The tall, gangly man twists a cone of paper in his hands as stories from nearly 30 years of addiction pour out: the robbery that landed him in prison at 17; never getting his GED; going through the horrors of detox, maybe 40 times, including this latest, which he finished two weeks ago. He’s now in a residential unit for at least 30 days.

“I’m a serious addict,” says Julio Cesar Santiago, 44. “I still have dreams where I’m about to use drugs, and I have to wake up and get on my knees and pray, ‘let God take this away from me,’ because I don’t want to go back. I know that if I go back out there, I’m done.”

Santiago has some reason to worry. Data on opioid addiction in his home state of Massachusetts shows the overdose death rate for Latinos there has doubled in three years, growing at twice the rate of whites and blacks.

Opioid overdose deaths among Latinos are surging nationwide as well. While the overall death toll is still higher for whites, it’s increasing faster for Latinos and blacks, according to data from the Centers for Disease Control and Prevention. Latino fatalities increased 52.5 percent between 2014 and 2016 as compared to 45.8 percent for whites. (Statisticians say counts for Hispanics are typically underestimated by 3 to 5 percent.) The most substantial hike was among blacks — 83.9 percent.

The data portrays a changing face of the opioid epidemic.

“What we thought initially, that this was a problem among non-Hispanic whites, is not quite accurate,” says Robert Anderson, mortality statistics branch chief at the CDC’s National Center for Health Statistics. “If you go back into the data, you can see the increases over time in all of these groups, but we tended to focus on the non-Hispanic whites because the rates were so much higher.”

There’s little understanding about why overdose deaths are rising faster among blacks and Latinos than whites. Some physicians and outreach workers suspect the infiltration of fentanyl into cocaine is driving up fatalities among blacks.

The picture of what’s happening among Latinos has been murky, but interviews with nearly two dozen current and former drug users and their family members, addiction treatment providers and physicians reveal language and cultural barriers and even fear of deportation could be limiting the access of Latinos to life-saving treatment.

Few bilingual treatment options

Irma Bermudez, 43, describes herself as a “grateful recovering addict.” She’s living in the women’s residential unit at Casa Esperanza, a collection of day treatment, residential programs and transitional housing in Boston’s Roxbury neighborhood.

Bermudez says the language barrier keeps anyone who can’t read English out of treatment from the start, as they try to decipher websites or brochures that advertise options. If they call a number on the screen or walk into an office, “there’s no translation — we’re not going to get nothing out of it,” Bermudez says.

Some of the Latinos interviewed for this story describe sitting through group counseling sessions, part of virtually every treatment program, and not being able to follow much, if any, of the conversation. They recall waiting for a translator to arrive for their individual appointment with a doctor or counselor and missing the session when the translator is late or doesn’t show up at all.

SAMHSA, the federal Substance Abuse and Mental Health Services Administration, maintains a Find Treatment website which includes listings of treatment offered in Spanish. But several Massachusetts providers listed there could not say how many translators they have or when they are available. The SAMHSA site is only available in English, with Spanish-language translators only available by phone.

At Casa Esperanza, 100 men are waiting for a spot in the male residential program, so recovery coach Richard Lopez spends a lot time on the phone trying to get clients into a program he thinks has at least one translator.

After battling with voicemail, says Lopez, he’ll eventually get a call back; the agent typically offers to put Lopez’s client on another waiting list. It frustrates him.

“You’re telling me that this person has to wait two to three months? I’m trying to save this person today,” he says. “What am I going to do, bring these individuals to my house and handcuff them so they don’t do nothing?”

Casa Esperanza Executive Director Emily Stewart says Massachusetts needs a public information campaign via Spanish-language media that explains treatment options. She’d like that to include medication-assisted treatment, which she says is not well understood.

Some research shows Latino drug users are less likely than others to have access to or use the addiction treatment medicines, methadone and buprenorphine. One study shows that may be shifting. But, Latinos with experience in the field say, access to buprenorphine (which is also known by the brand name Suboxone) is limited because there are few Spanish-speaking doctors who prescribe it.

Cultural barriers — ‘It’s not cool to call 911’

Lopez has close ties these days with health care providers, the police and EMTs. But that has changed dramatically from when he was using heroin. On the streets, he says,”It’s not cool to be calling 911,” when a person sees someone overdose. “I could get shot, and I won’t call 911.”

It’s a machismo thing, says Lopez.

“To the men in the house, the word ‘help,’ sounds like degrading, you know?” he says. Calling 911 “is like you’re getting exiled from your community.”

Santiago says not everyone feels that way. A few men called EMTs to help revive him. “I wouldn’t be here today if it wasn’t for them,” he says.

But Santiago and others say there’s growing fear among Latinos they know of asking anyone perceived as a government agent for help — especially if the person who needs the help is not a U.S. citizen.

“They fear if they get involved they’re going to get deported,” says Felito Diaz, 41.

Bermudez says Latino women have their own reasons to worry about calling 911 if a boyfriend or husband has stopped breathing.

“If they are in a relationship and trying to protect someone, they might hesitate as well,” says Bermudez, if the man would face arrest and possible jail time.

Ties in the community

Another reason some Latino drug users say they’ve been hit especially hard by this epidemic: A 2017 DEA report on drug trafficking noted that Mexican cartels control much of the illegal drug distribution in the United States, selling the drugs through a network of local gangs and small-scale dealers.

In the Northeast, Dominican drug dealers tend to predominate.

“The Latinos are the ones bringing in the drugs here,” says Rafael, a man who uses heroin and lives on the street in Boston, close to Casa Esperanza. “The Latinos are getting their hands in it, and they’re liking it.”

NPR agreed not to use Rafael’s last name because he uses illegal drugs.

Some Spanish-speaking drug users in the Boston area say they get discounts on the first, most potent cut. Social connection matters, they say.

“Of course, I would feel more comfortable selling to a Latino if I was a drug dealer than a Caucasian or any other, because I know how to relate and get that money off them,” says Lopez.

The social networks of drug use create another layer of challenges for some Latinos, says Dr. Chinazo Cunningham, who treats many patients from Puerto Rico. She primarily works at a clinic affiliated with the Montefiore Medical Center in the Bronx, in New York City.

“The family is such an important unit — it’s difficult if there is substance use within the family for people to stop using opioids,” Cunningham says.

The burden of poverty

Though Latinos are hardly a uniform community, many face an additional risk factor for addiction: poverty. About 20 percent of the community lives in poverty, compared to 9 percent of whites according to the Kaiser Family Foundation. In Massachusetts, four times as many Latinos live below the poverty line as do whites. The majority of Casa Esperanza clients were recently homeless. The wait time for one of the agency’s 37 individual or family housing units ranges from a year to a decade.

“If you’ve done all the work of getting somebody stabilized and then they leave and don’t have a stable place to go, you’re right back where you started,” says Casa Esperanza’s Stewart.

Cunningham says the Latino community has been dealing with opioid addiction for decades and it is one reason for the group’s relatively high incarceration rate. In Massachusetts, Latinos are sentenced to prison at five times the rate of whites.

“It’s great that we’re now talking about it because the opioid epidemic is affecting other populations,” Cunningham says. “It’s a little bit bittersweet that this hasn’t been addressed years before. But it’s good that we’re talking about treatment rather than incarceration, and that this is a medical illness rather than a moral shortcoming.”

Nationally, says the CDC’s Anderson, there’s no sign that the surge of overdose deaths is abating in any population.

“We’ve already had two years of declining life expectancy in the U.S. and I think that when we see the 2017 data we’ll see a third year,” says Anderson. “That hasn’t happened since the great influenza pandemic in the early 1900s.”

The death numbers for 2017 are expected out by the end of this year.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

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The number of kids who struggle with thoughts of suicide – or attempt to kill themselves – is rising. New research, published Wednesday in Pediatrics finds children ages 5-17 visited children’s hospitals for suicidal thoughts or attempts about twice as often in 2015 as in 2008.

The study found kids of all ages are affected though increases were greatest for older adolescents.

Lead author Gregory Plemmons, a pediatrician and researcher at Vanderbilt University in Nashville, Tenn., says the study results confirmed what he’d been seeing at the hospital.

He says he hopes clinicians and families take note. “The number one thing to take home is that it’s important to talk about this and important to ask about it,” he says.

The findings line up with past data showing a steady increase in teen suicide over the past decade. The Centers for Disease Control and Prevention reported last year that a drop in adolescent suicide in the 1990s and early 2000s reversed course in 2008, though it’s not yet reached peak levels seen in the 1980s. It’s not clear what has contributed to the increase, but the study noted the 2008 financial crisis may be one factor among others.

Plemmons and his co-researchers examined 2008-2015 billing data from a database of 49 children’s hospitals across the U.S. They included all emergency department encounters, stays for observation and inpatient hospitalizations at those hospitals, but did not include community hospitals.

The researchers turned up 115,856 visits for suicidal ideation or attempts, during the seven-year period. Such visits represented 0.7 percent of total children’s hospital visits in 2008 but by 2015 had increased to 1.8 percent of all visits. More than half the visits required at least one night of hospitalization, and nearly 1 in 7 required intensive care.

Older teens were more likely to end up in the hospital and had the greater increase in hospital visits. About half of suicide-related hospital visits for the time studied were from teens ages 15-17, but 12- to 14-year-olds closely trailed them, making up 37 percent of visits. Children ages 5-11 made up the remaining 13 percent.

One of the study’s most striking findings was a seasonal trend in hospital visits. Throughout the years, visits peaked in mid-fall and mid-spring and fell to the lowest point in the summer. “We knew there was an association with school seasons, but actually seeing that mapped out was surprising,” says Plemmons. It suggests a link with school pressures.

“It really speaks to the stress and the strain at school,” says Dr. Robert Dicker, associate director of Child & Adolescent Psychiatry at Zucker Hillside Hospital in Glen Oaks, New York. “Kids appear to be under much more academic success to achieve and their perception of falling short.”

Dicker, who was not involved in the study, also noted possible influences from the media, particularly social media.

Plemmons also drew attention to social media’s influence. “You’re becoming more disconnected and not having relationships with real people, and at the same time you’re being fed a false distortion of what reality is, where everything looks great on screen,” he says.

Cyberbullying and sexting he adds, could also be risk factors. “These kids have to deal with pressures that we didn’t deal with.”

Other possible contributors noted in the study included earlier puberty in girls, since reaching puberty is a risk factor for suicide. Girls made up two-thirds of the hospital visits in the study period.

But none of these possibilities is definitive.

“This type of study is very good at revealing trends but cannot address causality,” says Dr. Laurel Williams, chief of psychiatry at Texas Children’s Hospital in Houston, Texas. Despite being the third leading cause of death in adolescents, suicide is still relatively rare, making it harder to study causes, she says.

But it is important to screen for depression and anxiety, she says. Her institution also uses validated screening tools to screen adolescents and is exploring tele-consultation strategies to help pediatricians manage cases if they feel underprepared or uncomfortable.

“We know there are a lot of patients still out there who have clinical depression who are not accessing care,” Plemmons says, adding that it’s important for adults to identify resources in their area for struggling teens. Parents can start with their child’s primary care doctor.

But the most important first step is one anyone can take.

“The current best method for identifying risk is to ask,” Williams says. “Asking a young person how they are feeling, not just how they are doing, is essential. We need to give young people the time and space to talk about how they are feeling. This involves developing closer relationships over time, not something you can scramble at the last minute or only in moments of crisis.”

Plemmons also emphasized the importance of talking to adolescents about the issue.

“There’s still a huge stigma and anything you can do to destigmatize it helps,” he says, adding that a fear still exists among some pediatricians and parents that discussing suicide may suggest it to adolescents.

“We know from literature that that’s not the case,” Plemmons says. “Talking about it can sometimes help reduce the risk.”

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting 741741.

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Health and Human Services Secretary Alex Azar has this pen. It’s not all that remarkable looking, but he held it up multiple times Monday at a briefing with reporters.

“This pen,” he said, “has a lot of power.”

And he said he is prepared to use it.

Azar was making the point that in the area of drug prices, the head of HHS — which runs the Medicare and Medicaid programs and buys about $130 billion in prescription drugs each year — can make a lot of changes in the pharmaceutical market. And he doesn’t need congressional approval to do it.

He’s got plans to use that pen to change the way Medicare and Medicaid pay for medications and how the Food and Drug Administration goes about approving drugs for marketing.

Lots of the ideas are wonky and esoteric, but analysts say some could make a big difference over the long term.

Here are three of the big ideas Azar laid out Monday, three days after President Trump unveiled a blueprint to lower the cost of prescription drugs that was criticized for being light on substance.

1. Restructure the way pharmacy benefit managers deal with drugmakers

Azar’s most ambitious initiative would ban pharmacy benefit managers — the companies that administer prescription drug plans for insurance companies or employers – from negotiating discounts with drugmakers as a percentage of list prices.

Today PBMs, such as CVS Caremark or Express Scripts, make deals in the form of rebates. Pharmaceutical companies offer something like 30 percent off the list price of their drugs if the PBM places the medicines in a favorable spot on their preferred drug lists. When prices go up, PBMs often make more money as rebates grow.

“They’re taking money from both sides,” Azar said. “They’ve built into their system a regime where they get more money when the list price goes up.”

Azar said he intends to force PBMs to write contracts based on a set price for drugs, rather than a percentage-based rebate. And, he said, he’s looking to ban them from making any money at all from pharmaceutical companies. Instead, the companies would earn money only from the fees paid by the insurance companies or employers who hire them.

“This is nothing short of the complete and fundamental restructuring of over $400 billion of the U.S. economy,” he said.

David Mitchell, founder of the advocacy group Patients for Affordable Drugs, approves of the idea. “If they could do away with the rebates and have transparent net prices, I think that’s an enormous step forward,” he said.

But Express Scripts spokesman Brian Henry takes issue with targeting PBMs. “The root cause is the pharmaceutical companies who set these prices,” he said. “We are the ones who help drive down the costs. We drive competition.”

2. Change the way Medicare pays for some expensive drugs

Azar says he wants to simplify the way Medicare pays for many drugs by moving some expensive medications that are administered in doctors’ offices — like cancer drugs — into the standard Medicare prescription drug program.

Many of those expensive drugs are paid for through Medicare Part B. It’s a system in which doctors buy the drugs and get paid a percentage of their cost to administer them to patients. Under this system, the government pays the full list price and doctors make more money when they prescribe more expensive drugs.

Azar said he wants to move some of the most expensive of those drugs to the Part D program, which is administered by private health insurance companies that negotiate discounts with drug companies.

“This move from B to D gives us the power to negotiate against drug companies,” he said.

But analysts caution it could lead to higher out-of-pocket costs and less choice for patients.

“Moving drugs from Part B to Part D could get the prices of some drugs down by allowing insurers to bargain with drugmakers, but it would likely come with more restrictions on which drugs are covered,” said Larry Levitt, vice president of the Kaiser Family Foundation. “Some Part B drugs — many of which are infusions like chemotherapy — don’t have competitors, so negotiation may not help much.”

3. Make prices more transparent

The Centers for Medicare and Medicaid Services will release new versions of its Medicare and Medicaid drug price dashboards on Tuesday that HHS says will have more detail on how much the programs are paying for the medications they buy.

And on top of that, Azar says he is looking at whether he can require drug companies to include the price of their products in those television ads that already include seemingly endless lists of scary side effects.

Mitchell and Levitt both doubt that drug companies can be shamed into lowering prices and losing profit.

“It’s not going to lower drug prices,” Mitchell says. “But it would probably help for patients to know that the drug they’re getting costs $100,000.”

And finally, he wants to get rid of what he calls a “gag rule” in some PBM contracts that forbid pharmacists to tell patients they can get their drug cheaper by going outside their insurance plan.

“Note that there are a number of proposals they are suggesting that are controversial and will result in pitched battles,” says Rodney Whitlock, vice president of health policy at ML Strategies, a lobbying firm. “That said, they sure are talking a good game and should be given deference that action will approach rhetoric.”

Azar, who came to HHS after a stint as president of the U.S. operations of the pharmaceutical giant Eli Lilly, opened his talk by dispensing with the industry’s long-embraced argument that high prices are necessary to pay for research into future cures.

“I’ve been a drug company executive. I know the tired talking points: the idea that if one penny disappears from pharma profit margins, American innovation will grind to a halt,” Azar said. “I’m not interested in hearing those talking points anymore.”

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President Trump presented a broad-brush outline of how his administration hopes to stem the decades-long increase in prescription drug prices and spending, in a speech Friday in the Rose Garden of the White House.

The administration also released a 39-page document describing a variety of proposals it is either considering or studying in an effort to lower costs to individuals, corporations, the government and the economy as a whole.

There were few concrete actions taken today. The plan mostly lists dozens of “potential” steps the administration may take, along with many others that were included in the president’s budget proposal and will require congressional action. Several options are “requests for information.”

Nevertheless, the president characterized the proposal as “the most sweeping action in history to lower the price of prescription drugs for the American people.”

“We will have tougher negotiations, more competition and much lower prices at the pharmacy counter and it will start to take effect very soon,” Trump said.

The president was accompanied by Health and Human Services Secretary Alex Azar, who played a major role in developing the plan.

Trump said he wants to eliminate “middlemen” in the drug industry — which includes pharmacy benefit managers and wholesalers — and he criticized industry lobbyists for making a fortune at the expense of taxpayers and patients.

U.S. patients spent nearly $329 billion on prescription drugs in 2016, according to the National Health Expenditures Survey. That’s an increase of about $100 billion in the past 10 years.

Many researchers say the biggest reason behind the rising spending is high prices for prescription drugs. Often, companies are rewarded for setting a high retail price because insurers negotiate discounts off that initial price.

The blueprint released Friday reiterates proposals that were included in the White House budget proposal. Those include allowing Medicare’s prescription drug plans to slim down the number of drugs they pay for to spark price competition among pharmaceutical companies, and capping how much money Medicare patients themselves can spend on drugs each year.

“On the positive side, I will say that HHS does seem to be paying close attention to this issue, given all the issues they bring up in the blueprint document,” says Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.

“On the negative side, it’s a bunch of questions, not a specific plan for how to proceed.”

Azar, in a briefing following the Rose Garden speech, acknowledged the plan is sweeping and would take years to implement. He said the administration will pursue those ideas it can get done.

“This is a major restructuring of a huge portion of the U.S. economy. One doesn’t do that lightly,” he said.

The plan, like the budget, also proposes limiting price increases Medicare would pay to the rate of inflation and changing some rules around generic drug approvals to prevent companies from blocking new generic competition.

Many of those ideas would require legislation and congressional approval.

Azar, in his briefing, emphasized his desire to change the way pharmacy benefit managers operate — specifically a system where they negotiate rebates off high drug prices.

“We are calling into question today the entire structure of using rebates in the pharmacy channel,” he said.

The president also wants to take steps to ensure foreign governments don’t get lower prices for drugs than do U.S. taxpayers – which he referred to as “global freeloading.”

“It’s unfair, it’s ridiculous, and it’s not going to happen any longer,” he said.

Critics say that proposal is unlikely to help lower prices here in the U.S.

“Lifesaving medicines aren’t more expensive here because they cost less elsewhere,” Jason Cone, executive director of Doctors Without Borders USA, wrote in an article published in The Hill. “They’re priced out of reach everywhere because pharmaceutical corporations are charging exorbitant prices simply because they can—and the U.S. government lets them.”

One thing Trump did not propose was allowing Medicare, the government health care program for the elderly, to directly negotiate lower drug prices for its beneficiaries. That’s a change from his rhetoric during his campaign and transition.

“We’re the largest buyer of drugs in the world and yet we don’t bid properly,” he said at a news conference in early January 2017. “We’re going to start bidding and we’re going to save billions of dollars over a period of time.”

But shortly after Trump moved into the Oval Office he wavered on that commitment, first saying that he didn’t want Medicare to engage in what he called “price fixing” and then, through his former spokesman Sean Spicer, saying once again he favored allowing the federal government program to deal with drugmakers to get lower prices.

Medicare accounts for about one-third of U.S. prescription drug spending. Current U.S. law prohibits Medicare officials from interfering in the negotiations between drugmakers and the insurance companies that administer Medicare’s prescription drug plans.

The only government report that looks at the issue is a 2007 Congressional Budget Office study that concluded it would have a “negligible effect” on prices.

But Gellad says that report was limited, because it looked only at the effect if Medicare were not allowed to exclude drugs from its coverage list.

“There is no evidence that allowing Medicare to negotiate doesn’t help,” says Gellad. “In fact, the CBO said that in certain circumstances, with the right formulary, this type of negotiation could help.”

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Samantha Blackwell was working her way through a master’s degree at Cleveland State University when she found out she was pregnant.

“I was 25, in really good health. I had been an athlete all my life. I threw shot put for my college, so I was in my prime,” she says with a laugh.

Though it wasn’t planned, Blackwell’s pregnancy was embraced by her large and loving family and her boyfriend, who would soon become her husband. Her labor was quick, and she gave birth to a healthy baby boy.

Yet just days after she was discharged, Blackwell was back in the hospital, in a medically induced coma, fighting a runaway infection that left her hovering between life and death.

“It was like ‘I fell asleep at that hospital and woke up the next day’ kind of thing,” she says. She was in a coma for more than a month.

Blackwell’s story of reaching the brink of death is one that happens much too often, say researchers.

Over the past year, NPR and ProPublica have been investigating why American mothers die in childbirth at a far higher rate than in all other developed countries.

A mother giving birth in the U.S. is about three times as likely to die as a mother in Britain and Canada.

In the course of our reporting, another disturbing statistic emerged: For every American woman who dies from childbirth, 70 nearly die. That adds up to more than 50,000 women who suffer “severe maternal morbidity” from childbirth each year, according to the Centers for Disease Control and Prevention. A patient safety group, the Alliance for Innovation on Maternal Health, came up with an even higher figure. After conducting an in-depth study of devastating complications in hospitals in four states, it put the nationwide number at around 80,000.

“It’s referred to as the tip of the iceberg because for every woman we lose, there are lots of other women that we come very close to losing,” says obstetrician Peter Bernstein, the director of the Maternal-Fetal Medicine division at Montefiore Medical Center in New York.

But surviving can come with a cost.

“An experience that we would hope and expect would be natural, beautiful, uplifting, becomes one that’s terrifying,” Bernstein says. “Women can wind up losing their uterus and therefore becoming infertile. They can wind up with kidney problems. They can have heart attacks. They can have brain damage from all the blood that they’ve lost.”

Watch the video here.

And that is just a partial list of what can go wrong. Also on that list: Women develop pregnancy-induced high blood pressure known as pre-eclampsia, which can lead to a stroke and organ failure; parts of the placenta can be left behind, which can lead to infection; and a woman giving birth is more prone to blood clots that can be life-threatening.

The cost, though, is not just medical. The treatment for these complications can become an ongoing financial burden, and the trauma suffered from physical complications can lead to persistent emotional and psychological pain.

It is still rare for childbirth to involve truly severe complications, but in the U.S., say researchers, many of these worst-case scenarios need not have happened at all.

Samantha Blackwell doesn’t remember much about her ordeal. It began 11 days after giving birth, when she sat up in bed with a terrible pain. By the time she got to the emergency room, her medical records show, she was in septic shock from a massive infection. For weeks, her doctors couldn’t promise her family that she would live.

“They just knew that it was bad,” she says, “to a point of ‘expect the worst. We don’t know if she’s going to come out of this.’ “

When Blackwell did emerge from her coma, she discovered she had undergone an emergency hysterectomy, a last-ditch effort to stop the infection that had originated in her uterus.

“I don’t think I’m the type to overreact”

In the U.S., the rate of severe complications from childbirth has been rising faster than the rate of women who died. The rate of women nearly dying almost tripled between 1993 and 2014, according to the CDC. To help explain those dire statistics, experts point to risk factors that have increased in recent years: American women are giving birth at older ages and are more likely to have problematic conditions like obesity, high blood pressure and diabetes.

Early in our reporting, NPR and ProPublica launched an online call-out asking for stories of deaths and near deaths due to childbirth, and the tales of catastrophic complications and deaths poured in, ultimately more than 5,000 in all.

Alicia Nichols was among the thousands who wrote about their own experience. At 39, she and her husband had been trying hard to have a baby. She finally succeeded in getting pregnant through in vitro fertilization and gave birth in March 2017, just after she turned 40.

At her home outside of Boston, in a spacious, airy room strewn with baby toys, Nichols spoke of an easy pregnancy. It was how many stories we heard began. The birth, though, was different: a painful 42 hours of labor, until the baby’s “failure to descend” led to an emergency cesarean section.

Then, after healing well for four weeks, she was surprised to feel a gush of blood.

“I was rocking Diana in my rocking chair here in the living room, and when I stood up, blood [had] soaked through me onto the chair,” she says.

Her first reaction was to call an ambulance. “I don’t think I’m the type to overreact. It was just so foreign to me,” she says.

In the emergency room, the obstetrics resident who came over quickly chalked it up to natural postpartum bleeding, something that didn’t merit the ultrasound Nichols was requesting.

“I felt that she was just dismissing me, annoyed, a new mother being paranoid of some blood. I felt like she was not listening at all,” Nichols says.

Throughout our NPR/ProPublica investigation, we heard many variations on the perception by postpartum mothers that their physical concerns were not taken seriously. In Nichols’ case, she was familiar with a medical environment. She worked as an aesthetician and office administrator for a plastic surgeon in the same building as her obstetrician.

In the weeks following her first scare, her obstetrician assured Nichols — in both an office visit and on phone calls — that the episodes of bleeding were most likely the beginning of her menstrual period.

For her part, Nichols pointed out to her doctor that she had never experienced a period like that.

“I had no cramping,” she says. “It was just bright red blood. And, we all know, we’re women. I don’t want to be graphic, but we know it’s different.”

“Denial and delay”

It was before dawn two months after giving birth, that Nichols — up with baby Diana — had another episode of sudden bleeding.

By chance, her own doctor was on call that early morning and picked up the phone. She remembers him saying, “You’re going to be fine. Check back later in the day if this continues.”

Instead, she went to his office right after it opened.

“I got on the elevator, and the minute the elevator door opened, that’s when I began to hemorrhage,” she says.

The obstetrician immediately called an ambulance, but Nichols was already in the midst of a life-threatening emergency.

“I remember putting my hand down, and when I lifted up my hand, it was just, my whole left hand. I remember seeing my wedding ring, just blood. My left hand was soaked with blood,” she says.

According to her medical records, Nichols lost nearly half the blood in her body.

As a last resort — as in the case of Samantha Blackwell in Cleveland — Nichols’ doctors in Boston performed an emergency hysterectomy.

In an addendum attached to Nichols’ records 24 hours later, her obstetrician stuck with his original theory about her bouts of bleeding. He wrote “patient came to office with onset of first period that seemed heavier than average,” and she “suddenly hemorrhaged.”

Though NPR received written permission for Nichols’ obstetrician to share details of her case, he declined to be interviewed for this story.

But a pathology report included in her records found an entirely different cause for Nichols’ on-and-off bleeding. The pathologist’s diagnosis was placental site vessel subinvolution, or VSI.

That essentially means that the enlarged blood vessels in the lining of the uterus, which had sent nutrition and oxygen to the developing fetus, had failed to return to their pre-pregnancy state. They stayed enlarged and intermittently bled into Nichols’ uterus.

Though rare, VSI can be detected early with a scan and treated before leading to a life-threatening hemorrhage.

Obstetrician Elliott Main, a national leader in the movement to reform maternal health care, says that because most mothers do well during and after pregnancy, obstetricians and nurses strongly tend to expect the best and often are not prepared for the worst.

“That sets up the opportunity for what we call the twin demons of denial and delay. Denial that it’s actually something serious,” says Main, “leading to delay before you get the care that’s going to make the difference.”

Indeed, NPR and ProPublica found a medical system that bases care on the idea that it’s rare for a woman to die in childbirth. It’s a system in which funding and resources are dedicated mostly at saving babies.

The price tag of life-threatening complications

Severe complications due to childbirth are not common in the U.S., where nearly 4 million babies are born each year.

Yet bringing down the rate of these complications would not only spare tens of thousands of mothers from nearly dying, but it would also bring down the cost of health care, points out obstetrician Barbara Levy. She oversees health policy at the American College of Obstetricians and Gynecologists.

“Severe morbidity is expensive. ICU care is expensive. Transfusions are expensive. Dialysis is expensive,” she says. “We can actually save money by putting processes in place that reduce risk.”

The cost of Samantha Blackwell’s long hospital stay, rehabilitation and home care soared to nearly $540,000.

Because she was younger than 26, she was covered by her mother’s insurance, which paid for most of that.

But the experience was still financially devastating.

Blackwell couldn’t return to her job at Men’s Wearhouse for months. Her husband, DeVon, spent so much time at the hospital that he lost his job at a car dealership. And Samantha Blackwell’s mother never left her bedside. Cynthia Murphy is still thankful that the K-Mart distribution center where she worked gave her a two-month leave, even though it was unpaid.

“I would have moved from my house, lived on the street. I really would not have cared at that time,” Murphy says. “Samantha was my No. 1 priority.”

Alicia Nichols, whose hemorrhage led to an emergency hysterectomy, measures her financial burden by what she estimates it would take to have another baby via surrogate: at least $80,000.

No single study has tallied the total cost of America’s high rate of severe complications. But there are clues that it runs into the billions. A report in the American Journal of Obstetrics and Gynecology found the cost of caring for mothers suffering from pre-eclampsia is more than a billion dollars each year.

And the federal Agency for Healthcare Research and Quality put a dollar figure on the average cost of a hysterectomy related to childbirth complications: In 2014, it was more than $95,000.

“I was just a wreck”

And then, of course, there is the human cost.

“I have a lot of anger. I do. I know that my obstetrician feels terrible that things went this way, but it just makes me so angry,” says Alicia Nichols, “because I know I’m not the only one. There are so many women out there.”

In Nichols’ case, her troubles did not end with the massive hemorrhage. Just days later, while she and her baby were resting at her parents’ home in Cape Cod, Nichols began feeling dizzy.

And this time, at a local hospital, the doctor paid close attention to her complaint.

“He knew my history, and he said something’s not adding up,” she recalls.

The results of a test that helps identify the presence of blot clots worried this new doctor enough to call for a CT scan, which proved his suspicion.

“He came back, and he’s like, ‘I’m sorry, you’re not going home, you have multiple pulmonary emboli in both your right and left branches,’ ” she says.

Nichols remembers her shock at looking at the scan: “It was like someone splattered paint into my lungs.”

Six days later, Nichols left the hospital with an anti-clotting drug, and a new fear: anticoagulants come with a risk of bleeding, leading her to imagine a nightmare scenario in which she hemorrhaged again.

“So I was just a wreck at that point,” says Nichols, who is now being treated for post-traumatic stress disorder.

“It’s funny, I remember speaking with the critical care pulmonologist, and I was sort of having a pity party and was just devastated,” she says. “I said I’m so unlucky. And he said, ‘No, you should go buy a lottery ticket, because you shouldn’t be alive right now.’ “

It is a common theme among the thousands of women we’ve heard from: Their trauma, both physical and emotional, is hard to shake and impossible to forget.

And that anxiety radiates out to the families who also survived a terrible time.

Two full years after Samantha Blackwell’s son was born, she spoke of how she is continually reminded of the high fever from the raging infection that nearly killed her. That reminder comes from her mother, who nearly lost a daughter.

“My mom, I make fun of her, because she checks my temperature with her hand,” says Blackwell. “Every time she hugs me goodbye, her hand is on my forehead.”

ProPublica’s Nina Martin and NPR’s Meg Anderson contributed to this report.

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One reader suspects a double standard — how come people with private health insurance are allowed to use a manufacturer’s discount coupon for medicine, but Medicare patients can’t? Another consumer wonders what ever happened to cost-free primary care appointments. We have answers to these health care questions that may have been worrying or frustrating you, too:

My doctor wants me to take Repatha for my high cholesterol, but my Medicare drug plan copayment for it is $618 a month. Why can’t I use a $5 drug copay coupon from the manufacturer? If I had commercial insurance, I could. I’m on a fixed income. How is this fair?

The explanation may offer you little comfort. Under the federal anti-kickback law, it’s illegal for drug manufacturers to offer any type of payment that might persuade a patient to purchase something that federal health care programs like Medicare and Medicaid might pay for.

Here’s the scenario, and the federal government’s rationale: Makers of brand-name medicines use the coupons to help increase access to and demand for their products. Patients with commercial insurance like the coupons because they can help make expensive brand-name drugs more affordable. But the coupons may also discourage patients from considering appropriate lower-cost alternatives, including generics, says Leslie Fried, a senior director at the National Council on Aging.

According to a 2013 analysis coauthored by Dr. Joseph Ross, associate professor of medicine and public health at Yale University, and published in the New England Journal of Medicine, 62 percent of 374 drug coupons were for brand-name drugs for which there were lower-cost alternatives available.

If patients choose to use the coupons to buy a higher-cost drug over a generic or other cheaper alternative, the cost to Medicare and other federal health programs is likely to be more than what they would otherwise pay.

There’s also a hitch for any patient using the coupons, Ross points out: The discounts often have annual maximums that leave patients on the hook for the entire copayment after a certain number of months.

Last year, my marketplace plan covered five primary care visits at no charge before I paid down my $2,200 deductible. This year, it doesn’t cover any appointments before the deductible, and I had to pay $80 out-of-pocket when I went to the doctor. Is that typical now? It makes me think twice about going.

Under the Affordable Care Act, marketplace plans are required to cover many preventive services, including an annual checkup, without charging consumers anything out-of-pocket. Beyond that, many marketplace plans cover some services before you reach your deductible — such as some primary care visits or generic drugs.

But the likelihood of having a plan that offers to pay some portion of the cost of primary care before you reach your deductible (rather than requiring you to pay 100 percent of the cost until you hit that amount) varies significantly, depending on whether you’re in a bronze, silver or gold plan, according to a recent analysis by the Robert Wood Johnson Foundation.

In 2018, 77 percent of silver-level plans offer some cost sharing for primary care visits before enrollees have paid off their typical deductible of $3,800, the analysis finds. In most cases, that means people owe a copayment or coinsurance charge for each visit until they reach their deductible.

A small number of plans offer a limited number of no-cost or low-cost visits first, and then people using more services either have to pay the full charge for each visit or must share at least part of the cost until the deductible is met.

Bronze plans for 2018 are much stingier than silver plans in how much they’ll contribute to payments for primary care before people their deductible — the median deductible in 2018 plans is $6,400.

Only 38 percent of bronze plans offer any primary care coverage before the deductible, and generally patients still have to pay a copayment or coinsurance amount. A smaller percentage of bronze plans offer limited visits at no cost or low cost before the deductible is met.

The share of people who chose bronze plans grew from 23 percent in 2017 to 29 percent this year, says Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. While premiums are typically significantly lower in bronze plans than other “metal”-level plans, it can be worthwhile to check out how plans handle primary care services before the deductible, she says.

Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.Follow Michelle Andrews on Twitter: @mandrews110.

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The Trump administration has made clear it would like to remake the American health care system. There’s been the protracted battle over the Affordable Care Act. Now, there are some new moves on the future of Medicaid.

On Monday, the federal government released decisions on requests from two states to change the way they administer the health care program for low-income people.

The first decision came on lifetime caps. Kansas wanted to cut off Medicaid benefits for some people after 36 months.

At a meeting of the American Hospital Association in Washington, D.C., Seema Verma, administrator of the Centers for Medicare and Medicaid Services, made clear that she wants states to have lots of flexibility. But she also drew a line on how far that flexibility can go.

“We’re also determined to make sure that the Medicaid program remains the safety net for those that need it most,” Verma said. “To this end, we have determined we will not approve Kansas’ recent request to place a lifetime limit on Medicaid benefits for some beneficiaries.”

In Kansas, the number of adults eligible for Medicaid is already pretty small, mostly the elderly and the disabled. “Non-disabled adults who don’t have minor children are not eligible for Medicaid at all in Kansas, no matter how low their income is,” says Louise Norris, who writes about health care policy for healthinsurance.org.

The cap would therefore have affected only parents of young kids with extremely low incomes — those who make 38 percent of the federal poverty limit. “So to put that in perspective, if you have a household of three people — like a single parent with two kids — you’re talking $8,000 a year in total income,” Norris said.

The rejection of lifetime caps in Kansas sends a signal to the handful of other states — Maine, Arizona, Utah and Wisconsin — that have similar proposals pending.

Later in the day, there was another decision on Medicaid, when New Hampshire became the fourth state to have its request approved to add work requirements.

Joan Alker of the Georgetown University Center for Children and Families said the timing of the decisions on Kansas and New Hampshire was probably planned. “The fact that they rushed them out together suggests that they wanted to quickly get back to their message that states know best,” she said.

What wasn’t determined Tuesday was the outcome of Kansas’ proposal to add its own work requirements. All of the states that have received approval so far — Indiana, Kentucky, Arkansas and now New Hampshire — expanded eligibility for Medicaid under the Affordable Care Act.

If Kansas’ request is approved, it would be a first for a nonexpansion state. And Alker says many adults in Kansas would lose their Medicaid coverage. “You have a parent who, if they met the work requirement their income would be too high and they’d lose Medicaid, and if they don’t meet the work requirement they’d get kicked off,” Alker says. She calls it a Catch-22.

Other states that didn’t expand Medicaid and also want a work requirement — like Mississippi and Alabama — are closely watching what happens with Kansas’ proposal.

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A few months ago, Kourtnaye Sturgeon helped save someone’s life. She was driving in downtown Indianapolis when she saw people gathered around a car on the side of the road. Sturgeon pulled over and a man told her there was nothing she could do: Two men had overdosed on opioids and appeared to be dead.

“I kind of recall saying, ‘No man, I’ve got Narcan,’ ” she says, referring to the brand- name version of the opioid overdose antidote, naloxone. “Which sounds so silly, but I’m pretty sure that’s what came out.”

Sturgeon sprayed a dose of the drug up the driver’s nose, and waited for it to take effect. About a minute later, she says, the paramedics showed up.

“As they were walking towards us, the driver started slowly moving,” she says. Both people survived.

Sturgeon had the drug with her because she works for Overdose Lifeline, a non-profit devoted to distributing naloxone, but many bystanders would be unprepared to help.

Last month, U.S. Surgeon General Jerome Adams issued an advisory urging more Americans to learn to use naloxone, and carry it with them in case they encounter someone who has overdosed.

With the increase in overdoses nationwide, the advisory suggests that lay responders — people who may witness an overdose before police or EMS arrive — can play a critical role in saving lives.

But if you’re not a medical professional, getting a dose of naloxone can be difficult. It is a prescription drug and normally a doctor or nurse would have to directly prescribe it for the person at risk of overdosing. Corey Davis, an attorney for the National Health Law Program, says that creates a barrier for people with addiction.

“A lot of people at risk of an overdose don’t have contact with a medical provider or they’re afraid because of stigma,” he says.

To broaden access, every state and Washington, D.C., have passed laws making it easier for friends and family members or bystanders to get and use naloxone. Just how easy it is still depends on your state, or even the pharmacy you go to.

Davis says most states allow something called third-party prescribing, which lets doctors prescribe naloxone to someone who knows the person at risk of an overdose. And most states have also passed some kind of Good Samaritan law providing legal immunity for people who administer the drug or call 911.

Davis says another type of law allows a kind of prescription called a standing order.

“But instead of having a person’s name on it, it has a group of people,” says Davis.

A standing order could apply, for example, to anyone who takes opioid painkillers, or suffers from addiction. Or, Davis says, “Anybody who might be in a position to assist someone, which unfortunately, today means essentially everybody.”

In his home state of Indiana, Jerome Adams signed a statewide standing order in 2016, while serving as the state’s health commissioner. It allows pharmacies, local health departments or nonprofits that register with the state and follow certain requirements to dispense the drug to anyone who requests it.

But two years later, only about half of Indiana pharmacies are registered, and local advocates say many people, even some pharmacists, are still unaware of the law.

Even if you understand the laws regulating naloxone in your state — and you feel comfortable asking for it at the pharmacy counter — there’s still the cost, which has gone up in recent years. Two pharmacies near WFYI in Indianapolis, stock naloxone. One charged $80 for two doses of the generic form of the drug. The other charged $95 for two doses of Narcan, the brand-name version.

“It’s expensive,” says Brad Ray, a researcher at Indiana University’s School of Public and Environmental Affairs. “People who are users are scraping money together to buy drugs. They’re not prepared to buy naloxone with that money.”

Several U.S. Senators have signed on to a letter urging Health and Human Services Secretary Alex Azar to negotiate with drug companies to lower the price of naloxone.

For people who can’t afford the drug, Ray says health departments and nonprofits can help. Laws in many states allow these organizations to dispense naloxone to lay responders.

Indiana’s health department used federal and state funds to purchase nearly 14,000 naloxone kits since 2016, the state reports. The state distributes those free doses through county health departments. But nearly half of Indiana counties didn’t request kits. And the majority of the kits went to first responders.

Local health departments, Ray says, need to work harder to get naloxone to people who might use it. People who use drugs, after all, may not feel comfortable going to the government for naloxone.

“Getting it in the hands of users — that’s the trick we need to figure out,” Ray says.

Corey Davis says there is one change that could really help. The Food and Drug Administration or Congress could make naloxone an over-the-counter medication to make it easier to access, and maybe cheaper. FDA Commissioner Scott Gottlieb has the authority to do so, Davis says, but so far he has not.

This story is part of a reporting partnership with NPR, WFYI, Side Effects Public Media and Kaiser Health News.

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