out of every five uninsured kids in the U.S. lives in Texas. And a big percentage of those uninsured children are Latino.

The report shows that after years of steady decline, the number (and percentage) of uninsured children in the U.S. increased in 2017, the first year of Trump’s presidency. Nationally, 5 percent of all kids are uninsured — and in Texas the rate rose to 10.7 percent, up from 9.8 percent in 2016.

Joan Alker, the author of the Georgetown report, says the Trump administration’s effort to crack down on both legal and illegal immigration is one of many factors driving up the uninsured rates. And it’s especially perceptible in Texas, where a quarter of children have a parent who is either undocumented, or who is trying to become a legal resident.

“For these mixed-status families, there is likely a heightened fear of interacting with the government, and this may be deterring them from signing up their eligible children up for government-sponsored health care,” Alker said in a phone call with reporters in November, when the report was released.

Anderson says the repercussions fall hardest on kids with disabilities — kids who need services.

“Texas is proud to be Texas in so many ways, but this is one way in which we are failing ourselves,” she says.

From the perspective of Reub, a disability rights specialist, timing is an essential issue for these children.

“The sooner you catch [the diagnosis or condition], the sooner you support the child [and] the sooner you support the family,” Reub says. “I think it’s just a win-win for everybody. You are supporting the emotions of the family, and then that supports the child.”

For now, Ana says she’s relying on the services offered by her daughter’s public school — which aren’t counted in the federal government’s “public charge” assessment. And she’ll keep doing that until she gets that green card.

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

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