The death of a former major league baseball player in his native Venezuela this week is renewing concerns over the Latin American country’s growing health crisis amid ongoing economic and political turmoil.

Marcos Carvajal, a 34-year-old former pitcher for the Colorado Rockies and Florida Marlins, died of pneumonia on Tuesday. He fell sick in December, but the antibiotics needed to treat the illness were hard to find. Drugs for Carvajal eventually were sent from abroad but he relapsed, returned to the hospital on Monday and died the next day.

The Pharmaceutical Federation of Venezuela estimates the country is suffering from an 85 percent shortage of medicine amid an economic crisis also marked by severe hyperinflation and food scarcity.

The entire Venezuelan health care system is on the verge of collapse, says Francisco Valencia, head of the public health advocacy group Codevida. Some hospitals lack electricity, and more than 13,000 doctors have left Venezuela in the past four years in search of better opportunities.

“They don’t give food to the patients in the hospital,” Valencia tells Here & Now’s Peter O’Dowd. “They don’t have the proper medical supplies to take care of the people who go to the emergency [room] like gloves, like every basic thing they need for an emergency.”

According to the pharmaceutical association, there is also a 90 percent deficit of other medical supplies and drugs used to treat more serious conditions like cancer.

The shortage has forced Venezuelans to go looking for medicine on the black market, Valencia says. Even if they find the right medicine, which is often smuggled from Colombia and Brazil and could be expired, most people can’t afford it.

The crisis affects Valencia personally, who relies on medication for a kidney transplant.

“I haven’t received my medicine since August last year,” he says. “Right now, I’m taking medicines that [have] expired, and my transplant is at risk.”

Venezuela’s President Nicolas Maduro has refused to accept humanitarian aid, blocking shipments of medicine and first aid supplies. Government data shows infant mortality rose by 30 percent in 2016 and malaria infections shot up 76 percent, Reuters reports.

“So most countries when they’re hit by a crisis, they’re taking aid from other countries, from NGOs,” Associated Press reporter Hannah Dreier told NPR in 2016. “But Venezuela keeps refusing to take donations that other countries are offering and is actually turning back shipments of donations that people have given in places like the U.S., not letting medicine in.”

Drug prices have skyrocketed along with those for food and other basic necessities. The International Monetary Fund predicts inflation will soar to 13,000 percent this year and the economy will shrink by 15 percent.

Earlier this week, the government announced it would abandon one of its two official foreign exchange rates, which had been used for food and medicine imports, Reuters reports. The policy change could encourage businesses to import more goods, but critics say it won’t be very effective due to the lack of hard currency in Venezuela.

The elimination of the exchange rate was “a step in the right direction because it helps correct foreign exchange distortion,” Asdrubal Oliveros of local consultancy Ecoanalitica told Reuters. “But without dollars, things will continue to be more complicated.”

Since the collapse of Venezuela’s oil-rich economy in 2014, the country has struggled to raise hard currency. The monthly minimum wage for many Venezuelans is now equal to $3, according to the AP.

Maduro blames the country’s growing crisis on foreign economic sanctions, claiming that the U.S. is leading an effort to wipe out socialism in Venezuela, according to Reuters. Presidential elections are set to be held by April 30, which is much earlier than usual, but Venezuela’s pro-government Supreme Court last week banned the main opposition party from running.

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What happens after a cancer diagnosis?

That’s the question investigated by a study published by the CONCORD program on cancer survival published on Tuesday in The Lancet. The study looks at patient records for adults and children diagnosed with a variety of cancers in 71 countries. The records are from 2010 to 2014. The goal is to compare five-year survival rates, a number used to assess effectiveness of treatment.

The overall message is that there is improvement in cancer survival rates but with a caveat. As lead author Dr. Claudia Allemaninotes, “That is particularly true in developed countries and less so in developing countries.”

Case in point: Childhood cancers in upper–income countries — like the U.S. and much of Europe —are treated so successfully that the five-year survival rate often reaches 90 percent or even higher. That was reflected in the data for acute lymphoblastic leukemia, the most common childhood cancer. By contrast, in some middle-income countries — China, Mexico and Brazil, for example — it’s less than 60 percent.

But there are some surprising revelations. Some countries in Asia do a far better job diagnosing and treating stomach and esophageal cancers than the United States does. Five-year survival rates in South Korea and Japan are 68 percent and 60 percent, respectively, versus 33 percent in the U.S.

To learn more, we spoke with Allemani from the Cancer Survival Group at the London School of Hygiene & Tropical Medicine and Michel Coleman, professor of epidemiology and vital statistics at the same institution. Here are some of the topics we discussed.

Why are children diagnosed with leukemia in Mexico and Brazil not faring as well as children with the same diagnosis in countries like the U.S.?

First, says Coleman, remember that in the 1950s and ’60s, in Western countries, the survival rate for children diagnosed with leukemia was five percent or lower after five years. “There was really no treatment available,” he says.

Today, largely because of chemotherapy as well as some other treatments, like stem cell transplants, survival rates have soared in the West.

But that doesn’t mean that having the right drugs is the solution for countries still struggling with these cancers. “The treatments are quite aggressive and repress the immune system so a child’s ability to defend against infections can be drastically reduced,” he says. “It isn’t simply a question of buying more drugs but a broader upgrading of the health service” to provide supportive care for the child during chemo.

What’s behind the stomach cancer success in parts of Asia?

Countries like South Korea, Japan and Taiwanhave historically had high rates of stomach and esophageal cancer. So local governments as well as companies have set up annual screenings. “They are very skilled at diagnosing very early and at very aggressive surgical techniques to manage those cancers,” says Coleman. But as Allemani points out, the survival rates for other cancers — melanoma and leukemia, for example — “are really quite low.”

Middle-income countries can be as effective in treating cancer as high-income countries.

Allemani points to Costa Rica: “Generally speaking we found very good survival for some cancers” in this upper middle-income nation. It’s one of the countries in the group with a five-year survival rate of 85 percent or higher, including the U.S., Canada, Japan and 16 European countries.

Getting cancer data is harder than you think.

The information in the report comes from registries that cite cancer diagnoses and deaths from cancer. Of the 85 countries contacted, “more than 20 wanted to participate but could not,” says Coleman, because registries have closed or lacked resources to keep reliable data — or did not have legal permission to link data from registries of diagnosis to registries of deaths from cancer. And these problems cropped up in a variety of countries, from low-income to high-income. For example, there is no data from any country in Africa in the childhood cancer section. And, Coleman says, “four of the 13 jurisdictions in Canada were not able to provide data in time for this study.”

That lack of data is “lamentable,” he says.

Without such data, Allemani says, “health ministries are flying blind on cancer control.”

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For the past year, the Trump administration and Republicans in Congress have led a charge to roll back the Affordable Care Act, signaling an openness to changes at the state level.

Now, Idaho has jumped in, with the insurance department saying Wednesday it will allow insurers to ignore some ACA rules on plans not sold on the marketplace. The department aims to make these state-based plans less costly. Several of the changes are viewed by the health law’s supporters as hits to its core consumer protections.

Critics say Idaho can’t unilaterally skip provisions of federal law, including some of the ACA’s protections for pre-existing conditions and its limits on how much more insurers can charge older or sick people.

Idaho’s approach has national implications because of a key underlying question: Will the administration compel Idaho to follow the ACA or offer a green light that could prompt other states to take even more sweeping action?

Idaho argues its aim is to bring people back into the market, particularly the young, the healthy and those who can’t afford an ACA plan.

“Our goal is not to take away from the ACA, but to add to it or complement it,” said Dean Cameron, director of the state’s Department of Insurance. For instance, insurers could veer from the ACA rules in creating the new plans, so long as they offer other ACA-compliant policies.

Premiums for marketplace policies have risen sharply amid continuing GOP efforts to undermine the ACA. Middle-income Americans who don’t get subsidies are struggling to afford coverage.

“States are trying to figure out what they can do,” said Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation. “How do you provide them with cheaper insurance?”

Idaho says the answer is to skip some of the ACA rules.

Here is a quick look at some of the questions that approach raises:

1. Can Idaho do this?

Many experts say no. Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, tweeted early Thursday that the move was “crazypants illegal.”

In a follow-up call, he explained that the ACA created rules that — among other things — prevent insurers from discriminating against people based on their health or excluding coverage for those conditions.

“I’m completely flummoxed,” he said. “Idaho appears to be claiming they do not have to adhere to federal law.”

But Idaho officials believe there’s precedent for what they are doing, pointing to actions taken by President Obama when he promised people that if they liked their health plans, they could keep them. Obama issued an executive order directing his agencies to allow the continuance of some plans purchased before the marketplaces opened— even though they fell short of ACA rules, Cameron noted.

Additionally, Cameron pointed to state laws that allow insurers to sell short-term policies that don’t meet all the ACA rules.

“We have tried to do everything we can to adhere to and follow the requirements,” said Cameron, who added that the state consulted with administration officials as it developed its plan.

“I recognize we are pushing the envelope a bit,” he said. “We think this is what is needed.”

2. What might happen?

A lawsuit challenging Idaho’s move seems likely, perhaps on behalf of someone with a pre-existing condition alleging harm because the state-based plans will cost the sick more or limit coverage in other ways.

Secondly, some experts say the argument might include concerns that the state-based plans could pull healthy people out of the ACA market and drive up premiums there.

Cameron expects the effect will be the opposite, helping stabilize those premiums by bringing more healthy people into insurers’ risk pools through the state-based plans. Insurers would have to pool their claims from both ACA and state-based plans.

3. How different are these plans from ACA coverage?

Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, said they are “in the middle in terms of the consumer protections they provide, but they’re not as good as the ACA.”

They’re better than some non-ACA compliant alternatives already on the market, such as limited-benefit plans, which can be really skimpy — paying paltry amounts or nothing at all toward hospital care or drugs, for example.

By contrast, Idaho’s directive says the new plans must cover outpatient services, emergency care, hospitalization, mental health and substance abuse treatment, drugs, rehabilitation, lab services and preventive care. Insurers must include maternity coverage in at least one state-based plan.

“Setting aside the question of whether a state can do this, it would not be a radical change,” said Haislmaier at Heritage.

But, unlike ACA plans, the state plans could cap coverage at $1 million annually. They could charge older people up to five times more than younger ones (the ACA limits the ratio to 3-to-1) and sick people could be charged up to 50 percent more for premiums than standard rates. On the flip side, very healthy people could have rates of up to 50 percent below standard rates.

On pre-existing conditions — which is among the ACA’s most popular provisions — the Idaho rules would require insurers to accept people with medical problems, but they could exclude coverage for those specific conditions if the person were uninsured within 63 days of the new plan taking effect.

Still, Cameron argues that the rules of the Idaho plan — in practice — would not be much different than what people face now.

Those who fail to sign up during the annual open enrollment period for the ACA then find out they have a health problem have few other options and would have to wait until the next ACA open enrollment, he noted.

Under Idaho’s plan, such consumers could buy a state-based plan and “have coverage on everything else, except for the ‘pre-ex’ [pre-existing condition], until the next open enrollment period,” Cameron said.

4. What could happen legally?

At a minimum, states must follow federal law, although they generally can set more stringent standards. Some states, for example, are considering putting in place their own “individual mandate” to replace the ACA tax penalty for those who are uninsured. The tax bill Congress passed in December removes that federal penalty as of 2019.

But states cannot create rules that fall short of federal law. If the state doesn’t enforce federal rules, the ACA grants the federal government authority to step in.

Idaho may be “banking on … the Trump administration [not enforcing] the ACA,” said Bagley.

This could be one of the first tests for new Health and Human Services Secretary Alex Azar.

“If HHS does not go in and enforce the federal floor… then Idaho can do whatever it wants. Any other state can do whatever it wants,” said benefits attorney Christopher Condeluci,who formerly served as the tax and benefits counsel to the Senate Finance Committee.

“If HHS declines to step in to enforce the law, the executive branch headed by the president is responsible for enforcing the law,” Bagley said. “Trump’s job is to make sure his agencies enforce federal law.”

5. Insurers have not said if they will offer such plans. What are their liabilities?

The ACA set fines of $100 per day, per enrollee, for violating provisions of the law. Multiplied by thousands of enrollees across several violations, that could quickly add up. The state may allow the plans, but “it’s not clear that a future administration could be prevented from looking back at past violations and imposing pretty significant penalties,” said Georgetown’s Corlette.

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

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Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt of Everett, Wash., waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top of her head.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” says Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, which is more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Designed for Medicaid’s most fragile

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. It requires the transport of certain people to and from medical services like mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” says Holt. “Now that she’s older and more disabled, it’s crucial.”

However, citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. That includes nearly 104 million NEMT trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

Current flexibility through waivers

But there is some flexibility for states already. Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March 2017 letter.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states — Iowa, Indiana and Kentucky — have received federal waivers and extensions allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” says Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, says Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman calls the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

In a 2014 survey of Medicaid users, CMS found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman says. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is often cost-effective because patients who got to a health appointment stayed healthier.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Left out and struggling

Still, some Medicaid clients struggle without transport services. Fallon Kunz, 29, of Mishawaka, Ind., has cerebral palsy, migraine headaches and chronic pain. She uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she says.

Kunz is studying psychology online at Southern New Hampshire University. She lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she says. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The only way I can get rides to and from my doctor’s appointment is to ride the two miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she says. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she says on a Tuesday in December. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” says Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick adds. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients and bad for the country.

“[Ninety] percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” Verma notes in a 2016 Health Affairs essay.

But there are some who can’t.

“I’m a college student, I have a cat,” says Kunz. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

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

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A tobacco product that its maker claims to be safer than cigarettes won qualified support from a Food and Drug Administration advisory panel Thursday.

The advisers voted 8-1 to support cigarette giant Philip Morris’ claim that its “iQOS” system “significantly reduces your body’s exposure to harmful or potentially harmful chemicals.” The device heats tobacco but doesn’t ignite it.

But on the question of whether that approach translates into a reduction in the risk for tobacco-related diseases, the panel said the tobacco company’s studies didn’t demonstrate that. The vote was eight against, with one abstention.

Similarly, they said Philip Morris hadn’t proved that reducing harmful exposure would necessarily “translate to a measurable and substantial reduction in morbidity and/or mortality.” The vote was 5-2 against, with one abstention.

There was some support for the company’s claims that “switching completely to iQOS presents less risk of harm than continuing to smoke cigarettes.” But the measure failed on a vote of 4-5 against.

The FDA doesn’t have to follow the advisory panel‘s advice but usually does.

During the two-day hearing, the company presented claims that iQOS poses less danger because the device heats tobacco, instead of igniting it, to produce an aerosol that contains 90 percent lower levels of dangerous chemicals than found in cigarette smoke.

If the agency grants the company’s request and approves the product, iQOS would become the first tobacco product authorized by the FDA to be marketed as causing less harm than regular cigarettes.

Advocates and some smoking-cessation counselors urged the committee to endorse the product to make an alternative they consider to be safer available to millions of U.S. smokers. But some anti-smoking advocates question whether the device really is safer and fear it could hook more people on nicotine, including children.

Philip Morris argued the device would be exclusively marketed to smokers and estimates the iQOS could save 90,000 lives over 20 years in the United States.

“IQOS emits toxicants and is not risk-free,” Manuel Peitsch, Philip Morris’ chief scientific officer, said on the opening day of the hearing. “Nevertheless, iQOS emits significantly lower levels of toxicants than regular cigarettes. Switching to iQOS can significantly reduce the risk of disease compared to regular smoking.”

The device could be more appealing to many smokers than electronic cigarettes because the iQOS heats tobacco instead of a liquid containing nicotine. That gives the user more of the taste and experience of regular cigarettes, the company argues.

Critics, however, questioned Philip Morris’s safety claims.

“I think the whole thing is a scam,” said Stanton Glantz, a prominent anti-smoking advocate at the University of California, San Francisco, to NPR before the hearing. “When you look at the actual evidence that Philip Morris has submitted to the FDA, it doesn’t support the claim that these things are any better than cigarettes in terms of health effects in people.”

Glantz noted that the tobacco industry has a long history of selling products that it claimed were safer, such as cigarettes marketed as “light,” “mild” or “low-tar,” that turned out to be just as dangerous.

“What we’re seeing is just a replay of the old light and mild scam,” Glantz said.

One study conducted in Switzerland found that while the iQOS produces many toxic chemicals at lower levels than cigarette smoke, some are higher than the company claims. Philip Morris disputes that research.

Some of the chemicals found are components of smoke, the researchers say. “We found lower concentrations of these compounds; however, we found them. And because we found them, we think this is smoke,” Reto Auer, an assistant professor at the University of Bern in Switzerland who conducted the study, said in an interview before the hearing. “We disagree with the claim that it’s smokeless. People should be aware there are still toxic substances in the iQOS.”

Auer and Glantz’s concerns were echoed by several people who spoke during a public comment period on the second day of the hearing.

The iQOS looks suspiciously similar to the most popular e-cigarettes among children, Matthew Myers, president of the Campaign for Tobacco-Free Kids, told the committee.

“It is high-tech. It is sleek. It is designed in exactly the way that would appeal to young people,” Myers told the committee.

If the iQOS wereapproved, it could hook children and teenagers on nicotine, reversing the progress that has been made to reduce smoking among young people, Myers fears.

But most of the speakers at the hearing urged the committee to recommend approval to give smokers a potentially safer alternative to cigarettes. More than 36 million Americans currently smoke.

“There is no health threat that compares to smoking,” said Hank Campbell, president of the American Council on Science and Health. “Even though we have been opposed to smoking for 40 years, we support these devices.”

“Patients who smoke clearly need more tools to help them quit,” said Jeff Fortenbacher, president and CEO of Access Health in Muskegon, Mich.

In an interview before the hearing, Jonathan Foulds, a professor of public health sciences and psychiatry at Penn State University, agreed.

“I think it’s a step in the right direction for tobacco companies to be developing products that have the probability of being significantly less harmful than conventional cigarettes,” Foulds says.

Philip Morris is already selling iQOS in more than 30 countries and argued there was no evidence it was enticing children to use the product or start smoking. In fact, the company said, cigarette smoking had dropped dramatically since the device was introduced in Japan.

The iQOS consists of several parts. One part is called a “heatstick,” which is made from compressed wads of tobacco. If approved, three versions would be sold: Marlboro HeatSticks, Marlboro Smooth Menthol HeatSticks and Marlboro Fresh Menthol HeatSticks.

The iQOS device is reusable, but the heatsticks are not.

Users would insert a heatstick into a holder that has a blade that penetrates the middle of the tobacco wad. When the user presses a button, the blade heats the tobacco to temperatures only capable of producing an aerosol that contains nicotine, according to the company.

The tobacco never gets hot enough to combust, according to Philip Morris. Burning tobacco produces far greater levels of potential toxic substances than just heating it, the company says. The devices stay on for six minutes or 14 puffs, whichever comes first, before shutting off automatically.

Philip Morris hasn’t said how much the device would cost in the United States. But in Japan, the device sells for about $80, and a pack of heatsticks costs about the same as a pack of cigarettes.

The FDA advisory committee’s recommendation Thursday pertains only to the company’s claims about the safety of the product. Philip Morris would still have to get the FDA to sign off on a separate application to actually sell the devices in the United States for the first time.

The hearing comes after the FDA announced plans to eventually reduce the amount of nicotine in regular cigarettes in the hopes of weaning more Americans off cigarettes. As part of that effort, the FDA has said the agency hopes to offer more alternative sources of nicotine that would be safer than cigarettes.

Separately, the FDA has begun reviewing the safety of electronic cigarettes. Those devices heat fluid containing nicotine to produce a vapor that users inhale. E-cigarettes have become increasingly popular, especially among young people. The growth in use has alarmed many public health experts.

While e-cigarettes may be safer than regular cigarettes, experts say e-cigarettes aren’t completely safe and fear they are hooking a new generation of children on nicotine and acting as a gateway to traditional cigarettes.

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Philadelphia is a step closer to opening what could be the nation’s first supervised site for safe drug injection. But turning the idea into reality won’t be easy.

City officials gave the proposition the green light Tuesday. They were armed with feasibility studies, harrowing overdose statistics and the backing of key leaders, including the mayor and a newly elected district attorney.

“There are many people who are hesitant to go into treatment, despite their addiction, and we don’t want them to die,” said Dr. Thomas Farley, Philadelphia’s health commissioner and co-chair of the city’s opioid task force. Supervised safe injection sites, he said, save lives by preventing overdose deaths and connecting people with treatment.

While one big hurdle has now been cleared, the details of how safe injection sites would actually work in Philadelphia have yet to be figured out. Who will actually fund and operate a site? Where will it be located? Will users really be safe there?

“We have a long way to go,” said Brian Abernathy, first deputy managing director for the city.

Neither city council approval nor special zoning ordinances would required to proceed, Abernathy said, but the city doesn’t plan to actually operate or pay for any sites. Instead Philadelphia officials would play the roles of facilitator and connector with providers of addiction services.

In that way, Tuesday’s announcement by the city was more like an open call to potential investors and operators than it was the roll out of a specific plan.

“We took a really really big first step,” said Jose Benitez, executive director of Prevention Point Philadelphia, a large nonprofit needle exchange. “It’s early to talk about our involvement at this particular point. As the city officials said, there’s a lot to consider.”

Broadly, the city envisions a place where people would be allowed to bring in drugs and inject them using clean equipment. If someone overdosed, trained staff would respond to prevent death. The sites could save lives and money otherwise lost to hospitalizations and emergency response efforts. Advocates say the sites also could reduce neighborhood problems associated with addiction, like people injecting in public and discarding needles.

A safe, supervised site wouldn’t just be about a spot to inject, Farley stressed, but also somewhere people could connect with other services and treatment.

Still, the effort to open a site will likely face many additional hurdles and unknowns, from community buy-in to legal concerns.

For one, Councilwoman Maria D. Quiñones-Sánchez, who has voiced opposition to a safe injection site in her district (one at the heart of the crisis), is wary of the city’s plan.

“This notion of letting a private developer or a private person come tell us how this could be done, we’re not paying for it, we’ll do wrap-around services, so much of that is just up in the air,” Quiñones-Sánchez said. “So why make an announcement with no answers?”

Another question: Could such a site be immune from federal prosecution? Realistically no, said Philadelphia official Abernathy, though some legal scholars are exploring potential safeguards.

The city’s police commissioner, Richard Ross, has gone from “adamantly against” any injection site to having an open mind. Whether police will take a hands-off approach remains to be seen. So would what the department’s role would be, what police officers would be asked to do, and how that would affect the policing of narcotics?

“I don’t have a lot of answers,” he said.

One point of clarity: Philadelphia’s Distract Attorney, Larry Krasner, has no plans to prosecute.

“What will we do? We will allow God’s work to go on,” Krasner said, citing state laws of justification that allow the committing of minor violations in the interest of preventing greater harms. “We will make sure that idealistic medical students don’t get busted for saving lives and that other people who are trying to stop the spread of disease don’t get busted.”

After all this, it should come as no surprise that the timeline is really unclear, too. Rollout will take months, at least, leaders have said. Though if it were up to Krasner, one would had opened years ago.

“My biggest concern moving forward with harm reduction is that government takes forever,” he said. “When we have three or four people dying every day, nobody can afford to wait.”

This story is part of a reporting partnership with NPR, WHYY’s health show The PulseandKaiser Health News.

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When parts of the federal government ground to halt this past weekend, Linda Nablo, who oversees the Children’s Health Insurance Program in Virginia, had two letters drafted and ready to go out to the families of 68,000 children insured through the program, depending on what happened.

One said the federal government had failed to extend CHIP after funding expired in September and the stopgap funding had run out. The program would be shutting down and families would lose their insurance.

The other letter said they didn’t need to worry anymore because federal funding had finally come through and the program’s future was assured.

Since Monday’s deal to end the shutdown included a six-year reauthorization of CHIP, enrolled families in Virginia will get that second letter. The program will go on and no children will lose their health insurance.

Taking Stock Of Costs

After months of uncertainty, Nablo said she’s relieved. “Hugely relieved. It’s over and the program is safe, and we can all go back to our normal jobs,” she laughed.

Preparations to shut down the program in Virginia down began over the summer, even before funding expired. Staff spent untold hours getting ready to end the program, retooling enrollment systems, changing contracts and more.

“Those aren’t huge dollar amounts,” Nablo said. “I think the cost more is in the worry from parents.”

CHIP covers children in low-income families — most can’t afford private insurance and their children might have had to go uninsured. Nationally, about 9 million children get health coverage through CHIP.

An Unprecedented Situation

In its 20-year history, CHIP had always been uncontroversial, even popular in both parties. Its funding needs to be periodically renewed, and it always had been taken care of well in advance of the money running out.

CHIP is a match program — states and the federal government split the cost. When states made their budgets for this year, they assumed federal funding for CHIP would be there, so they were blindsided by the funding gap.

Every state’s calculus for how long they could run on leftover money was different. In Texas, Hurricane Harvey threw off that state’s projections. Because of the disaster, it waived fees for CHIP and enrollment spiked, so it had less money coming in and more going out.

A handful of states — including Virginia — sent out letters warning families their coverage was in jeopardy because of the uncertainty in Congress.

“One state — Connecticut — did freeze enrollment between the week of Christmas and New Year’s,” said Joan Alker of the Georgetown University Center For Children and Families, which monitored CHIP funding closely during the last few months.

Virginia’s Nablo said there might be other, more subtle, costs from all the uncertainty.

“I can’t quantify it, but I am sure there are states that held off on things like mounting an outreach program to encourage people to enroll because they didn’t know if the program was going to be there for them,” she said. “There may have been states that were thinking of implementing some efficiencies or innovations, but didn’t because — again — is the program going to be there?”

Six Years Of Certainty

Alker is happy with the CHIP deal Congress passed. She does point out it’s the same one they agreed on in September, so she’s not sure why it took a shutdown to finally get it through.

The deal keeps the federal investment in the program at its current level for two fiscal years. After that, the amount that states have to pay for the program will increase.

“At least states now have time to plan for that,” Alker said. “Overall, it really was a fair and reasonable compromise.”

She is puzzled, though, as to why it was only a six-year extension when the Congressional Budget Office estimated extending CHIP for 10 years would save the federal government $6 billion.

“The six-year [extension] is a small saver — it saves just under a billion dollars,” Alker said. “Now there’s nothing preventing Congress from coming back as they move ahead with the bigger budget deal — they could come back and extend CHIP for four more years and grab those savings.”

Impact On Children’s Uninsured Rate

Alker does worry that the months of uncertainty around CHIP may have already caused children to drop out of the program, increasing the uninsured rate among children. That should become clear in the fall, when the Georgetown Center For Children and Families does its annual assessment of the children’s uninsured rate.

If that trend develops nationally, it hasn’t been the case in Virginia, where CHIP enrollment went up this past fall.

“We actually saw a boost in enrollment,” Nablo said. “I can’t really quite explain it.”

Maybe, she said, it was all the attention the unprecedented funding crisis brought to CHIP. A silver lining, perhaps, to many months of anxiety.

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

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As a presidential candidate, Donald Trump promised abortion opponents four specific actions to “advance the rights of unborn children and their mothers.”

One year into his presidency, three of those items remain undone. Nevertheless, opponents of abortion have made significant progress in changing the direction of federal and state policies.

Indeed, on Friday, as anti-abortion protesters gathered in Washington for the 45th annual March for Life, the Trump administration announced two new policies. One is a letter to states aimed at making it easier for them to exclude Planned Parenthood facilities from their Medicaid programs; the other is a proposed regulation to allow health care providers to refuse to perform services that conflict with their “religious or moral beliefs.”

“In my administration, we will always defend the very first right in the Declaration of Independence, and that is the right to life,” President Trump said in a video address from the Rose Garden to the marchers.

Marjorie Dannenfelser, president of the anti-abortion group the Susan B. Anthony List, led the Trump campaign’s Pro-Life Coalition. The then-candidate said he was committed to “nominating pro-life justices to the U.S. Supreme Court,” which happened with the nomination and confirmation of Justice Neil Gorsuch in April.

Despite many attempts, Congress did not pass a federal ban on abortions occurring after 20 weeks, didn’t cut off Planned Parenthood’s federal funding and didn’t write into permanent law the Hyde Amendment, which bans most federal abortion funding but needs annual renewal.

Still, there was progress on scaling back abortion and, in some cases, access to contraception at the federal level.

The administration made myriad changes. It reinstituted and expanded the “Mexico City” policy, which forbids funding of international aid programs that “perform or promote” abortion. It issued rules aimed at allowing religious-affiliated and other employers to not offer contraceptive services if they have a “religious belief” or “moral conviction” against them, although federal courts have blocked the new rules from being implemented. And just last week the administration created a new “conscience and religious freedom” division in the Department of Health and Human Services’ Office of Civil Rights. That new division is designed to enforce both existing laws protecting the rights of conscience for medical personnel as well as the new regulations.

Most important, according to many in the anti-abortion movement, the president nominated and the Senate confirmed a dozen and a half federal district court and appeals court judges who are considered likely to rule in their favor.

Abortion rights supporters concede that while the priorities on their opponents’ wish list weren’t accomplished, plenty still happened.

“This administration is the worst we’ve ever seen for women and families,” says Kaylie Hanson Long of NARAL Pro-Choice America in a statement. “Its attacks on reproductive freedom are relentless, under the radar, and aren’t supported by the majority of Americans who believe abortion should remain legal.”

Dannenfelser says one of the biggest changes is the number of anti-abortion advocates now working in the Department of Health and Human Services in key roles. “I can say there is more unity in this administration than there has been in any presidency on this,” she says.

Abortion opponents know their biggest obstacle is the Senate, where they don’t have the 60 votes required for most legislation. “Without making advances in the Senate, it’s going to be really tough,” says Dannenfelser.

Meanwhile, outside Washington, states continued their efforts to restrict access to abortion and family planning. States have passed 401 separate measures since Republicans took over most state legislatures in 2011, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

During 2017, 19 states enacted 63 separate restrictions, says Elizabeth Nash, who tracks state legislation for Guttmacher. Among the notable laws was one in Ohio to outlaw abortions of fetuses diagnosed with Down syndrome. Arkansas and Texas passed laws to ban “dilation and evacuation” abortions, a procedure that uses suction and medical instruments to remove the fetus and is the most common procedure for abortion after the first trimester of pregnancy. Both bans have been blocked by federal courts.

Some of the new restrictions came from states that haven’t been active on the issue in recent years. A Wyoming law requiring ultrasounds to be offered to pregnant women seeking an abortion was that state’s first in 30 years, Nash says.

But 2017 was also notable for states seeking to widen or ensure access to abortion and other reproductive services. For example, Delaware passed a law enshrining abortion rights, while Oregon and New York require private health plans to cover abortion without patients’ cost sharing. Legislators in California, which has a long history of protecting abortion rights, have been pushing a bill that would require public universities to provide abortion pills to female students who are less than 10 weeks pregnant. The bill stalled last year, but it is being picked up again this year.

As a result, says Nash, “we are really living in a bifurcated country. The states that are progressive are looking to protect access” to abortion and contraception. “The states that are conservative are looking to restrict it.”

In other words, a nation that looks a lot like it did 45 years ago, when the Supreme Court legalized abortion nationwide in Roe v. Wade.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. California Healthline reporter Ana B. Ibarra contributed to this story.

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