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You Can Order a Dozen STD Tests Online — But Should You?

An STD testing kit from myLAB Box allows users to gather samples at home and mail them back to the company.

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Courtesy of myLAB Box

America is losing the battle against sexually transmitted infections. Cases of chlamydia, gonorrhea and syphilis all hit record-high numbers in 2015. Tens of thousands contract HIV every year in the U.S., and oral cancers caused by human papillomavirus are increasing.

So startups are popping up online to help serve what they see as unmet demand for STD testing. One advertises that you can “get a sexy deal” by ordering.

The question is whether those companies can survive — at least one left the market before its product even launched — and whether the services they offer get the right tests to the right people.

Although encouraging people to get tested is a simple enough public health message, that doesn’t mean it’s simple to carry out, says Kevin Ault, a professor of obstetrics and gynecology at the University of Kansas Medical Center in Kansas City, Kan.

“You have to make the appointment at the doctor’s office, drive to the doctor’s office, give the sample to the doctor, the doctor sends it to the lab, you wait for the results to come back, and then you wait for the doctor to call you,” Ault says. And the Centers for Disease Control and Prevention recommend that people in some at-risk groups do all that several times a year.

“The biggest advantage of home tests in general is if you catch HIV or chlamydia early on, you can change the natural course of the disease,” Ault says.

Few options exist to make the process easier. So far, there is just one test approved that gives rapid results in the home, and it’s for HIV. The startups are hoping that being able to collect samples at home will be enough to encourage people to get tested.

“The concept of providing the possibility of a self-sampling approach to test for STDs is really going to be our future in terms of diagnostic testing,” says Jennifer Smith, an associate professor of epidemiology at the University of North Carolina Gillings School of Global Public Health in Chapel Hill. Hill also consults for myLAB Box, one of companies offering these services. “Getting the actual test to the patient is going to be a way of not only increasing access and improving acceptability, but also cutting down on unnecessary medical visits,” Smith says.

Big increases in people infected with STDs

A sobering report from the CDC last October revealed just how much new approaches are needed to combat increasing infection rates. More than 1.5 million people contracted chlamydia in 2015, an increase of 5.9 percent from the year before. Similarly, gonorrhea cases jumped 12.8 percent to almost 400,000 cases. The nearly 24,000 new cases of primary and secondary syphilis (the two most infectious disease stages) represented a 19 percent increase.

Aside from early symptoms that several STDs can cause — such as painful urination, discharge, bleeding, swelling or pain — long-term symptoms in people who don’t receive treatment can be serious. Untreated gonorrhea, for example, can cause infertility and long-term pelvic or abdominal pain in men and women as well as ectopic pregnancies, which can be fatal. If syphilis is not treated, it can damage the brain, eyes and nervous system, potentially resulting in severe headaches, poor muscle coordination, paralysis, numbness, dementia or blindness. In rare cases, syphilis can cause death 10 to 30 years after infection.

STDs also have downstream consequences for the next generation. Cases of congenital syphilis, which can cause severe illness and stillbirth, has increased in newborns 38 percent from 2012 to 2014, according to the CDC, even though women don’t even represent 10 percent of new infections overall.

New HIV infections have been steadily dropping, but 2015 still saw more than 39,500 new cases. And although HPV, the most commonly transmitted STD, resolves on its own in most people, it still causes about 31,500 new cancers annually.

“When something affects millions of people, even a low rate of serious outcomes translates to a lot of people,” says H. Hunter Handsfield, a professor emeritus at the University of Washington who consults for the CDC on STDs and spent a quarter of a century directing the STD control program for Seattle’s public health department. “We have an ongoing and important public health problem of people getting HIV and getting cervical and other HPV-related cancers. The numbers of those actual cancers are small, but that’s a big deal for each of those people.”

Startups See An Opportunity

The idea of online STD testing isn’t new, but most services so far have been localized, limited in test options or still require visiting a lab or pharmacy.

For example, residents of Maryland, Washington, D.C., and Alaska can request kits to be mailed to them with self-collection instructions and materials for genital and/or rectal swabs, but only for gonorrhea, chlamydia and trichomoniasis. Planned Parenthood has begun offering similar services but only for gonorrhea and chlamydia and only in Idaho, Minnesota and Washington. More than a dozen commercial companies nationally let consumers order STD testing kits online for other infections, but buyers still have to visit a local lab for sample collection.

The online businesses aim to offer many more tests without customers needing to go anywhere except the mailbox. The two business models are subscription-based or one-off orders: Consumers order the test, receive it in the mail, collect their own blood, urine, genital and/or rectal samples, mail samples back in a prepaid envelope and then wait until results are available to check online.

One company, GetTested, still has a live website but has ceased operation, according to a spokesperson. Another, Mately, doesn’t appear operational and did not respond to multiple attempts to request an interview. That leaves myLAB box, which has been tweaking its services and procedures since its launch in December 2013 as executives learn what does and doesn’t work.

The CDC generally supports the idea of at-home STD testing, according to John Papp, a microbiologist in the CDC’s Division of STD Prevention and author of CDC’s lab testing recommendations for gonorrhea and chlamydia.

“From our perspective in public health, we want people to have access,” Papp says. “The concept of greater access, however that looks, if it’s by a website or a van down by the river, is always a good thing. But the regulatory piece needs to be adhered to.”

But little regulation exists for online, at-home STD testing. The labs where tests are performed should meet the standards of the Clinical Laboratory Improvement Amendments, and the tests themselves should be FDA-approved when available. The tests offered by myLAB Box meet both those requirements.

“There’s no FDA indication for at-home collection and sending it into a laboratory,” Papp says. “Having said that, if the specimen is collected properly, regardless of the setting, the test is probably being performed adequately.”

Most of the tests detect some piece of the organism itself. Three others, for hepatitis C, syphilis and herpes simplex type II, test for the body’s antibodies made in response to the infection. The HIV test looks for both the virus and antibodies. The tests have been shown to work even with samples exposed to extreme temperatures, so having a blood spot and urine sample sitting in a Florida mailbox in August shouldn’t affect results, Handsfield says.

Reaching the right people

But Handsfield says online tests don’t reach the people who need testing and treatment the most.

“It’s a good idea, with a giant caveat that it reaches the wrong people,” Handsfield says about online services. “The highest infection rates are in people with lesser education or lower income, in inner cities or the rural kid in a red state immersed in a methamphetamine world.”

He would like to see public health departments partner with online sites and subsidize the cost to promote home self-testing for a broader population of high-risk, lower-income people. The CDC’s October report, for example, showed that 15- to 24-year-olds make up half of gonorrhea cases and almost two-thirds of all chlamydia ones. “These are not the same people who are paying money to buy tests online,” Handsfield says.

MyLAB Box offers three pricing tiers: the “Safe Box” for $189 (HIV, chlamydia, gonorrhea and trichomoniasis); the “Uber Box” for $269 (adds hepatitis C, herpes simplex type II and syphilis); and the “Total Box” for $399 (adds HPV, Mycoplasma genitalium and ureaplasma plus rectal and throat testing for chlamydia and gonorrhea). Each test can also be purchased individually for $79.

But Gary Richwald, myLAB Box’s medical director and chief scientific officer, says the company is reaching the right people. He says their rates of positive tests are on par with or higher than what he saw when he ran STD clinics for Los Angeles County, the largest such program in the U.S., from 1989 to 2000. For example, 7.3 percent of myLAB Box clients’ tests for chlamydia were positive in February. Community rates at L.A. clinics two decades ago, where the population would presumably have been high risk, ranged from 4 percent to 5 percent, Richwald says, with family planning clinic rates lagging just behind that.

“The data show in every study that people who voluntarily go somewhere to be tested have higher rates than the general population who might be tested door to door,” Richwald says. And yet “the vast majority of people with STDs never get tested, and they are the principal source of new infections.”

Richwald describes the company’s customer base as people mostly in their mid- to late 20s, with many in their 30s and 40s as well, and often at a transitional stage in their life, such as having recently ended a relationship or gotten divorced. Economically, they seem to hover between lower middle class and middle upper class, he says. Customers include residents of areas with doctor shortages, where getting tested requires going to urgent care or the ER; single mothers without time to get to a clinic or doctor’s office; and individuals with previous unsatisfactory health care experiences.

They also tend to have three other characteristics: comfort and familiarity with using the Internet, a desire for convenience — “I can’t tell you how many people said they collected their specimen after midnight,” Richwald says — and concerns about privacy.

“With this election and general concerns about privacy in this country, people are afraid that even their request for a test, much less their positive, would end up in some place that collects health-related information,” Richwald says. A number of customers include those in the health care field themselves, he says, such as physicians, dentists and nurse practitioners.

Choosing the right tests

One big question is what to test for.

Public health clinics generally offer free testing of gonorrhea, chlamydia, syphilis and HIV, with some offering various additional tests, such as trichomoniasis, HPV or herpes type II. Few public health clinics test for ureaplasma, hepatitis C or Mycoplasma genitalium.

A person’s first instinct may be to test for “everything,” especially if they have a sexual history or recent sexual experience that could be a concern. But not everybody should be tested for every infection.

Hepatitis C, for example, is currently among the tests offered by myLAB Box, but it’s not considered a sexually transmitted disease for anyone other than men with HIV who have sex with men, Handsfield says. (All individuals born between 1945 and ’65 are recommended to be tested once for hepatitis C, however.) And men are not typically tested for HPV because no treatment exists for the infection, and it’s unclear what to do with a positive result.

MyLAB Box company co-founder Lora Ivanova says the company trusts the consumer to do the homework on what tests to order.

“Our role is to make it as easy as possible for the person who has decided to get tested to get the test they want,” Ivanova says. “For a long time, consumers have been limited to the tests they can take based on the medial debate. We’re taking the position that the consumers ultimately have the right to know. We don’t see why we as providers should limit their access to care.”

But if doctors and public health policymakers cannot agree on who should be tested for infections like Mycoplasma genitalium and ureaplasma, Handsfield says, then how would a consumer make that decision?

“The issue of who to test and what tests to do continues to be a question that’s very important but does not have an exact answer,” Richwald acknowledges. That’s partly why he was brought on, and Ivanova did say the company’s system “is in constant flux” based on “recommendations and available data.” The company doesn’t offer testing for herpes simplex type I, for example, because 60 percent to 70 percent of individuals already have antibodies, acquired non-sexually in childhood.

Richwald also says the company isn’t testing for ureaplasma anymore, but the test still appears on the company website. Mycoplasma genitalium presents a conundrum as well.

First, no FDA-approved diagnostic test for the bacteria exists. Experts disagree on how to interpret positive results, Handsfield says. It’s a common bacteria found in about 1 percent of the population, but most people don’t have symptoms. Treatment is challenging and not recommended for infections without symptoms. But for those with symptoms — vaginal pain or itching, discharge from the urethra, painful urination and painful or swelling joints — treatment can prevent pelvic inflammatory disease or worsening symptoms, Richwald says.

Another consideration people must weigh is when to test, because incubation periods vary by disease. If someone has been regularly sexually active, especially without using a condom, and has not been tested in the six months, timing is less relevant. But if someone is testing after a specific encounter, some infections, such as HIV, cannot be detected immediately.

“Often people get tested too soon, such as a week after exposure,” Handsfield says. Chlamydia and gonorrhea can usually be detected after several days (a week on the conservative side), but herpes and one HIV test require up to three months of delay before testing.

A chart on the myLAB Box site provides time frames for testing and, when necessary, retesting. It recommends that people wait until the end of the time frames listed before testing unless the person plans to retest. The ideal testing window for Mycoplasma genitalium, however, is unknown, Handsfield says.

“For the panel as a whole, I would say wait three months if you have no symptoms,” Handsfield says. “If you have symptoms — if you’re having urethral discharge, unexplained vaginal discharge, abdominal pain — online testing is not for you. You need to see a doctor.”

Handling positive tests, whether true or false positives, also requires careful consideration. The newest syphilis tests, for example, are known for giving a lot of false positives, Handsfield says, and that can lead to increased anxiety between a first test and a retest, although the same concern would exist at a community clinic. At myLAB Box, Richwald personally calls all customers with a positive HIV result and ensures they get an appointment with an HIV specialist group. Immediate treatment can dramatically reduce their infectiousness while improving their health, he says. A positive result for syphilis requires confirmation at a clinic in person, and someone with chlamydia and symptoms of pelvic pain, for example, would be told to go to a clinic or urgent care.

MyLAB Box regularly reviews new research to inform their decisions, but it remains a tricky line to walk: making tests widely available to the public while trying to guide them toward the best tests for their situation without driving them away.

“There’s a lot of fear, hesitation and confusion, and I think what it has ultimately done is turn people to the point where they’re sweeping it under the rug,” Ivanova says. “At the end of the day, it’s about getting the person to get tested. If we lose that one single time in a year or in two or five years that they have mustered the courage to get online and get the tests, they might spend the next five years infecting every partner they have.”


Tara Haelle is the co-author of The Informed Parent: A Science-Based Resource for Your Child’s First Four Years. She’s on Twitter: @tarahaelle

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From Alaska To Florida, States Respond To Opioid Crisis With Emergency Declarations

Overdoses from heroin and other opioids have led six states to declare public health emergencies.

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Public health officials and others concerned about the nation’s opioid crisis are hailing President Trump’s decision to declare it a national emergency. A Presidential commission on opioids said in its interim report that an emergency declaration would allow the administration to take immediate action and send a message to Congress that more funding is needed.

But while the Trump administration prepares the presidential order, governors in six states have already declared emergencies to deal with opioids. They range from Alaska and Arizona in the West to Florida, Virginia, Maryland and Massachusetts in the East.

In Maryland, where 550 overdose deaths were reported in just the first three months of this year, Gov. Larry Hogan declared opioids a public health emergency in March.

“It’s a call to order and a call to action,” says Clay Stamp, head of Maryland’s Opioid Operational Command Center. Stamp comes to the job with a background as an emergency manager and compares this effort to the state’s response to a hurricane.

“We need all the right people in the room to make sure we can make a decision in time to move people out of harm’s way, shelter them and everything else,” he says. “This is no different.”

Since declaring an emergency, Maryland has tightened practices for those prescribing opioids and received a waiver to allow Medicaid to pay for residential drug treatment.

Massachusetts was the first state to declare opioids a public health emergency in 2014. Then-Gov. Deval Patrick acted on the recommendations of a special task force, says Michael Barnett, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health.

The recommendations were “to open up funding for the Department of Public Health — for instance, to open up more treatment beds, to create funding and make it easier for … first responders to use naloxone, which reverses opioid overdoses in the field,” he says.

Making naloxone freely available and putting it in the hands of more people has helped save lives. That has been one of the most immediate impacts of emergency declarations in states that have issued them.

Arizona Gov. Doug Ducey declared a public health emergency in June. Will Humble, executive director for the Arizona Public Health Association says with that declaration, the state began gathering badly needed data on the crisis.

“Who it’s hitting, where it’s hitting, who is doing the prescribing, what portion of it are fentanyl and heroin and what portion are prescribed pills,” he says. “And, as you get that more complete information, it allows you to craft better public policy.”

In Florida, the emergency declaration issued in May enabled Gov. Rick Scott to quickly allocate some $27 million in federal funds for drug treatment and prevention.

Palm Beach County, Fla., saw nearly 600 fatal overdoses last year, mostly related to opioids. Alton Taylor, executive director of the county’s Drug Abuse Foundation says although the emergency declaration was welcome, Palm Beach County and the rest of the state still don’t have enough publicly-funded beds available to treat people with opioid addictions.

“Today as I’m talking to you, we have over 200 people on a waiting list,” he says. “These are people where we’ve done a clinical assessment of them and determined them to be in need of that service.”

Despite the emergency declaration, Florida, unlike some other states, hasn’t tapped Medicaid to help pay for drug treatment. Taylor says he’s hopeful President Trump’s emergency declaration, when finalized, will free up more money to treat people in recovery from opioid addictions.

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Democrats Fear Medicare-For-All Plan Could Sharpen Party Divisions

Sen. Bernie Sanders is promoting a Medicare-for-all health care plan, and some Democrats are worried it could sharpen divisions in the party.

AUDIE CORNISH, HOST:

When Congress returns to Washington next month, Vermont Senator Bernie Sanders will introduce a bill creating a single-payer government-run health care system. He calls it Medicare for All. More and more progressive voters want the Democratic Party to fully embrace the idea. As NPR’s Scott Detrow reports, party leaders are wary of doing that.

SCOTT DETROW, BYLINE: Bernie Sanders has been ready to introduce his single-payer bill all year. He’s just been waiting for Republicans to finish their effort to repeal and replace the Affordable Care Act, which means Sanders has been waiting for a while.

BERNIE SANDERS: Look, I have no illusions that under a Republican Senate and a very right-wing Republican House and an extremely right-wing president of the United States that suddenly we’re going to see a Medicare-for-all, single-payer passed. You’re not going to see it. That’s obvious.

DETROW: The point of the bill, Sanders says, is to force a conversation.

SANDERS: Excuse me, why is the United States the only major country on earth not to guarantee health care to all people? Why are we spending far, far more per capita on health care than any other nation? Why do we pay the highest prices in the world for prescription drugs?

DETROW: The bill will likely force a conversation within the Democratic Party, too, a party Sanders now acts as a leader of despite not being a member. Polls do show more and more voters like the idea of government-run health care. But top Democrats are keeping it at arm’s length. DNC Chairman Tom Perez typically pivots to this broader answer when he’s asked whether he would push for single payer.

(SOUNDBITE OF ARCHIVED RECORDING)

TOM PEREZ: We believe that health care is a right for all and not a privilege for a few. And right now in Washington, D.C., in the political climate in which we live, preserving the Affordable Care Act is a major victory.

DETROW: House Minority Leader Nancy Pelosi is more direct.

(SOUNDBITE OF ARCHIVED RECORDING)

NANCY PELOSI: The comfort level with a broader base of the American people is not there yet. Doesn’t mean it couldn’t be. States are a good place to start.

DETROW: The resistance is tactical, not ideological. It took decades to pass something like Obamacare. And the fear is that despite what polls might suggest, something as aggressive as single-payer just isn’t politically feasible right now. In fact, the congressional leaders you hear talking about single-payer are often Republicans, not Democrats. House Speaker Paul Ryan and other Republicans regularly float it as a worst-case Democratic alternative.

(SOUNDBITE OF ARCHIVED RECORDING)

PAUL RYAN: Ultimately, it’s very clear that they’re more interested in a single-payer system, which means government-run health care. Government-run health care is not in our nation’s interest.

DETROW: Senate Republicans even forced a vote on a single-payer option on the Senate floor last month, hoping to get Democrats on record supporting the idea. Most Democratic senators voted present. No one voted yes. Still, more than half of the House Democrats sponsored a separate single-payer bill this year. A longtime aide to Bernie Sanders, Jeff Weaver, argues the broad public opposition to the Republican Obamacare repeal should spur Democrats to become more aggressive on health care.

JEFF WEAVER: This is a very powerful issue in that people are prepared to be mobilized in support of their health care.

DETROW: Like Sanders admits, this bill isn’t going anywhere anytime soon. The whole thing is more about political framing, getting Democrats to the point where this would be a top priority whenever the day comes where the party is back in power. Scott Detrow, NPR News.

(SOUNDBITE OF HENRI-PIERRE NOEL’S “AZAKA”)

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NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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47 Hospitals Slashed Their Use Of Two Key Heart Drugs After Huge Price Hikes

Valeant Pharmaceuticals, based in Bridgewater Township, N.J., bought two specialty heart drugs used in emergency treatment from Marathon Pharmaceuticals in 2015, and then dramatically increased each drug’s price.

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Even before media reports and a congressional hearing vilified Valeant Pharmaceuticals International for raising prices on a pair of lifesaving heart drugs, Dr. Umesh Khot knew something was very wrong.

Khot is a cardiologist at the Cleveland Clinic, which prides itself on its outstanding heart care. The health system’s internal monitoring system had alerted doctors about the skyrocketing cost of the drugs, nitroprusside and isoproterenol. But these two older drugs, frequently used in emergency and intensive care situations, have no direct alternatives.

“If we are having concerns, what is happening nationally?” Khot wondered.

As it turned out, a lot was happening.

Following major price increases, use of the two cardiac medicines has dramatically decreased at 47 hospitals, according to a research letter Khot and two others published Wednesday in the New England Journal of Medicine.

The number of patients in these hospitals getting nitroprusside, which is given intravenously when a patient’s blood pressure is dangerously high, decreased 53 percent from 2012 to 2015, the researchers found. At the same time, the drug’s price per 50 milligrams jumped more than 30-fold — from $27.46 in 2012 to $880.88 in 2015.

The use of isoproterenol, key to monitoring and treating heart-rhythm problems during surgery, decreased 35 percent as the price per milligram rose from $26.20 to $1,790.11.

The two drugs, which are off patent, have long been go-to medicines for doctors.

“This isn’t like a cholesterol medicine; these are really, very specialized drugs,” says Khot, who is lead author on the peer-reviewed research letter. When patients get the drugs, he says, “they are either sick beyond sick in intensive care or they’re under anesthesia [during] a procedure.”

Valeant bought the drugs in early 2015 from Marathon Pharmaceuticals.Last year, Valeant announced a rebate program to lower the price hospitals paid for the drugs.

And Valeant’s Lainie Keller, a vice president of communications, says the company is committed to limiting price increases.

“The current management team is committed to ensuring that past decisions with respect to product pricing are not repeated,” Keller says.

Pharmacist Erin Fox, the director of drug information at University of Utah Health Care, said the findings by Khot and his colleagues reveal “exactly what a lot of pharmacists have been talking about. When prices are unsustainable, you have to stop using the drug whenever you can. You just can’t afford it.”

Fox says her Utah health system has removed isoproterenol from its bright-red crash carts, which are stocked for emergencies like heart attacks. But Nitroprusside is more difficult to replace.

“If you need it, you need it,” Fox says. “That’s exactly why the usage has not gone down to zero, even with the huge price increases.”

Cleveland Clinic leaders spent months investigating each drug’s use and potential alternatives, Khot says.

“We’re not going to ration or restrict this drug in any way that would negatively impact these patients,” Khot says, adding that he hopes to do more research on how the decreased use of both drugs has affected patients.

Dr. Richard Fogel is a cardiologist and electrophysiologist at St. Vincent, an Indiana hospital that’s part of Ascension, a large nonprofit chain with facilities in 22 states and the District of Columbia. He told a Senate committee last year that the cost of the two drugs alone drove a nearly $12 million increase in Ascension’s spending over one year.

“While we understand a steady, rational increase in prices, it is the sudden, unfounded price explosions in select older drugs that hinder us in caring for patients,” Fogel told the committee.

The NEJM letter also analyzed the use of two drugs that remained stable in price over that time period, as a control group — nitroglycerin and dobutamine. The number of patients treated with nitroglycerin, a drug used for chest pain and heart failure, increased by 89 percent. Khot warns that the drugs can’t always be used as substitutes.

Kaiser Health News, a nonprofit health newsroom, is an editorially independent part of the Kaiser Family Foundation. Sarah Jane Tribble is a senior correspondent at KHN.

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First Responders Spending More On Overdose Reversal Drug

Battalion Chief Mark St. Laurent, seen here at the Franklin Square firehouse in Washington, D.C., says sometimes multiple doses of naloxone are needed to stop an overdose.

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In Prince George’s County, Md., every first responder carries naloxone, the drug that can reverse an opioid overdose.

“We carry it in our first-in bags,” says Bryan Spies, the county’s battalion chief in charge of emergency services. “So whenever we arrive at a patient’s side, it’s in the bag, along with things like glucose, aspirin and oxygen.”

The first responders in Prince George’s County are pulling the drug out of the bag more than ever. Last year they administered 877 doses to people who had overdosed. This year, they’re on track to administer 1,230 doses, Spies says. That averages out to more than three doses a day in just one county.

In Washington, D.C., it’s the same story.

“Depending on the strength [of the opioid], you may see that we’d use two of these,” says Battalion Chief Mark St. Laurent, holding up a 2-milligram vial of naloxone.

If the patient has taken fentanyl — a particularly potent opioid — he says, “sometimes it takes 10 milligrams just to get them to breathe.”

Opioid addiction has reached crisis levels across the country. Overdose deaths from prescription painkillers and heroin totaled about 33,000 in 2015, according to the American Society of Addiction Medicine.

Naloxone reverses the progress of an overdose and revives the victim so they start breathing again. It’s been around since the 1960s but has become so ubiquitous in the emergency response arena in recent years that even the bomb squad in Prince George’s County carries it — to safeguard their bomb-sniffing dogs.

“Obviously, they’re sniffing a lot of things in a lot of different places,” Spies says. “So if they come across white powder or any type of the drug, the bomb team does have the naloxone readily available to give to the canines.”

Prince George’s County will spend about $45,000 of its $600,000 equipment budget this year on naloxone. Spies says the price of the drug had been rising but has leveled off in recent years.

The Washington, D.C., fire department confirms this. The city paid about $6 for a prefilled syringe of naloxone in 2010, says spokesman Vito Maggiolo. This year, that same syringe runs about $30. Maggiolo says the fire department spent about $170,000 on naloxone in the last 10 months.

That worries Sen. Claire McCaskill, D-Mo., who last week sent letters to four pharmaceutical companies that make naloxone, asking them to provide details about the discount programs they offer to emergency management and public health agencies. It’s part of an ongoing inquiry she launched last year with Sen. Susan Collins, R-Maine, into rising drug prices.

First responders in Washington, D.C., bring naloxone on every emergency call.

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“The rise in costs associated with acquiring naloxone has caused significant accessibility issues for those on the front lines of this epidemic,” she wrote in the letters. The letters were following up on an earlier request about naloxone costs, in which the companies responded by saying they had donated doses and offered discounts on naloxone to first responders.

The prices of some brands of naloxone have risen in recent years, according to an analysis by the investment research firm SSR Health for NPR. The price of a vial of generic naloxone made by the company Amphastar rose from about $4 in 2009 to about $16 this year, according to SSR.

McCaskill was particularly concerned about a naloxone auto-injector called Evzio, made by Kaleo Pharmaceuticals, whose price rose from $288 per dose when it hit the market in 2014 to more than $2,000 this year. McCaskill sent the company a separate letter asking it to justify its price in February.

Kaleo CEO Spencer Williamson said in a statement that no customers actually pay that much because of all the discounts and rebates the company offers.

The company says it has donated more than 250,000 of the devices to nonprofit groups, fire departments and public health agencies. It says 3,600 lives have been saved by those donated devices.

Not all prices are rising. Narcan is probably the best-known brand of naloxone. It’s made by Adapt Pharma and comes in a nasal spray. The list price has been $125 since it went on sale in 2015, according to the company and SSR. Company spokesman Thomas Duddy says Adapt sells Narcan to emergency responders and other public agencies for $75 for a two-pack.

“You get a sense of the premium being charged for the unique delivery mechanism,” says Richard Evans, general manager at SSR. But Evans says the higher prices for those specialty products have also driven up the price of generic naloxone.

Last week, President Trump’s opioid commission, chaired by New Jersey Gov. Chris Christie, issued a report that included a recommendation to declare the opioid epidemic a national emergency. Doing so would give the Department of Health and Human Services the power to negotiate lower prices for naloxone, the report said.

Today, HHS Secretary Tom Price said the administration believes they already have the resources and focus they need to tackle the problem without needing an emergency declaration, but he did add that “all things are on the table for the president.”

The report also asked the president to require every law enforcement officer in the country to carry naloxone.

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Flattening The 'Mummy Tummy' With 1 Exercise, 10 Minutes A Day

Women work on strengthening their core abdominal muscles in Leah Keller’s exercise class for new moms, inside a San Francisco clothing store called Monkei Miles.

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I admit it. I have a “mummy tummy,” also known as “mommy pooch.” You know, that soft, jelly belly you retain after having a baby — it makes you look a few months pregnant.

I’ve tried to convince myself that the pooch is a valiant badge of motherhood, but who am I kidding? The pooch bothers me. And it turns out it’s been causing me back pain.

So when I hear that a fitness coach and doctor have come up with a technique that can flatten the pooch quickly and easily, I think, “Why not?”

A few weeks, later I’m rolling out a yoga mat with a dozen other moms and pregnant women in San Francisco.

“We will see a dramatic change,” says Leah Keller, who leads the class. “You can easily expect to see 2 inches off your waist in three weeks of time,” Keller says. “That’s not an unrealistic expectation.”

Decked out in purple yoga pants and leather cowboy boots, Keller is a personal trainer from New York City. She has developed an exercise that allegedly shrinks the mommy pooch.

There’s science to back up the method, she says.

“A doctor at Weill Cornell and I did a study on the exact same program we’re going to do,” Keller says. “And we found 100 percent of women achieved full resolution.”

Keller measures the separation in a student’s abdominal muscles using her fingers as a guide.

Talia Herman for NPR

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Talia Herman for NPR

OK! Wait a second. Two inches off my belly in three weeks? That sounds too good to be true. I decide to do a little digging into the science of mummy tummy and Keller’s claim.

Putting the six-pack back together

It turns out the jelly belly actually has a medical term: diastasis recti, which refers to a separation of the abdominal muscles.

And it’s quite common. Last year, a study from Norway reported about a third of moms end up with diastasis recti a year after giving birth.

“This is such a ubiquitous issue,” says Dr. Geeta Sharma, an OB-GYN at Weill Cornell Medical Center-New York Presbyterian Hospital.

And it’s not just a cosmetic problem. Diastasis recti can cause another big issue for new moms: lower back pain.

“People can start feeling some back pain because the core is weakened,” Sharma says.

The Diastasis Recti

During pregnancy, the abdominal muscles responsible for a “six pack” stretch apart (left) to accommodate a growing fetus. After birth, the muscles don’t always bounce back, leaving a gap known as the mommy pooch.

distasis recti

Source: Nick Sousanis/Courtesy of Sustainable Fitness Incorporated

There’s a simple way to see if you have diastasis recti:

  1. Lie flat on your back with your knees bent.
  2. Put your fingers right above your belly button and press down gently.
  3. Then lift up your head about an inch while keeping your shoulders on the ground.
  4. If you have diastasis recti, you will feel a gap between the muscles that’s wider than an inch.

In rare occasions, the tissue in the abdomen isn’t just stretched, but it is also torn a bit. This can cause a hernia, Sharma says.

If there’s a defect in a layer of tissue called the linea alba, then the bowel can poke through,” Sharma says. “That’s going to be more dangerous.”

A hernia may require surgery. “So I will refer patients to a general surgeon to have a C.T. scan if there’s really a true concern about a hernia,” Sharma says.

Diastasis recti arises during pregnancy because the growing fetus pushes the abdominal muscles apart — specifically the rectus abdominal muscles.

“These are the muscles that give you a ‘six pack,’ ” says Dr. Linda Brubaker, an OB-GYN at the University of California, San Diego. “People think these muscles go horizontal across the belly. But they actually go vertical from head to toe.”

The rectus abdominal muscles should be right next to each other, on either side of the belly button, Brubaker says. “There shouldn’t be much of gap between them.”

But during pregnancy a gap opens up between the muscles, right around the belly button. Sometimes that gap closes on its own, but other times it stays open.

That leaves a spot in the belly where there’s very little muscle to hold in your stomach and other organs, a spot that can be one to two inches wide. That lets the organs and overlying tissue bulge out — and cause mommy pooch.

To flatten the area, women have to get those abdominal muscles to realign. And that’s where the exercises come into play.

If you search online for ways to fix diastasis recti, you’ll turn up a deluge of exercise routines, all claiming to help coax the abdominal muscles back together.

But the quality of much of that information isn’t good, Brubaker says. “Some of it is actually potentially harmful.”

Even some exercises aimed at strengthening the abdomen can exacerbate diastasis recti, says Keller, including simple crunches.

“You have to be very careful,” she says. “For example, please don’t ever again in your life do crossover crunches or bicycle crunches. They splay your abs apart in so many ways.”

That said, there are a few exercise programs for diastasis recti that many doctors and physical therapists support. These include the Tupler Technique, Keller’s Dia Method and the MuTu System in the U.K.

Most such courses, taught once a week for an hour in New York, San Francisco and at least a few other places, tend to run about four to 12 weeks and cost around $100 to $300. Some places offer online classes and videos, which are much less expensive.

The American College of Obstetricians and Gynecologists also recommends abdominal exercises for the perinatal period. But the organization’s guidelines don’t provide details — such which exercises work best, or how often women should do them and for how long.

Plus, ACOG focuses more on preventing diastasis than fixing the problem; it recommends strengthening the abdomen before and during pregnancy.

Keller (right) checks a student’s progress after the the final class. The fitness coach worked with an OB-GYN from Weill Cornell Medicine to standardize and evaluate her exercise program, which primarily targets abdominal muscles.

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Talia Herman for NPR

“The best way is prevention,” says Dr. Raul Artal, an OB-GYN at St. Louis University, who helped ACOG write its exercise guidelines for the perinatal period. “The best way to do that is to exercise during pregnancy.”

But, as Sharma, the Cornell OB-GYN, points out, no one has really vigorously studied these various exercises to see if they actually fix diastasis recti.

“There’s a general knowledge that exercise is going to help,” Sharma says. “But no one has really tested them in a standardized way.”

In fact, the few studies that have been done haven’t been high enough quality to draw conclusions, researchers in Australia concluded a few years ago.

Sharma hopes to change that. A few years ago, she teamed up with Keller to start to gather some evidence on her technique.

“We did a pilot study to see if the method is helpful for women,” Sharma says.

The study was small — just 63 women. But the results were quite promising. After 12 weeks of doing Keller’s exercise — 10 minutes a day — all the women had fixed their diastasis recti, Sharma and Keller reported at ACOG’s annual meeting few years ago.

“We had patients that were even one year out from giving birth, and they still had such great benefit from the exercises,” Sharma says. “We love to see that there is something we can do to help women.”

The key exercise is typically performed while sitting crossed-legged, standing up or on all fours. But during Keller’s four-week class, she teaches many versions of the exercises. Here Tania Higham (left) and Maeve Clancy, do a version laying on their backs.

Talia Herman for NPR

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Talia Herman for NPR

Now Sharma says she’s working to put together a larger study to really nail down when the exercise works and how well.

Tight and tighter

Back at the class in San Francisco, Keller is taking us moms through the key exercise. It’s surprisingly simple to do.

“The exercise is a very small, very intense movement. That’s almost imperceptible,” Keller says. “OK. We’re going to do another set.”

Sitting on the floor cross-legged, with our hands on our bellies, we all take a big breath. “Let the belly fully expand,” Keller says.

And then as we exhale, we suck in our belly muscles — as far back as they’ll go, toward the spine. “Now we’re going to stay here near the spine. Hold this position,” she says.

Then we take tiny breaths. With each exhale, we push our stomachs back further and further.

“Tight, tighter,” Keller chants, rhythmically.

You can do the exercise in several different positions, Keller says: sitting crossed-legged, sitting on your knees, standing with knees slightly bent, on all fours or laying on your side in the fetal position.

The key is to be sure your back is flat. And that you do the exercise 10 minutes each day, changing positions every two minutes or so. For the rest of the time, your belly is pulled all the way back into the spine.

“The fingertips on the bellybutton are really important for this reason,” she says. “So you know that you’re squeezing tight, tighter with the belly, and you’re never bulging the bellybutton forward.”

This is our fourth week of class, and we’ve been doing this same exercise on our own every day for at least 10 minutes. So it’s judgement day. Time to see if we’ve flattened our bellies and resolved the diastasis recti.

Keller pulls out a measuring tape and starts wrapping it around women’s middles. She also has us lie down on the floor, so she can measure the separation in our abdominal muscles.

One by one, there’s success after success. Several moms completely closed up their abdominal separations. Many lost inches from their bellies.

One woman had amazing results. “Oh my goodness, you lost nearly four inches from your belly circumference,” Keller exclaims. “That’s amazing!”

How did I fare? Well, after three weeks, I didn’t completely close up the abdominal separation. My separation decreased from 1.2 inches to 0.8 inches.* But I did drop more than an inch from my belly circumference.

And I am quite happy with the results. My abs are definitely firmer. And regularly doing this exercise brought a bonus benefit: My lower back pain has almost completely gone away.


*I continued to do the exercises after the class had finished. I checked with in Keller three weeks later to have her measure my diastasis recti. At that point, the separation had dropped down to 0.6 inches, which meant technically I no longer have diastasis recti.

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Your ZIP Code Might Be As Important To Health As Your Genetic Code

Shannon McGrath, pictured with her son Rayder, says it has been a lot easier to make her medical appointments recently, thanks to help from a “patient navigator” — assigned to her by Kaiser Permanente — who arranged McGrath’s transportation.

Kristian Foden-Vencil/OPB

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Kristian Foden-Vencil/OPB

When a receptionist hands out a form to fill out at a doctor’s office, the questions are usually about medical issues: What’s the visit for? Are you allergic to anything? Up to date on vaccines?

But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.

Some doctors even think someone’s ZIP code is as important to their health as their genetic code.

That’s why Shannon McGrath was asked to fill in a “life situation form” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant.

“When I got pregnant, I was homeless,” she says. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids, transportation, financial struggles.”

The form asked about her rent, her debts, her child care situation and other social factors. On the strength of her answers, Kaiser Permanente assigned her what is called a “patient navigator.”

“She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle,” McGrath says. “She assured me that child care wouldn’t be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be.”

McGrath’s navigator helped her get in touch with local nonprofits that helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep Kaiser’s medical costs lower.

McGrath says her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.

Angelette Hamilton works as a patient navigator at Kaiser Permanente Northwest, helping patients get social services. After Kaiser started offering patients this sort of support, one study found a 40 percent reduction in emergency room use.

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Kristian Foden-Vencil/OPB

Patient navigators have been around for a while. What is new is the form that McGrath filled out and how hospitals are using the socioeconomic and other data the forms glean to serve patients. The details now go into a patient’s file, which means providers such as Dr. Sarah Lambert have more information at a glance.

“I find it incredibly helpful because it can be very hard to find out,” says Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”

Federal officials introduced new medical codes for the social determinants of health a few years ago, says Cara James, director of the Office of Minority Health at the Centers for Medicare and Medicaid Services.

“More providers are beginning to recognize the impact that the social determinants have on their patients,” she says.

Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agrees. But she goes one step further.

She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics.

“My personal belief is that putting more money into health care is a moral sin,” she says. “We need to take money out of health care and put it into other social inputs like housing and food and transportation.”

Linking health organizations like Kaiser with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman says.

For example, spending more on affordable housing for homeless people can also have health benefits, in turn saving the government money down the line.

Friedman says that when Kaiser started addressing people’s social needs, one study found a 40 percent reduction in emergency room use.

McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.

“I didn’t want someone to see my situation and have it raise alarms,” she says.

But ultimately she was glad to have shared that information.

“I’m able to look at life and not feel overwhelmed or burdened,” she says, “or like I’ve got the whole world on my shoulders.


This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism organization and not affiliated with Kaiser Permanente.

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Bill Moyers On Working With LBJ To Pass Medicare 52 Years Ago

Journalist Bill Moyers once worked as the special assistant to President Johnson, where he witnessed first-hand the political maneuvering that resulted in the landmark health care legislation.

TERRY GROSS, HOST:

This is FRESH AIR. I’m Terry Gross. The failure of the latest attempt to repeal and replace the Affordable Care Act coincided with the 52nd anniversary of the passage of Medicare and Medicaid. My guest Bill Moyers has written a new article about how President Lyndon Johnson coaxed, cajoled, badgered, buttonholed and maneuvered Congress into enacting Medicare for the aging and Medicaid to help low-income people. At the time, Moyers was a special assistant to Johnson.

Later, from 1965 to ’67, Moyer’s served as Johnson’s press secretary. He was a journalist before entering the political sphere and after leaving the Johnson administration, Moyers returned to journalism. He hosted public TV shows from 1971 until just a couple of years ago. He racked up about 36 Emmys and nine Peabody Awards. Although he’s retired from hosting his own shows, he’s the managing editor of billmoyers.com, where his article about the passage of Medicare is published. Bill Moyers, welcome back to FRESH AIR. It is great to have you back again.

BILL MOYERS: And I’m delighted to be here.

GROSS: So Medicare – the idea of health coverage for older people – took a long time to pass, but it dates back to 1935, when FDR proposed it. What was his proposal?

MOYERS: He wanted to get health insurance included as part of Social Security. Social Security was quite popular but health care was not. And the Republican Party and conservative Democrats and doctors around the country and an early form of the American Medical Association won that victory. It took us 40 years and four Democratic presidents before we finally accomplished Medicare 50 years ago in 1967.

GROSS: In your article, you describe what health care was like in your family. Why don’t you tell us about that? At the time. And we’re talking about the mid-’30s.

MOYERS: Well, in 1935, when Roosevelt made his proposal, I was a 1-year-old. My family was poor. The Great Depression had robbed my father of being a tenant farmer. He took a job for a dollar a day helping to build a highway in southeastern Oklahoma, a highway I think from Dallas to Oklahoma City. And my mother was marked all of her life by the fact that she had lost twin girls, one at birth and one some months later. I don’t remember just how many because the nearest doctor – the only doctor – was too far away to get through the countryside in his horse and buggy in time to help.

So eventually, my mother and dad moved into town. And to pay the doctor who did deliver me, my father carried by hand very large sandy stones to the site that the physician had bought to build his first office. It’s still there. This was exactly at the time, Terry, when, as I said earlier, those Republicans and conservative Democrats and the AMA were winning their fight to sink President Roosevelt’s proposals. So all through my life, I was reminded of what it had meant to my parents and my family and, of course, to many others of that generation and beyond who didn’t have coverage and good health care when they most needed it.

GROSS: Truman tried and failed to pass a version of Medicare. Then, Kennedy and LBJ made it a plank in their platform. You write that, you know, Kennedy’s death helped Lyndon Johnson actually enact that agenda. How did LBJ use Kennedy’s death to try to unite people behind the passage of Medicare?

MOYERS: Well, they knew that Kennedy’s program was – his proposals on health care and civil rights and others were very important but were stalled in Congress. And on the plane back from Dallas – on Air Force One coming back from Dallas with the new president, a small coterie of aides and friends in the front compartment, and LBJ intuitively felt that this was the moment to try to move what had been a stalled agenda in the Congress. And so in a very – his first major address to Congress a few days after the funeral of Kennedy, Johnson at the end of it said in that slow Texas drawl of his but with genuine conviction, let us continue.

And that kind of sparked the awakening of America from their deep grief and a realization that life had to go on. Government had to work. We had a new president. Let’s back him as he does what he feels he needs to do. And he felt he needed to act not on some new agenda but on an agenda that had been much discussed, much very carefully conceived and stalled in Congress. And that’s how it came about that he pulled the lever and sent us into action to do what eventually came to be known as the Great Society legislation, although I often had some doubts about that sort of grandiose term. But it nonetheless was the most aggressive legislative agenda since Franklin Roosevelt and Harry Truman, who – whose New Deal was a very important part of his surprise upset victory in 1948.

GROSS: So you became Lyndon Johnson’s press secretary. So you were his press secretary during the passage of Medicare, right?

MOYERS: Well, the first two years in the White House – I came back with him from Dallas, went right to the White House with him, stayed in his home for a few days. And then although I at the time was the deputy director of the Peace Corps and wanted to go back to the Peace Corps, he insisted I stay. And my first major assignment – I had two major assignments in 1964. One was to manage the – his campaign for election in November in his own right.

But the most important assignment I had was to put together the task forces that would lead to the legislative program of 1965. That included, by the way, the Public Broadcasting Act, which was passed in 1967 to include education. It included poverty, and it included health insurance. So for 15 months, I worked intensely on helping to shape that legislation including Medicare. Then, in the mid part of 1965, as he had run through two or three press secretaries, he insisted that I take that job, and I did reluctantly.

GROSS: Why were you reluctant?

MOYERS: I loved what I was doing. I mean, I loved – at first, I wanted to go back to the Peace Corps when I could first get free. Secondly, I thought creating this legislation and working with some of the best minds in government and from around the country was exhilarating. It was exhausting, but it was exhilarating, and there was something coming out of it. There was something being created that would make a real difference in the lives of Henry and Ruby Moyers in Marshall, Texas, and millions of people like them that I liked doing that.

I liked the anonymity of it. It was easier to get things done when you were not Scaramucci or Bannon or somebody like that. And the second thing is I did not want to be press secretary. I mean, the third time he asked me, I couldn’t say no. I said no twice. The third time, he insisted. And I still have a sore shoulder from that encounter.

And I went home. And that night, I said to my wife as we went to bed, well, this is the beginning of the end. And she said, why? And I said, because – obviously appealing to the New Testament with which I was familiar – no man can serve two masters. And I just didn’t want to get caught in the middle between the press and the president. I loved what I had been doing. And I didn’t covet that job. And the truth of the matter is in time, as I anticipated, our credibility was so bad we couldn’t believe our own leaks.

GROSS: That was in part because of the war in Vietnam, right?

MOYERS: Yes – mainly. It was also because Lyndon Johnson, you know, was a – 13 of the most complex people I ever knew. And it was – you had to deal with a different persona from day to day or from week to week. And sometimes it was difficult to figure out who he was at that particular time. And you’d find yourself contradicting yourself, even though you hadn’t intended to.

When I took the job, when it was announced, my father sent me a telegram. And he said, Bill – telegram, most of your listeners don’t know what a telegram is, but it was the end – a tweet that took a long time to come by wire and paper. But he said, Bill, tell the truth if you can. But if you can’t tell the truth, don’t tell a lie. And I tried very hard to walk that line, sometimes I felt like on the wrong side of it, but I – it was a tough and tenuous assignment.

GROSS: If you’re just joining us, my guest is journalist Bill Moyers, who’s received about 36 Emmys and nine Peabodys. And he retired from hosting his own PBS shows, but he’s still writing and is the managing editor of billmoyers.com, where his latest piece was just published. It’s about how LBJ launched Medicare 52 years ago in spite of the opposition. Moyers was LBJ’s press secretary from ’65 to ’67 and was a special assistant to LBJ before that. We’ll be back after a break. This is FRESH AIR.

(SOUNDBITE OF DJ RADE’S “FREAK OUT”)

GROSS: This is FRESH AIR. And if you’re just joining us, my guest is journalist Bill Moyers, who is now the managing editor of billmoyers.com, in which he has a new piece about how LBJ launched Medicare 52 years ago in spite of the opposition. And it’s a very interesting piece to read in the light of the attempts by Republicans and the Trump administration to repeal and replace Obamacare. One of the people trying to influence public opinion against Medicare was Ronald Reagan. He was a spokesperson for the AMA at the time. What was his role in the debate?

MOYERS: He was hired by the AMA to be their pitchman for the campaign to stop Medicare. He was not yet in politics. He would not run for governor of California for two more years. This was 1964, remember. And he would travel the country making speeches to organize groups. And then he also cut a very persuasive audio and film – short film – that was circulated by an organization composed mainly of doctors’ wives, who in their local communities – where they knew everybody because mostly small towns in those days and small and medium-sized towns – they would get together their neighbors and the patients of their doctors – husbands and play this audio or this little film clip if they had the means to do so.

And Ronald Reagan was very persuasive on that. Not persuasive enough to stop the Medicare legislation, but he was probably our most effective adversary. And Barry Goldwater, who was in 1964 the Republican presidential candidate – and I thought about this, by the way, when John McCain flew up from Arizona recently to make his stand – Barry Goldwater interrupted his campaign in the fall of 1964, flew to Washington and voted against the Medicare legislation we were then advocating. And we lost by four votes. His was one of those four votes. But Reagan was clearly – he could touch people in those days, just as he did when president. He was a superb communicator, as the saying goes.

GROSS: Well, embedded in your article about LBJ and Medicare, you have a short excerpt of the recording Ronald Reagan made when he was a spokesperson for the AMA trying to persuade people against Medicare. So thanks to you, let’s hear a short excerpt of that recording. This is Ronald Reagan in 1964?

MOYERS: Yes.

GROSS: OK.

(SOUNDBITE OF ARCHIVED RECORDING)

RONALD REAGAN: Behind it will come other federal programs that will invade every area of freedom as we have known it in this country. Until one day, as Norman Thomas said, you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.

GROSS: That sounds kind of familiar to me, the whole idea that, like, government’s going to take over medicine and then it’s going to take over your life. And that’s going to be the end of freedom in America.

MOYERS: Well, that’s a consistent conservative refrain, and it has been from the very beginning. It’s not a – it’s not one you can dismiss frivolously because none of us want to live in George Orwell’s state, a state in which government is totalitarian, tyrannical and we’re under constant surveillance. And you could hold out those fears of what was then, you know, the Stalinist, Communist state in Russia as a dystopian vision of America’s future. And, of course, none of us want to be dictated to by anyone. And it was an argument that struck home with Americans who had – with many Americans who had a strong sense of individualism.

The country was founded in no small part on liberty and justice for all and each, therefore. So it was an argument that persuaded people, particularly when their local doctors and their doctors’ local wives were saying, well, this is going to put the United States government – it’s going to put Roosevelt or Truman or Kennedy or Johnson between you and your doctor. I mean, Reagan, who voted several times for Franklin Roosevelt, by the way, didn’t seem to think then that his vote was going to diminish his freedom. And so conservatives had taken that article to a very extreme level.

I mean, there are many, many countries in the world who have some form of universal health care, even single-payer health care. And on the whole, there are always complaints because you can’t have one policy that does fit all. On the whole, most people in Norway and Sweden and Taiwan and Canada and Japan and places where they do have a form of single payer or universal health care, they don’t seem to feel that they’ve lost their freedom. It was an alarmist but effective argument.

GROSS: So Johnson had quite a reputation for being, like, a brilliant tactician in Congress. Give us an example of an arm he twisted or a deal he made to get an essential vote.

MOYERS: Well, he had very effective powers of persuasion. He knew how to phrase an issue or a challenge so that it would connect to people who had to vote on it in the House and Senate. I mean, when we were working on our bill in 1965, I and others had urged that the Medicare bill include a provision for a retroactive increase in Social Security payments because they would be an economic stimulus, and we sort of needed that at the moment. And he called me on the phone. And he said, well, I think it’s fine to be retroactive, but I think it can be defended. I think Medicare can be defended on a hell of a better basis in Congress than this. I mean, we do know that it affects the economy. It helps in that respect. And here’s a direct quote from that telephone call to me, “that’s not the basis to go to the Hill, Moyers. It’s not the justification. We’ve just got to say that, by God, you can’t treat grandma this way. She’s entitled. And we promised it to her.”

And when he talked like that to members of Congress, they got it. I mean, he could tailor his appeal to the interests and prejudices of the member of the Senate or House in front of him, but he knew how to get them to see it differently than the arcane language in the bill itself. And at one point, we were paralyzed again on the Medicare bill. We’d gotten a good bill out of the House, and it was in the Senate. And there was a conflict between the House and the Senate. And we went to him, said, how do you want us to sell it? We’re down to the last round. And if we get the argument right, we can get a good majority in the Senate and a good majority in the House.

And he said, give everybody bragging rights. He said, you go to them and you say, one day, their grandson or their granddaughter is going to look back and say – I’m paraphrasing here – my grandfather was in the Congress when they passed Medicare. And he said, you know, those grandchildren are going to be so grateful to you, and their parents are going to be so great for you because they didn’t have to find the money to pay for grandma and grandpa in the nursing home. So you go to them and say they can brag that they were there when the moment came to decide for their parents and their own generation.

And you know what? I can tell you one after – I saw the light go off in one congressional face after another when that argument was made. You’re writing history. You can brag about it to your grandchildren. That was how he did it. And then, of course, he knew how to play the tough game of threats against members of Congress who didn’t vote for it. He could offer a dam. You know, he knew – Lyndon Johnson was a genius in knowing everyone’s price. And he knew that some senators just wanted to bring their wives to dinner at the White House. Some senators wanted a photograph of them with the president. Some senators wanted a dam built on a river in their home state. He knew how to trade.

He once said to us, you know, the cardinal rule of what you’re doing up in Congress is if you don’t got something to give, you’re not going to get something to get. In other words, you got to trade. And that was his mandate. When you go up to see Wilbur Mills, the chairman of the House – powerful conservative Democrat who was chairman of the House Ways and Means Committee who could have killed this bill at any moment and did for some time kill the Medicare bill – you’ve got to give him something for what you want to get from him. That was his genius.

I mean, what all of this shows is that it takes a president who is informed and engaged and active in the legislative process respecting the differences between the branches. But it takes somebody who knows what’s going on, who cares about the details of the bill, who is willing to sit one-on-one. I mean, I can see right now Lyndon Johnson having individual and collective members of Congress to have coffee in the morning, lunch at noon, a drink at 6 o’clock, even dinner sometimes. And then he would invite in the head of the Chamber of Commerce, the head of the AFLCO (ph), very important to passage of Medicare. They brought their 14 million members to back it. That’s how he worked at it.

You know, he had a large persona. He was out doing bawdy things in public, making speeches and that sort of thing, but he on Medicare preferred to work quietly and behind the scenes because he did not want the public to think he was dominating Congress. And he wasn’t dominating Congress. He was persuading Congress.

GROSS: My guest is Bill Moyers. His article about how LBJ convinced Congress to pass Medicare is published on billmoyers.com. After we take a short break, we’ll talk about some of his experiences as LBJ’s press secretary, his thoughts about President Trump’s spokespeople. And he’ll reflect on his life at the age of 83. I’m Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF TED NASH’S “WATER IN CUPPED HANDS – AUNG SAN SUU KYI”)

GROSS: This is FRESH AIR. I’m Terry Gross, back with Bill Moyers. His latest article is about how President Johnson managed to convince Congress to pass Medicare. The latest attempt to repeal and replace Obamacare coincided with the 52nd anniversary of the passage of Medicare and Medicaid. Moyers worked as LBJ’s special assistant and press secretary. After leaving the administration, Moyers returned to journalism. He hosted public TV series from 1971 until just a couple of years ago. He’s now managing editor of billmoyers.com, where his article about Medicare is published.

You left the LBJ administration during the period when the war in Vietnam was at the center of American politics. And my understanding is when you left the administration, when you left your job as press secretary, that you and LBJ never spoke again. Why?

MOYERS: We didn’t. That was in – well, that was in January of 1967. I had been press secretary for over a year. He was escalating the war in Vietnam. I wish I could tell you that I had been a moral prophet and warning against the war. I wasn’t. As the war went on and the damage was evident, it began to be deeply troubling. I was an advocate for stopping the bombing of North Vietnam. When I used to come to meetings in the cabinet room late, as I was often late because I was also press secretary and somebody had me cornered, he would sort of half-amusedly and half-cynically say, here comes Ban-The-Bomb Bill.

And – but mainly, Terry, I had, as I said earlier, been working on the domestic legislation. It was deeply satisfying to deal with the work on education reform and health reform and a better tax system and the war on poverty and all of that. And as the war escalated, more and more of the resources that the president intended to commit to these domestic programs, to a healthier, saner society, were going to war. If you wanted to make creative policy, it was not a good time and – to be in government because of the war was consuming everybody’s energy, everybody’s passion and everybody’s time. And it was very hard to be constructive in such a destructive era. And I left.

GROSS: I understand that as a reason for leaving but not necessarily as a reason for never talking to LBJ again.

MOYERS: Well, this is difficult to talk about personally, but some people said he and I had a father-son relationship. And I don’t know if that was true. I mean I never mistook him for Henry Moyer, who’s my father whom I love deeply and who loved me. But he always had some young men recently graduated from college working for him because he had been head of the National Youth Administration for Franklin Roosevelt in Texas. That was a Depression-era organization that found jobs for young people, mostly young men. And he believed in nurturing the next generation of political leaders in Texas. And he saw in me possibly a politician of the future.

And we had a very special relationship. And I think both of us were heartbroken when we parted, with some other people feeding some rumors and some gossip and speculating, you know, what had caused us to part. And it just never – I mean I wrote him two or three letters, and he would respond tepidly but appropriately. And then – I did see him when we – at the dedication of the LBJ Library. I think that was in 1971. We just said hello, and a year – 18 months later, he was dead. And I – we never had a chance to talk again.

GROSS: Since you were the press secretary, I am really interested in hearing your reactions to what’s been happening at the White House Communications Office. So what’s your impression of how first Spicer and now Sanders has dealt with difficult questions from the press?

MOYERS: Well, let me say that I’m wary of criticizing my successors as press secretary. It’s a hard job under any circumstance, and I certainly didn’t handle the press secretary job beautifully or perfectly when I was there. You know, Terry, to be very frank, it’s very hard to be a journalist today because we are supposed to observe behavior, not examine motives or psychological issues inside the people we’re watching.

And it’s hard to be a journalist because I don’t have the language to describe adequately for my viewers or readers the malevolent furies that have been released into our body politic. This penchant for chaos, which is at the – a dagger being twisted in the heart of our political process – I don’t get it, and I don’t know how to explain it to people.

You have to watch – I watched the briefings of Sean Spicer to see if I could understand and explain the chaos that was there. It goes to the character and persona of the person they’re trying to help communicate to the public. And I cannot explain satisfactorily as a journalist – perhaps I could as a psychoanalyst or a psychiatrist – what we’re seeing.

But what we’re seeing is a kind of chaos we don’t have – have not have had. We’ve had failed presidents and brilliant and unsuccessful press secretaries. We’ve never had this situation where the president is living in a different reality from everybody else, including those who are trying to serve him in the White House. And penetrating that reality and helping the country – even his own administration – understand it is almost an impossible job. It’s like that movie “Arrival” where the aliens come from beyond and try to communicate with humans. And because neither humans can communicate with the aliens, nor the aliens with the humans, it’s a tragic exercise and a failed effort.

That’s where we are right now. This is an alien force in the persona and presence of our president. And I feel for the people who try to serve him. I mean obviously they do it because they want to, and they’re willing to put up with it. But it’s very, very difficult to understand. Sean Spicer didn’t have to do it. He could have quit. But he wanted to. He obviously felt drawn to. He wanted to try to make a difference. And it’s impossible.

And there – the fact that you have a new chief of staff – the new chief of staff is not going to change the character of the principal whom he’s trying to help. So it’s a weird, bizarre and very, very tumultuous situation that is very difficult to decipher.

GROSS: So in one of your articles, you called Kellyanne Conway the Queen of Bull.

MOYERS: Yeah, absolutely.

GROSS: So when you hear one of the White House spokespeople saying things that you know are factually not true and, say, you hear it on TV, how would you like to see it treated? I think so many journalists are just struggling to keep up with correcting misstatements that are coming out during live interviews.

MOYERS: And that’s very difficult because it changes the relationship of the conversation. But I really wish all of our interrogators, our interviewers, our hosts would, you know, try to learn from the BBC, which although it’s a state-sponsored, taxpayer-paid-for system, they really are tougher on politicians than we are. And they’re really harder on the propagandas for the other side.

And look; I was not a perfect press secretary. I made a lot of mistakes, but I did feel that the job was to try to help the reporters get what they needed to tell their stories and help the president understand what the reporters were trying to do. I never did think of myself as a propagandist for the administration or the White House. But these people I’m listening to and have been watching in the Trump administration are really just – you know, they’re lying. They’re deceiving us. And if you don’t call that out, then the lie becomes a part of the lived experience of the people who are watching or listening.

And it’s true. We haven’t found a way to deal with the Kellyanne Conways or the Sean Spicers who deliberately are lying in behalf of their president. I wouldn’t have lasted. Pierre Salinger wouldn’t have lasted. James Hagerty wouldn’t have lasted. We wouldn’t have lasted six weeks if we had said we were going to lie for the president that we served.

GROSS: If you’re just joining us, my guest is Bill Moyers. And his latest piece on his website, billmoyers.com, is about how LBJ launched Medicare 52 years ago in spite of the opposition, a piece that’s interesting to read in the light of the attempts to repeal and replace the ACA. We’re going to take a short break, and then we’ll be right back. This is FRESH AIR.

(SOUNDBITE OF MARCO BENEVENTO’S “GREENPOINT”)

GROSS: This is FRESH AIR. My guest is journalist Bill Moyers, who’s received about 36 Emmys and 9 Peabodys. He hosted several public television shows over many years. Now he’s the managing editor of billmoyers.com, where his latest piece was published. It’s about how LBJ launched Medicare 52 years ago in spite of the opposition. And Moyers was LBJ’s press secretary from ’65 to ’67 and, before that, was a special assistant to President Johnson.

Let’s talk about you. You’re 83 now. It’s an age most people are retired. Now, you’re not doing your TV shows anymore, but you’re still writing and serving as managing editor of the website billmoyers.com. Why have you chosen to not fully retire?

MOYERS: Well, you know, I took on a weekly series when I was 70. And I kept it going until I was 82. And it was exhilarating, and it was satisfying. And it gave me – I didn’t think of it as a treatment for old age. I just thought of it as a challenge of every day. And I’m lucky with my DNA. My mother lived to be in her early 90s. My grandmother lived that long. My father lived into his late-80s. I just have the DNA in me. Some of us are blessed that way, and some of us aren’t.

And as long as you can – as long as there’s something useful to do every day and something that’s – is satisfying and challenging, I don’t see any reason to give it up. I did give up the show because there’s some other things I do want to do, including writing, as you say. But I just think being engaged in the life of the mind, and the life of your country and the life of your craft is the greatest blessing that a man or woman can have. And I am blessed that way. And I’m going to do what I can every day to contribute to my grandkids’ future.

GROSS: What did the 80s mean to you when you were considerably younger?

MOYERS: I didn’t know. When I was growing up, Terry, sick people in their 60s were very old to me.

GROSS: Yeah, me too, yeah, mmm hmm.

MOYERS: They seemed very old. I didn’t think my – of myself old when I turned 60 or 70 or 75 or 80. You know, I retired three times from my work as a television journalist and came back not for any sense of distress – out of any sense of distress but just because I had a more – another opportunity to do it.

You know, we’ve raised every penny of every production that we have created, my wife and I, over these years. She was my business partner as well as my marital partner of the last 62 years. And there were times when it was more difficult to raise money than other times, so we’d take a hiatus. And during that hiatus, we’d raise more funds and come back and do something interesting.

But I never thought of the 80s as a downward slope. I mean I’m quite aware. I mean I’ve done seven eulogies in the last couple of years for dear friends of mine who are my age. I’m quite aware that every step is a potential last step. I’m well aware that I may not see tomorrow’s dawn. On the other hand, I might see 10 more. I might be one of those Lyndon Johnson anticipated would live to be 100. I want to find something every day to do to keep me alive and with the world. And it’s just – it’s not something I gave a great deal of thought to – becoming 80. I might when I become 90.

But I’m very – one of my dearest friends is Norman Lear. At 94, he’s still producing situation comedies out in California and still actively engaged through his organization People For the American Way. He’s lucky. I’m lucky. I’m going to keep at it as long as I can.

GROSS: You’ve mentioned the eulogies that you’ve given lately. Do you find yourself thinking more about mortality?

MOYERS: No. I find myself wondering what it’s like not to be here.

GROSS: Mmm hmm.

MOYERS: I mean I’ve been around a long time. I have no idea where I came from. I have no idea where I’m going. But being here has been remarkable. And it’s difficult to imagine not being here. But I sometimes think about that. What will it be like (laughter) not to be here? And of course, like any officer in the military who’s had a long career in that, he doesn’t want to quit before the next war begins. And I don’t want to quit before the next big story or the next big evolution in American democracy happens. But of course I will be. And I’m accustomed to it. I can’t tell you what it’s going to be. I mean I’m just reading this wonderful memoir on dying.

And, you know, Judith and I did a – one of our most popular series, believe it or not, was about death and dying. It was called “On Our Own” and how most Americans want to choose the way they go. I occasionally think about what it will be like in the last hours or days or weeks of one’s life. But for the moment, I can’t see that far ahead. I can only see the challenge of the next day on the website, the next essay, the next special.

We just did a very important documentary called “Rikers: An American Jail” about the culture of cruelty in New York’s largest and meanest jail, Rikers Island, here between Queens and Manhattan. That kept me engaged fully for two years with young men and women who had been brutalized at Rikers. I mean I can’t think of not having done that documentary over the last two years between my 81st and 83rd birthday.

I can’t think of what documentary I don’t want to do between 83 and 85. And if I die in the – halfway through it, somebody will finish it. That I know. The work will go on. The world will go on. And there will be other people as concerned and more concerned about democracy than I am.

GROSS: You said you have no idea where you came from or where you’re going. You had been a Baptist minister. You’re very well-read in the Bible. You’re very well-schooled in other religions as well. You’ve done a lot of programs about faith and reason. Do you feel like all of your immersion in religion has not given you answers to where you came from or where you’re going? And do you mind that it hasn’t given you answers?

MOYERS: No, I think that – you know, seminary was where I got my questions answered. And life is where I got my answers questioned.

GROSS: (Laughter).

MOYERS: And I mean that. I mean that. The experience of life is remarkable. And you learn far less than you want to learn and far more than you expected to. And the big questions that religious – people ask me, why do you keep covering religion so much? And by the way, I do as much expose – investigative journalism of corruption and wrongdoing and Wall Street and all that as anybody else. But I do keep coming back to religion because I know that religion is a powerful, animating force in people’s lives, far more than I think many of us who live in a secular world of journalism understand.

But religion is a motivator of behavior. It’s a motivator of – you know, probably more wars have been fought over religion than for any other reason. But also more hospitals have been built for – from people convicted to a good thing, who are religious. Religion is a mixed blessing in our lives. But it’s a powerful presence in the lives of millions of millions of people. And for a journalist to ignore it would be irresponsible. Or it would – not irresponsible, but it would be unfortunate because that journalist would be overlooking the powerful intuitions that come from faith.

GROSS: Bill Moyers, it’s been great to talk with you again. Thank you so much for coming back to our show.

MOYERS: Thank you, Terry, for being who you are.

GROSS: Thank you. Bill Moyers’ latest article about how LBJ convinced Congress to pass Medicare is published on billmoyers.com. After we take a short break, David Edelstein will review the new film “Wind River,” starring Jeremy Renner and Elizabeth Olsen. This is FRESH AIR.

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Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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Many Avoid End-Of-Life Care Planning, Study Finds

People with chronic illnesses were only slightly more likely than healthy individuals to put their wishes down on paper in a living will.

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Before being deployed overseas for the Iraq war in 2003, Army reservist Don Morrison filled out military forms that gave instructions about where to send his body and possessions if he were killed.

“I thought, ‘Wow, this is mortality right in your face,'” Morrison, now 70, recalls.

After that, his attention was keenly focused on how things might end badly. Morrison asked his lawyer to draw up an advance directive to describe what medical care he wanted if he were unable to make his own decisions.

One document, typically called a living will, spells out Morrison’s preferences for life-sustaining medical treatment, such as ventilators and feeding tubes. The other, called a health care proxy or health care power of attorney, names a friend to make treatment decisions for him if he were to become incapacitated.

Not everyone is so motivated to tackle these issues. Even though advance directives have been promoted by health professionals for nearly 50 years, only about a third of U.S. adults have them, according to a recent study.

People with chronic illnesses were only slightly more likely than healthy individuals to put their wishes down on paper.

For the analysis, published in the July issue of Health Affairs, researchers reviewed 150 studies published between 2011 and 2016 that looked at the proportion of adults who completed advance directives. Of nearly 800,000 people, 37 percent completed some kind of advance directive. Of those, 29 percent completed living wills, 33 percent filed health care proxies and 32 percent remained “undefined,” meaning the type of advance directive wasn’t specified or was combined.

People older than age 65 were significantly more likely to complete any type of advance directive than younger ones — 46 percent of older people, versus 32 percent of those who were younger. But the difference between people who were healthy and those who were sick when they filled out the directive was much smaller — 33 percent compared with 38 percent.

To encourage more physicians to help people to plan for their care, the Medicare program began reimbursing them in January 2016 for counseling beneficiaries about advance-care planning.

This study doesn’t incorporate data from those changes. But it can serve as a benchmark to gauge improvement, says Dr. Katherine Courtright, an instructor of medicine in pulmonary and critical care at the University of Pennsylvania. She is the study’s senior author.

There are many reasons that people are reluctant to sign a living will. “Many people don’t sign advance directives because they worry they’re not going to get any care if they say they don’t want [cardiopulmonary resuscitation],” says Courtright. “It becomes this very scary document that says, ‘Let me die.’ “

Living wills also don’t account for the fact that people’s wishes may change over time, says Dr. Diane Meier, a geriatrician and the director of the New York-based Center to Advance Palliative Care.

“In some ways, the public’s lack of excitement about this is related to the reality that it’s very hard to make decisions about the kind of care you want in the future when you don’t know what that will be like,” she says.

Sometimes as patients age and develop medical problems, they’re more willing to undergo treatments they might have rejected when they were younger and healthier, Meier says.

“People generally want to live as well as they can for as long as they can,” she says. If that means going on a ventilator for a few days in order to get over a bout of pneumonia, for example, many may want to do that.

But if their living will says they don’t want to be put on a ventilator, medical staff may feel bound to honor their wishes. Or not. Although living wills are legal documents, medical staff and family members or loved ones can reinterpret them.

“At the moment, I’m very healthy,” Morrison says. If he were to become ill or have a serious accident, he’d want to weigh life-saving interventions against the quality of life he could expect afterwards. “If it were an end-of-life scenario, I don’t want to resuscitated,” he says.

If someone’s wishes change, the documents can be changed. There’s no need to involve a lawyer in creating or revising advance directives, but they generally must be witnessed and may have to be notarized.

While living wills can be tricky, experts strongly recommend that people at least appoint a health care proxy. Some even suggest that naming someone for that role should be a routine task that’s part of applying for a driver’s license.

“Treatment directives of any kind all assume we can anticipate the future with accuracy,” says Meier. “I think that’s an illusion. What needs to happen is a recognition that decisions need to be made in real time and in context.”

That’s where the health care proxy can come in.

But to be effective, though, people need to have conversations with their proxy and other loved ones about their values and what matters to them at the end of life.

They may tell their health care proxy that they want to die at home, for example, or that being mobile or able to communicate with their family is very important, says Jon Radulovic, a vice president at the National Hospice and Palliative Care Organization.

Some may opt to forgo painful interventions to extend their lives in favor of care that keeps them comfortable and maintains the best quality of life for the time that remains.

“The most important thing is to have the conversation with the people that you love around the kitchen table and to have it early,” says Ellen Goodman, a Pulitzer Prize-winning writer who founded The Conversation Project, which provides tools to help people have conversations about end-of-life issues.

Morrison says he’s talked with his health care proxy about his wishes. The conversation wasn’t difficult. Rather than spell out precisely what he wants done under what circumstances, Morrison is leaving most of the decisions to his health care proxy if he can’t make his own choices.

Morrison says he’s glad he’s put his wishes down on paper. “I think that’s very important to have. It may not be a disease that I get, it may be a terrible accident. And that’s when [not knowing someone’s wishes] becomes a crisis.”

Kaiser Health News, a nonprofit health newsroom, is an editorially independent part of the Kaiser Family Foundation. Follow Michelle Andrews on Twitter @mandrews110.

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Understanding CSRs In The Health Care Debate

Tennessee Insurance Commissioner Julie Mix McPeak talks with NPR’s Ari Shapiro about cost sharing reductions — federal reimbursements to insurance companies that are key to the Affordable Care Act.

ARI SHAPIRO, HOST:

In the debate over health care, three letters are making insurance companies very nervous – CSR. It stands for cost-sharing reductions. It’s a critical part of the individual insurance markets that were set up under the Affordable Care Act. And they’re now in jeopardy. To help us understand what CSRs are and why people are so anxious about them we’ve called Julie Mix McPeak. She’s the insurance commissioner from Tennessee and president-elect of the National Association of Insurance Commissioners. Last time we spoke to her she mentioned that the CSRs were causing her a lot of heartburn. Julie, welcome back.

JULIE MIX MCPEAK: Thank you so much. Glad to be here.

SHAPIRO: First, just explain what cost-sharing reductions are and why they’re so important.

MCPEAK: Cost-sharing reductions were included in the original Obamacare act to assist those low-income consumers with their out-of-pocket expenses for health insurance – copayments, deductibles, coinsurance amounts – particularly for individuals in the 100 to 150 percent of the federal poverty level range.

SHAPIRO: So that money has been coming from the federal government. But President Trump says he’s thinking about ending these payments. What would happen then?

MCPEAK: Well, certainly the discussion about ending these payments, which are flowing directly from the federal government to the insurers to offset those losses incurred for those individuals, is concerning to companies because number one, they have covered those losses and they had priced their premium rates expecting those reimbursements to come back through. So when there’s any uncertainty surrounding the continuation of those payments, the insurers are doing two things. They are raising premium rates for 2018 and they’re making decisions about whether or not to participate in the individual exchange markets across the nation.

SHAPIRO: So basically, if the federal government isn’t paying this, then insurance companies are going to have to pay it. And you’re saying they’re probably going to pass that cost along to consumers.

MCPEAK: Right. They’ll pass the costs on consumers or they will decide not to even participate in the exchange markets for 2018.

SHAPIRO: Well, that would obviously have dramatic consequences. Do you see consequences in the president even just hinting that he might end these payments?

MCPEAK: Well, I do. It’s very concerning that we’re watching all indicators from Washington, D.C., both from Congress and then the statements of the president himself about the bailouts being discontinued because, you know, we are really in a critical time for insurers to decide about participation decisions in markets. And then also, my colleagues and I are looking at rate increase requests that need to be approved by mid-August or so. And so when you don’t know whether those cost-sharing reduction payments are going to be made, you know, past July, that could cause a premium rate increase of about 15 to 20 percent.

SHAPIRO: You use the word bailouts. That’s how the president has described these payments. Do you think that’s a fair characterization?

MCPEAK: I certainly do not think bailouts is a fair characterization. These payments were originally contemplated in Obamacare and have been flowing from the government to insurers to cover the real and accurate losses of these low-income individuals. And so I feel like it’s much more of a contractual payment than a bailout for insurers.

SHAPIRO: So if insurance commissioners are having to make decisions about the future with this cloud of uncertainty hanging over them, what kinds of decisions are they making?

MCPEAK: Well, we’re trying to make the best decisions that we have on the information that we have before us at that time. I ask for rate increase requests to come in assuming CSRs were not going to be paid so that we could break that out if something were to change in that regard. Other commissioners have asked for duplicate filings, one with and without CSR payments. And we’re sort of waiting till the last minute to see which rate increase request we need to consider.

SHAPIRO: Wow. So in your state of Tennessee you’re saying, let’s just act as though the federal government is going to wash its hands of this, and other states are saying, well, let’s hope the federal government stays engaged, and then we’ll deal with it if they don’t.

MCPEAK: Right. And very problematic is that none of us know. We’re really watching the news and trying to determine on a month-to-month basis whether the payments will continue.

SHAPIRO: So ultimately, if President Trump and Health and Human Services Secretary Price say they want to let Obamacare implode, this sounds like a pretty good way to do it.

MCPEAK: It does. And that’s what’s concerning to all of us as regulators. I think that, you know, choosing to end the CSR payments even midstream in 2017 would cause chaos in the markets for 2018. And what we would really prefer is to have CSR payments funded through 2018 at least. That would provide a level of certainty for our insurers.

SHAPIRO: That’s Julie Mix McPeak, Tennessee’s insurance commissioner and president-elect of the National Association of Insurance Commissioners. Appreciate your coming back on the program. Thanks a lot.

MCPEAK: Thank you so much.

SHAPIRO: And this afternoon, after we recorded that conversation, we learned that the Senate plans to hold hearings in September focused on stabilizing the Affordable Care Act’s marketplaces. Republican Senator Lamar Alexander of Tennessee, who chairs that committee planning those hearings, has called on President Trump to continue making CSR payments to insurers.

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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