Sen. Joni Ernst Said the Quiet Part Out Loud

By Crystal Lindell

Last week Sen. Joni Ernst (R) of Iowa said the quiet part out loud at a town hall meeting. 

While responding to a comment about President Trump’s planned Medicaid cuts possibly killing people, Ernst shrugged and said, “Well, we all are going to die.”

Her remark drew a chorus of boos, as you’ll see in the video:

Ernst may have been talking about Medicaid, but the implication was that everyone was going to die eventually. Of course, the key word here is “eventually.”

There’s a big difference between dying at 21 and dying at 97. Just because someone is going to die eventually, that doesn’t mean that it’s OK for them to die today. In fact, that’s why when someone cuts another person’s life short via murder, we usually punish them for doing so. 

I’m sure Ernst can understand this concept when it comes to herself. After all, I doubt she’d be OK with being denied urgent medical care herself, and then being met with a shrug and a dismissive, “Well she was going to die anyway.” 

The thing is, Ernst wasn’t thinking of herself when she made the comment. Rather, she was thinking of the general public, the masses if you will.  

She was thinking of you and me. 

And to Ernst, our lives are disposable. We are just the peasants who are going to die eventually, so we might as well die today as far as she’s concerned.

Just in case you thought that perhaps Ernst misspoke or was taken out of context, she doubled down a day later with a weird selfie video filmed in a cemetery, of all places. 

“I made an incorrect assumption that everyone in the auditorium understood that yes, we are all going to perish from this Earth. So I apologize,” she said in the video, before glibly adding, “And I'm really, really glad that I did not have to bring up the subject of the tooth fairy as well."

You can see her full “apology” here:

Our lives are truly just a joke to Sen. Ernst.

The thing is, as a chronically ill patient with a bachelor’s degree in political science, I can report that Ernst’s blase attitude about our deaths is all too common. Both our political leaders and many of our healthcare professionals view the (lack of) value of our lives the same way she does. 

You saw it in the government’s poor response to the COVID pandemic, when they did things like prioritizing the economy over people’s lives. 

You also see it Trump’s “One Big Beautiful Bill,” which would take healthcare benefits away from 10 million people and cut $700 billion from Medicaid

And you see it in the way that chronic pain patients are treated by doctors and government policies. 

Many doctors will do anything to avoid the personal stress and intense scrutiny from law enforcement and state medical boards for prescribing opioids. And some don’t care if it means that patients suffer or even die as a result. Doctors know that untreated pain can be dangerous, especially if it pushes patients to the black market looking for relief. 

They share the same attitude that Ernst expressed: “We all are going to die.”

Most doctors would do anything possible to extend their own lives. They would also do anything possible to extend the quality of their lives, even if that means taking the same opioids they might deny pain patients. 

The root of these issues is that a lot of people with power – whether its political power or power in the exam room – see themselves as belonging to a superior class of humans. And anytime a human feels like they are superior to another human, they can start to justify some really awful things. 

Ernst saying, “We all are going to die” is the natural end point of that thought process. 

But she wasn’t talking about herself.

What Ernst really meant was much darker: “You are all going to die – and I don’t care.”

How and Where the Trump Administration Will Cut Healthcare Spending

By Elisabeth Rosenthal, KFF Health News

Health care has proved a vulnerable target for the firehose of cuts and policy changes President Donald Trump ordered in the name of reducing waste and improving efficiency. But most of the impact isn’t as tangible as, say, higher egg prices at the grocery store.

One thing experts from a wide range of fields, from basic science to public health, agree on: The damage will be varied and immense.

“It’s exceedingly foolish to cut funding in this way,” said Harold Varmus, a Nobel Prize-winning scientist and former director of both the National Institutes of Health and the National Cancer Institute.

The blaze of cuts have yielded nonsensical and perhaps unintended consequences. Consider instances in which grant funding gets canceled after two years of a three-year project. That means, for example, that $2 million has already been spent but there will be no return on that investment.

Some of the targeted areas are not administration priorities. That includes the abrupt termination of studies on long covid, which afflicts more than 100,000 Americans, and the interruption of work on mRNA vaccines, which hold promise not just in infectious disease but also in treating cancer.

While charitable dollars have flowed in to plug some gaps, “philanthropy cannot replace federal funding,” said Dustin Sposato, communications manager for the Science Philanthropy Alliance, a group that works to boost support from charities for basic science research.

Here are critical ways in which Trump administration cuts — proposed and actual — could affect American health care and, more important, the health of American patients.

Cuts to the National Institutes of Health

The Trump administration has cut $2.3 billion in new grant funding since its term began, as well as terminated existing grants on a wide range of topics — vaccine hesitancy, HIV/AIDS, and covid-19 — that do not align with its priorities. National Institutes of Health grants do have yearly renewal clauses, but it is rare for them to be terminated, experts say. The administration has also cut “training grants” for young scientists to join the NIH.

Why It Matters: The NIH has long been a crucible of basic science research — the kind of work that industry generally does not do. Most pharmaceutical patents have their roots in work done or supported by the NIH, and many scientists at pharmaceutical manufacturers learned their craft at institutions supported by the NIH or at the NIH itself.

The termination of some grants will directly affect patients since they involved ongoing clinical studies on a range of conditions, including pediatric cancer, diabetes, and long covid. And, more broadly, cuts in public funding for research could be costly in the longer term as a paucity of new discoveries will mean fewer new products:

A 25% cut to public research and development spending would reduce the nation’s economic output by an amount comparable to the decline in gross domestic product during the Great Recession, a new study found.

Cuts to Universities

The Trump administration also tried to deal a harrowing blow — currently blocked by the courts — to scientific research at universities by slashing extra money that accompanies research grants for “indirect costs,” like libraries, lab animal care, support staff, and computer systems.

Why It Matters: Wealthier universities may find the funds to make up for draconian indirect cost cuts. But poorer ones — and many state schools, many of them in red states — will simply stop doing research. A good number of crucial discoveries emerge from these labs.

“Medical research is a money-losing proposition,” said one state school dean with former ties to the Ivies. (The dean requested anonymity because his current employer told him he could not speak on the record.) “If you want to shut down research, this will do it, and it will go first at places like the University of Tennessee and the University of Arkansas.”

That also means fewer opportunities for students at state universities to become scientists.

Cuts to Public Health

These hits came in many forms. The administration has cut or threatened to cut long-standing block grants from the Centers for Disease Control and Prevention; covid-related grants; and grants related to diversity, equity, and inclusion activities — which often translated into grants to improve health care for the underserved. Though the covid pandemic has faded, those grants were being used by states to enhance lab capacity to improve detection and surveillance. And they were used to formally train the nation’s public health workforce, many of whom learn on the job.

Why It Matters: Public health officials and researchers were working hard to facilitate a quicker, more thoughtful response to future pandemics, of particular concern as bird flu looms and measles is having a resurgence. Mati Hlatshwayo Davis, the St. Louis health director, had four grants canceled, three in one day.

One grant that fell under the covid rubric included programs to help community members make lifestyle changes to reduce the risk of hypertension and diabetes — the kind of chronic diseases that Health and Human Services Secretary Robert F. Kennedy Jr. has said he will focus on fighting. Others paid the salaries of support staff for a wide variety of public health initiatives.

“What has been disappointing is that decisions have been made without due diligence,” Davis said.

Health-Related Impact of Tariffs

Though Trump has exempted prescription drugs from his sweeping tariffs on most imports thus far, he has not ruled out the possibility of imposing such tariffs. “It’s a moving target,” said Michael Strain, an economist at the American Enterprise Institute, noting that since high drug prices are already a burden, adding any tax to them is problematic.

Why It Matters: That supposed exemption doesn’t fully insulate American patients from higher costs. About two-thirds of prescription drugs are already manufactured in the U.S. But their raw materials are often imported from China — and those enjoy no tariff exemption. Many basic supplies used in hospitals and doctors’ offices — syringes, surgical drapes, and personal protective equipment — are imported, too.

Finally, even if the tariffs somehow don’t themselves magnify the price to purchase ingredients and medical supplies, Americans may suffer: Across-the-board tariffs on such a wide range of products, from steel to clothing, means fewer ships will be crossing the Pacific to make deliveries — and that means delays.

“I think there’s an uncomfortably high probability that something breaks in the supply chain and we end up with shortages,” Strain said.

Changes to Medicaid

Trump has vowed to protect Medicaid, the state-federal health insurance program for Americans with low incomes and disabilities. But House Republicans have eyed the program as a possible source of offsets to help pay for what Trump calls “the big, beautiful bill” — a sweeping piece of budget legislation to extend his 2017 tax cuts.

The amount of money GOP leaders have indicated they could squeeze from Medicaid, which now covers about 20% of Americans, has been in the hundreds of billions of dollars. But deep cuts are politically fraught.

To generate some savings, administration officials have at times indicated they are open to at least some tweaks to Medicaid. One idea on the table — work requirements — would require adults on Medicaid to be working or in some kind of job training. (Nearly two-thirds of Medicaid recipients ages 19-64 already work.)

Why It Matters: In 2024 the uninsured rate was 8.2%, near the all-time low, in large part because of the Medicaid expansion under the 2010 Affordable Care Act. Critics say work requirements are a backhanded way to slim down the Medicaid rolls, since the paperwork requirements of such programs have proved so onerous that eligible people drop out, causing the uninsured rate to rise.

A Congressional Budget Office report estimates that the proposed change would reduce coverage by at least 7.7 million in a decade. This leads to higher rates of uncompensated care, putting vulnerable health care facilities — think rural hospitals — at risk.

KFF Health News is a national newsroom that produces in-depth journalism about health issues.  

Social Security Was Boosted by Covid Deaths, But at What Cost?

By Crystal Lindell

Three years ago, on Feb. 24, 2022, I woke up at 3 am to use the bathroom, and realized I had double-digit missed text messages and voice mails – all of them filled with words like “urgent” and “immediately.”

I called my brother and he gave me the news. Overnight, our dad, David Jeffery Lindell, had died.

He had been fighting a bad COVID infection for three weeks and was hospitalized multiple times. But then he was sent home, where he had a heart attack. Paramedics tried to save his life, but my dad died hours later at the local hospital, just before midnight. 

He was 67 years old, and because he had been battling chronic physical and mental health problems for decades, he had long been declared permanently disabled by the federal government.

So, like millions of Americans who died of COVID over the last few years, my dad was on Social Security.

Now, a new report from the National Bureau of Economic Research reveals a dark twist to the pandemic: So many people died of COVID between 2020 and 2023, that it increased the Social Security Trust Fund by $205 billion.  

CRYSTAL AT AGE 3 WITH HER FATHER

Well, more specifically, the 1.7 million “excess deaths” during those years saved the fund about $294 billion. Many of those deaths were working people, which resulted in less future payroll tax contributions and more payments to surviving loved ones. Factoring that in resulted in a net increase in the fund of $205 billion. 

The most heartbreaking revelation from the report though is that $205 billion isn’t a lot of money when it comes to Social Security. According to a Marketplace article about the report, the $205 billion in savings “won’t change much in the long term; the government pays that amount in benefits every couple of months."

In other words, all those human lives lost, and it’s barely even a blip when it comes to the federal government’s finances. 

It’s easy to forget that economic reports like this are talking about real, human lives. And that those human lives touched many other lives around them. My dad’s death was like a meteor hitting our whole family, and three years later, we are only just now starting to find solid ground again. 

A lot of the framing and discourse about this new report makes it sound like the government should be happy about the financial savings. But, as a country, now would be a good time to remember that human life has value in and of itself.

My dad mattered and would still be alive today, if not for COVID. He lived at poverty levels on his monthly Social Security benefits. His death, and the deaths of millions of others who were either on social security or set to receive it, should never be framed as a “good thing” by bean counters simply because it saved our government a miniscule amount of money.  

And to be clear, it wasn’t just people currently on Social Security who “boosted” the fund. People like my long-time friend Bronson Peshlaki, who had diabetes and died of COVID in 2020 at just 44 years old, will never collect on the Social Security payments he made his entire working life. Yes, that means his death was a cost-benefit for the U.S. government, but it was also a detrimental loss to the world. 

It can feel easy to dismiss the lives of the disabled, the elderly, the mentally ill – especially as their deaths are framed as some sort of economic boost for the rest of us.

But as someone with a disability, my life has value in this world. My dad’s life also had value, and so did my friend Bronson’s life. Now, as the U.S. healthcare system faces the possibility of more severe cuts and harmful policies under the Trump administration, it’s even more urgent that we remember that.

Every time the government lets a deadly disease spread a little more or cuts back on Medicaid, real people, with souls, will die. Regardless of how much money those deaths might save us, the cost is too high.

Trump’s Early Moves Could Raise Drug Costs and Reduce Insurance Coverage

By Julie Appleby and Stephanie Armour, KFF Health News

President Donald Trump’s early actions on health care signal his likely intention to wipe away some Biden-era programs to lower drug costs and expand coverage under public insurance programs.

The orders he issued soon after reentering the White House have policymakers, health care executives, and patient advocates trying to read the tea leaves to determine what’s to come. The directives, while less expansive than orders he issued at the beginning of his first term, provide a possible road map that health researchers say could increase the number of uninsured Americans and weaken safety-net protections for low-income people.

However, Trump’s initial orders will have little immediate impact. His administration will have to take further regulatory steps to fully reverse Biden’s policies, and the actions left unclear the direction the new president aims to steer the U.S. health care system.

“Everyone is looking for signals on what Trump might do on a host of health issues. On the early EOs, Trump doesn’t show his cards,” said Larry Levitt, executive vice president for health policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

A flurry of executive orders and other actions Trump issued on his first day back in office included rescinding directives by his predecessor, former President Joe Biden, that had promoted lowering drug costs and expanding coverage under the Affordable Care Act and Medicaid.

Executive orders “as a general matter are nothing more than gussied up internal memoranda saying, ‘Hey, agency, could you do something?’” said Nicholas Bagley, a law professor at the University of Michigan. “There may be reason to be concerned, but it’s down the line.”

That’s because making changes to established law like the ACA or programs like Medicaid generally requires new rulemaking or congressional action, either of which could take months.

Trump has yet to win Senate confirmation for any of his picks to lead federal health agencies, including Robert F. Kennedy Jr., the anti-vaccine activist and former Democratic presidential candidate he has nominated the lead the Department of Health and Human Services. On Monday, he appointed Dorothy Fink, a physician who directs the HHS Office on Women’s Health, as acting secretary for the department.

During Biden’s term, his administration did implement changes consistent with his health orders, including lengthening the enrollment period for the ACA, increasing funding for groups that help people enroll, and supporting the Inflation Reduction Act, which boosted subsidies to help people buy coverage. After falling during the Trump administration, enrollment in ACA plans soared under Biden, hitting record highs each year. More than 24 million people are enrolled in ACA plans for 2025.

The drug order Trump rescinded called on the Centers for Medicare & Medicaid Services to test ways to lower drug costs, such as setting a flat $2 copay for some generic drugs in Medicare, the health program for people 65 and older, and having states try to get better prices by banding together to buy certain expensive cell and gene therapies.

That might indicate Trump expects to do less on drug pricing this term or even roll back drug price negotiation in Medicare.

The White House did not respond to a request for comment.

Biden’s experiments in lowering drug prices didn’t fully get off the ground, said Joseph Antos of the American Enterprise Institute, a right-leaning research group. Antos said he’s a bit puzzled by Trump’s executive order ending the pilot programs, given that he has backed the idea of tying drug costs in the U.S. to lower prices paid by other nations.

“As you know, Trump is a big fan of that,” Antos said. “Lowering drug prices is an easy thing for people to identify with.”

In other moves, Trump also rescinded Biden orders on racial and gender equity and issued an order asserting that there are only two sexes, male and female. HHS under the Biden administration supported gender-affirming health care for transgender people and provided guidance on civil rights protections for transgender youths. Trump’s missive on gender has intensified concerns within the LGBTQ+ community that he will seek to restrict such care.

“The administration has forecast that it will fail to protect and will seek to discriminate against transgender people and anyone else it considers an ‘other,’” said Omar Gonzalez-Pagan, senior counsel and health care strategist at Lambda Legal, a civil rights advocacy group.

“We stand ready to respond to the administration’s discriminatory acts, as we have previously done to much success, and to defend the ability of transgender people to access the care that they need, including through Medicaid and Medicare.”

Trump also halted new regulations that were under development until they are reviewed by the new administration. He could abandon some proposals that were yet to be finalized by the Biden administration, including expanded coverage of anti-obesity medications through Medicare and Medicaid and a rule that would limit nicotine levels in tobacco products, Katie Keith, a Georgetown University professor who was deputy director of the White House Gender Policy Council under Biden, wrote in an article for Health Affairs Forefront.

“Interestingly, he did not disturb President Biden’s three executive orders and a presidential memorandum on reproductive health care,” she wrote.

However, Trump instructed top brass in his administration to look for additional orders or memorandums to rescind. (He revoked the Biden order that created the Gender Policy Council.)

Democrats criticized Trump’s health actions. A spokesman for the Democratic National Committee, Alex Floyd, said in a statement that “Trump is again proving that he lied to the American people and doesn’t care about lowering costs — only what’s best for himself and his ultra-rich friends.”

Medicaid Cuts

Trump’s decision to end a Biden-era executive order aimed at improving the ACA and Medicaid probably portends coming cuts and changes to both programs, some policy experts say. His administration previously opened the door to work requirements in Medicaid — the federal-state program for low-income adults, children, and people with disabilities — and previously issued guidance enabling states to cap federal Medicaid funding. Medicaid and the related Children’s Health Insurance Program cover more than 79 million people.

“Medicaid will be a focus because it’s become so sprawling,” said Chris Pope, a senior fellow at the Manhattan Institute, a conservative policy group. “It’s grown after the pandemic. Provisions have expanded, such as using social determinants of health.”

The administration may reevaluate steps taken by the Biden administration to allow Medicaid to pay for everyday expenses some states have argued affect its beneficiaries’ health, including air conditioners, meals, and housing.

One of Trump’s directives orders agencies to deliver emergency price relief and “eliminate unnecessary administrative expenses and rent-seeking practices that increase healthcare costs.” (Rent-seeking is an economic concept describing efforts to exploit the political system for financial gain without creating other benefits for society.)

“It is not clear what this refers to, and it will be interesting to see how agencies respond,” Keith wrote in her Health Affairs article.

Policy experts like Edwin Park at Georgetown University have also noted that, separately, Republicans are working on budget proposals that could lead to large cuts in Medicaid funding, in part to pay for tax cuts.

Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning research group, also pointed to Congress: “On one hand, what we see coming from the executive orders by Trump is important because it shows us the direction they are going with policy changes. But the other track is that on the Hill, there are active conversations about what goes into budget legislation. They are considering some pretty huge cuts to Medicaid.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

What Will Trump’s White House Return Mean for Healthcare?

By Stephanie Armour, KFF Health News

Former President Donald Trump’s election victory and looming return to the White House will likely bring changes that scale back the nation’s public health insurance programs — increasing the uninsured rate, while imposing new barriers to abortion and other reproductive care.

The reverberations will be felt far beyond Washington, DC, and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health. Abortion restrictions may tighten nationwide with a possible effort to restrict the mailing of abortion medications.

And with the elevation of vaccine skeptic Robert F. Kennedy Jr. to Trump’s inner circle of advisers, public health interventions with rigorous scientific backing — whether fluoridating public water supplies or inoculating children — could come under fire.

Trump defeated Vice President Kamala Harris with 277 Electoral College votes, The Associated Press declared at 5:34 a.m. ET on Wednesday. He won 51% of the vote nationally to Harris’ 47.5%, the AP projected.

Trump’s victory will give a far broader platform to skeptics and critics of federal health programs and actions. Worst case, public health authorities worry, the U.S. could see increases in preventable illnesses; a weakening of public confidence in established science; and debunked notions — such as a link between vaccines and autism — adopted as policy.

Trump said in an NBC News interview on Nov. 3 that he would “make a decision” about banning some vaccines, saying he would consult with Kennedy and calling him “a very talented guy.”

‘Concepts of a Plan’

While Trump has said he will not try again to repeal the Affordable Care Act, his administration will face an immediate decision next year on whether to back an extension of enhanced premium subsidies for Obamacare insurance plans. Without the enhanced subsidies, steep premium increases causing lower enrollment are projected. The current uninsured rate, about 8%, would almost certainly rise.

Policy specifics have not moved far beyond the “concepts of a plan” Trump said he had during his debate with Harris, though Vice President-elect JD Vance later said the administration would seek to inject more competition into ACA marketplaces.

Republicans were projected to claim a Senate majority, in addition to the White House, while control of the House was not yet resolved early Wednesday.

Polls show the ACA has gained support among the public, including provisions such as preexisting condition protections and allowing young people to stay on family health plans until they are 26.

Trump supporters and others who have worked in his administration say the former president wants to improve the law in ways that will lower costs. They say he has already shown he will be forceful when it comes to lowering high health care prices, pointing to efforts during his presidency to pioneer price transparency in medical costs.

“On affordability, I’d see him building on the first term,” said Brian Blase, who served as a Trump health adviser from 2017 to 2019. Relative to a Democratic administration, he said, there will be “much more focus” on “minimizing fraud and waste.”

Efforts to weaken the ACA could include slashing funds for enrollment outreach, enabling consumers to purchase more health plans that don’t comply with ACA consumer protections, and allowing insurers to charge sicker people higher premiums.

Democrats say they expect the worst.

“We know what their agenda is,” said Leslie Dach, executive chair of Protect Our Care, a health care policy and advocacy organization in Washington, D.C. He worked in the Obama administration helping to implement the ACA. “They’re going to raise costs for millions of Americans and rip coverage away from millions and, meanwhile, they will give tax breaks to rich people.”

Theo Merkel, director of the Private Health Reform Initiative at the right-leaning Paragon Health Institute, which Blase leads, said the enhanced ACA subsidies extended by the Inflation Reduction Act in 2022 do nothing to improve plans or lower premiums. He said they paper over the plans’ low value with larger government subsidies.

Other Trump supporters say the president-elect may support preserving Medicare’s authority to negotiate drug prices, another provision of the IRA. Trump has championed reducing drug prices, and in 2020 advanced a test model that would have tied the prices of some drugs in Medicare to lower costs overseas, said Merkel, who worked in Trump’s first White House. The drug industry successfully sued to block the program.

Within Trump’s circles, some names have already been floated as possible leaders for the Department of Health and Human Services. They include former Louisiana Gov. Bobby Jindal and Seema Verma, who ran the Centers for Medicare & Medicaid Services during the Trump administration.

Kennedy, who suspended his independent presidential run and endorsed Trump, has told his supporters that Trump promised him control of HHS. Trump said publicly before Election Day that he would give Kennedy a big role in his administration, but he may have difficulty winning Senate confirmation for a Cabinet position.

While Trump has vowed to protect Medicare and said he supports funding home care benefits, he’s been less specific about his intentions for Medicaid, which provides coverage to lower-income and disabled people. Some health analysts expect the program will be especially vulnerable to spending cuts, which could help finance the extension of tax breaks that expire at the end of next year.

Possible changes include the imposition of work requirements on beneficiaries in some states. The administration and Republicans in Congress could also try to revamp the way Medicaid is funded. Now, the federal government pays states a variable percentage of program costs. Conservatives have long sought to cap the federal allotments to states, which critics say would lead to draconian cuts.

“Medicaid will be a big target in a Trump administration,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Less clear is the potential future of reproductive health rights.

Trump has said decisions about abortion restrictions should be left to the states. Thirteen states ban abortion with few exceptions, while 28 others restrict the procedure based on gestational duration, according to the Guttmacher Institute, a research and policy organization focused on advancing reproductive rights. Trump said before the election that he would not sign a national abortion ban.

State ballot measures to protect abortion rights were adopted in four states, including Missouri, which Trump won by about 18 points, according to preliminary AP reports. Abortion rights measures were rejected by voters in Florida and South Dakota.

Trump could move to restrict access to abortion medications, used in more than half of abortions, either by withdrawing the FDA’s authorization for the drugs or by enforcing a 19th-century law, the Comstock Act, that abortion opponents say bans their shipment. Trump has said he generally would not use the law to ban mail delivery of the drugs.

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Millions Lose Medicaid Benefits, Including Disabled

By Daniel Chang, KFF Health News

Jacqueline Saa has a progressive genetic condition called Ehlers-Danlos syndrome that leaves her unable to stand, walk on her own, or hold a job.

Every weekday for four years, Saa, 43, has relied on a home health aide to help her cook, bathe and dress, go to the doctor, pick up medications, and accomplish other daily tasks. She received coverage through Florida’s Medicaid program, until it abruptly stopped at the end of March.

“Every day the anxiety builds,” said Saa, who lost her home health aide for 11 days, starting April 1, despite being eligible.

The state has since restored Saa’s home health aide service, but during the gap she leaned on her mother and her 23- and 15-year-old daughters, while struggling to regain her Medicaid benefits.

“It’s just so much to worry about,” she said. “This is a health care system that’s supposed to help.”

Medicaid’s home and community-based services are designed to help people like Saa, who have disabilities and need help with everyday activities, stay out of a nursing facility

JACQUELINE SAA

But people are losing benefits with little or no notice, getting bad advice when they call for information, and facing major disruptions in care while they wait for the issue to get sorted out, according to attorneys and advocates who are hearing from patients.

In Colorado, Texas, and Washington, D.C., the National Health Law Program, a nonprofit that advocates for low-income and underserved people, has filed civil rights complaints with two federal agencies alleging discrimination against people with disabilities. The group has not filed a lawsuit in Florida, though its attorneys say they’ve heard of many of the same problems there.

Attorneys nationwide say the special needs of disabled people were not prioritized as states began to review eligibility for Medicaid enrollees after a pandemic-era mandate for coverage expired in March 2023.

“Instead of monitoring and ensuring that people with disabilities could make their way through the process, they sort of treated them like everyone else with Medicaid,” said Elizabeth Edwards, a senior attorney for the National Health Law Program. Federal law puts an “obligation on states to make sure people with disabilities don’t get missed.”

At least 21 million people nationwide have been disenrolled from Medicaid since states began eligibility redeterminations in spring 2023, according to a KFF analysis.

The unwinding, as it’s known, is an immense undertaking, Edwards said, and some states did not take extra steps to set up a special telephone line for those with disabilities, for example, so people could renew their coverage or contact a case manager.

As states prepared for the unwinding, the Centers for Medicare & Medicaid Services, the federal agency that regulates Medicaid, advised states that they must give people with disabilities the help they need to benefit from the program, including specialized communications for people who are deaf or blind.

The Florida Department of Children and Families, which verifies eligibility for the state’s Medicaid program, has a specialized team that processes applications for home health services, said Mallory McManus, the department’s communications director.

People with disabilities disenrolled from Medicaid services were “properly noticed and either did not respond timely or no longer met financial eligibility requirements,” McManus said, noting that people “would have been contacted by us up to 13 times via phone, mail, email, and text before processing their disenrollment.”

Benefits Cut Without a Call

Allison Pellegrin of Ormond Beach, Florida, who lives with her sister Rhea Whitaker, who is blind and cognitively disabled, said that never happened for her family.

“They just cut off the benefits without a call, without a letter or anything stating that the benefits would be terminating,” Pellegrin said.

Her sister’s home health aide, whom she had used every day for nearly eight years, stopped service for 12 days.

“If I’m getting everything else in the mail,” she said, “it seems weird that after 13 times I wouldn’t have received one of them.”

Pellegrin, 58, a sales manager who gets health insurance through her employer, took time off from work to care for Whitaker, 56, who was disabled by a severe brain injury in 2006.

Medicaid reviews have been complicated, in part, by the fact that eligibility works differently for home health services than for general coverage, based on federal regulations that give states more flexibility to determine financial eligibility. Income limits for home health services are higher, for instance, and assets are counted differently.

RHEA WHITAKER

In Texas, a parent in a household of three would be limited to earning no more than $344 a month to qualify for Medicaid. And most adults with a disability can qualify without a dependent child and be eligible for Medicaid home health services with an income of up to $2,800 a month.

The state was not taking that into consideration, said Terry Anstee, a supervising attorney for community integration at Disability Rights Texas, a nonprofit advocacy group.

Even a brief lapse in Medicaid home health services can fracture relationships that took years to build.

“It may be very difficult for that person who lost that attendant to find another attendant,” Anstee said, because of workforce shortages for attendants and nurses and high demand.

Nearly all states have a waiting list for home health services. About 700,000 people were on waiting lists in 2023, most of them with intellectual and developmental disabilities, according to KFF data.

Daniel Tsai, a deputy administrator at CMS, said the agency is committed to ensuring that people with disabilities receiving home health services “can renew their Medicaid coverage with as little red tape as possible.”

CMS finalized a rule this year for states to monitor Medicaid home health services. For example, CMS will now track how long it takes for people who need home health care to receive the services and will require states to track how long people are on waitlists.

Staff turnover and vacancies at local Medicaid agencies have contributed to backlogs, according to complaints filed with two federal agencies focused on civil rights.

The District of Columbia’s Medicaid agency requires that case managers help people with disabilities complete renewals. However, a complaint says, case managers are the only ones who can help enrollees complete eligibility reviews and, sometimes, they don’t do their jobs.

Advocates for Medicaid enrollees have also complained to the Federal Trade Commission about faulty eligibility systems developed by Deloitte, a global consulting firm that contracts with about two dozen states to design, implement, or operate automated benefits systems.

KFF Health News found that multiple audits of Colorado’s eligibility system, managed by Deloitte, uncovered errors in notices sent to enrollees. A 2023 review by the Colorado Office of the State Auditor found that 90% of sampled notices contained problems, some of which violate the state’s Medicaid rules. The audit blamed “flaws in system design” for populating notices with incorrect dates.

Deloitte declined to comment on specific state issues.

In March, Colorado officials paused disenrollment for people on Medicaid who received home health services, which includes people with disabilities, after a “system update” led to wrongful terminations in February.

Another common problem is people being told to reapply, which immediately cuts off their benefits, instead of appealing the cancellation, which would ensure their coverage while the claim is investigated, said attorney Miriam Harmatz, founder of the Florida Health Justice Project.

“What they’re being advised to do is not appropriate. The best way to protect their legal rights,” Harmatz said, “is to file an appeal.”

‘So Many People Are Calling’

But some disabled people are worried about having to repay the cost of their care. Saa, who lives in Davie, Florida, received a letter shortly before her benefits were cut that said she “may be responsible to repay any benefits” if she lost her appeal.

The state should presume such people are still eligible and preserve their coverage, Harmatz said, because income and assets for most beneficiaries are not going to increase significantly and their conditions are not likely to improve.

The Florida Department of Children and Families would not say how many people with disabilities had lost Medicaid home health services.

But in Miami-Dade, Florida’s most populous county, the Alliance for Aging, a nonprofit that helps older and disabled people apply for Medicaid, saw requests for help jump from 58 in March to 146 in April, said Lisa Mele, the organization’s director of its Aging and Disability Resources Center.

“So many people are calling us,” she said.

States are not tracking the numbers, so “the impact is not clear,” Edwards said. “It’s a really complicated struggle.”

Saa filed an appeal March 29 after learning from her social worker that her benefits would expire at the end of the month. She went to the agency but couldn’t stand in a line that was 100 people deep. Calls to the state’s Medicaid eligibility review agency were fruitless, she said.

“When they finally connected me to a customer service representative, she was literally just reading the same explanation letter that I’ve read,” Saa said. “I did everything in my power.”

Saa canceled her home health aide. She lives on limited Social Security disability income and said she could not afford to pay for the care.

On April 10, she received a letter from the state saying her Medicaid had been reinstated, but she later learned that her plan did not cover home health care.

The following day, Saa said, advocates put her in touch with a point person at Florida’s Medicaid agency who restored her benefits. A home health aide showed up April 12. Saa said she’s thankful but feels anxious about the future.

“The toughest part of that period is knowing that that can happen at any time,” she said, “and not because of anything I did wrong.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Pain Clinic Chain to Pay $11M to Settle Fraud Claims

By Don Thompson, KFF Health News

The owner of one of California’s largest chains of pain management clinics has agreed to pay nearly $11.4 million to California, Oregon, and the federal government to settle allegations of Medicare and Medicaid fraud.

The U.S. Department of Justice and the states’ attorneys general say Francis Lagattuta, a physician, and his Lags Medical Centers performed — and billed for — medically unnecessary tests and procedures on thousands of patients over more than five years.

It was “a brazen scheme to defraud Medicare and Medicaid of millions of dollars by inflicting unnecessary and painful procedures on patients whom they were supposed to be relieving of pain,” Phillip Talbert, U.S. attorney for the Eastern District of California, said in a statement this month.

The federal Medicare program suspended reimbursements to Lags Medical in June 2020, and Medi-Cal, California’s Medicaid program, followed in May 2021. Lags Medical shut down the same day the state suspended reimbursements. The company, based in Lompoc, California, had more than 30 pain clinics, most of them in the Central Valley and the Central Coast.

A KFF Health News review last year found the abrupt closure left more than 20,000 California patients — mostly working-class people on government-funded insurance — struggling to obtain their medical records or continue receiving pain prescriptions, which often included opioids.

Lagattuta and Lags Medical did not admit liability under the settlement. Lagattuta denied the governments’ claims, saying in a statement he was “pleased” to announce the settlement of a “long-standing billing dispute.” As part of the agreement, Lagattuta will be barred for at least five years from receiving Medicare and Medicaid reimbursements.

“Since the Centers have been closed for a couple of years, it made sense for Dr. Lagattuta to settle the dispute and continue to move forward with his other business interests and practice,” Malcolm Segal, an attorney for Lagattuta and the centers, said in the statement.

According to state officials, the federal government will receive the bulk of the money, about $8.5 million. California will receive about $2.7 million, and an additional $130,000 will go to Oregon. The settlement amount is based in part on Lagattuta’s and Lags Medical’s “ability to pay.” It does not cover the governments’ full losses, which the U.S. attorney’s office in Sacramento said are not public record.

Blanket Orders for Unnecessary Tests

A nearly four-year investigation by federal officials and the California Department of Justice found that from March 2016 through August 2021, Lagattuta and his company submitted reimbursement claims for unneeded skin biopsies, spinal cord stimulation procedures, urine drug tests, and other tests and procedures.

Lagattuta began requiring all his clinics to perform various medical procedures on every patient, the officials said, no matter if they were needed or requested by patients’ medical providers. Patients who refused were told they would have their pain medication reduced and could suffer adverse medical consequences.

U.S. and California investigators piggybacked on a federal claim filed in late 2018 by a whistleblower, Steven Capeder, Lags Medical’s former operations and marketing director, who will receive more than $2 million of the settlement.

As part of the settlement, Lagattuta and his company acknowledged that in mid-2016 he began requiring his providers to do at least two to three skin biopsies on Medicare patients each day and told providers to quit if they wouldn’t comply. Such biopsies are used to measure small-fiber neuropathy, which causes burning pain with numbness and tingling in the feet and lower extremities.

According to the settlement, a monthly report in early 2018 set a goal of performing 250 biopsies a week. Lagattuta created a separate team that was required to order at least 150 biopsies weekly, often overruling providers. And the company’s chief executive officer in late 2019 texted Lagattuta to report a particularly high number of biopsies, illustrating the text with emojis of a money bag and a smiley face.

Authorities said Lagattuta violated regulations requiring that skin biopsy results be interpreted by a trained pathologist or neurologist. Instead, they say, Lagattuta had the biopsies read by a family member who had no formal medical training and by a former clinic executive’s spouse, who was trained as a respiratory therapist.

Lags Medical clinics performed more than 22,000 biopsies on Medi-Cal patients from 2016 through 2019.

The settlement also alleges Lagattuta encouraged unsuitable patients to undergo spinal cord stimulation. It describes the procedure as “an invasive surgery of last resort,” in which implants placed near the spinal cord apply low-voltage electrical pulses to nerve fibers.

Lagattuta paid a psychiatrist $3,000 each month to falsely certify that every Lags Medical candidate for the procedure had no psychological or substance use disorders that would negatively affect the outcome, according to the settlement. For instance, the settlement says the psychiatrist overruled a Lags Medical social worker to OK the procedure for a young woman who had bipolar disorder with hallucinations that included hearing a man’s voice ordering her out of bed.

He also issued blanket orders for every patient to have urine drug testing, a policy the company’s CEO said “should be a big money maker.”

KFF Health News found that from 2017 through 2019 nearly 60,000 of the most extensive urine drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for those tests.

The clinics “carefully examined, tested, and treated” more than 60,000 patients during the time covered by the settlement, “when others might have been content to prescribe medication to mask pain,” said Lagattuta’s statement. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Few Fatal Overdoses Found in Rx Opioid Study

By Pat Anson, PNN Editor

The odds of having an overdose are relatively small for most people after getting their first opioid prescription, but are significantly higher if patients are over age 75, insured by Medicaid or Medicare, and have a history of depression or substance use disorders, according to a large new study.

Researchers analyzed health claims for nearly 237,000 opioid “naïve” patients in Oregon from 2013 to 2018, and found that about 3 in 1,000 (0.3%) experienced an overdose within three years of their first prescription. The vast majority of the 667 reported overdoses were non-fatal, and researchers could not determine if they involved illicit opioids or the opioids that patients were prescribed.  

“There were relative few fatal overdoses - I believe it was less than 100. So we didn't look further than that because there wasn't statistical power,” said lead author Scott Weiner, MD, an emergency physician at Brigham and Women’s Hospital in Boston. “Unfortunately, it is not possible to ascertain if the overdose was from illicit or prescribed opioids from the data.”  

One of the more surprising aspects of the study is that there was little association found between overdoses and high dose prescriptions. The CDC says opioids prescribed at daily doses that exceed 90 MME (morphine milligram equivalent) raise the risk of overdose, but Weiner and his colleagues found little evidence to support that.  

“Incidence of overdose was not associated with varying levels of MME that were received in the first 6 months, which may indicate that patient factors may be more important than the strength of the opioids prescribed. These are both novel findings,” researchers reported in in JAMA Network Open.

The research team did find a higher risk of overdose when patients were prescribed long-acting opioids such as oxycodone, or used opioids concurrently with benzodiazepines, a class of anti-anxiety medication.  

Patients in the study who refilled an opioid prescription 6 or more times also had a higher overdose risk, as did those who got refills from three or more pharmacies. 

Patients with alcohol or substance use disorders had the highest risk of overdose, as did those with a history of depression or psychosis. 

Medicaid, Medicare and Elderly Patients at High Risk

Another high risk factor associated with overdose is insurance coverage. Patients covered by Medicaid had an overdose risk almost four times higher than those covered by a private insurer, while those insured by Medicare Advantage had an overdose risk nearly 8 times higher than commercially insured patients. 

The finding that patients over age 75 had an overdose risk nearly three times higher than other age groups is not surprising, according to one pain management expert.

“Obviously, this older age group has more comorbidities which is also associated with increased risk,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine. “What we don’t know is why opioids were prescribed and if severity of pain or suicidality or denial to prescribe opioids for severe pain could be contributing factors for the higher risk of overdose with elderly patients.”

Weiner cautioned doctors against taking the findings too literally. For example, although African-Americans were found to have a higher risk of overdose compared to white patients, they make up only a small percentage of Oregon’s population, making the data for them statistically weak.

“I absolutely do not advocate for suboptimal pain control for any patient, regardless of their risk profile. However, I do want prescribers to be careful when prescribing opioids to any previously naive patient, and to be extra careful when prescribing to the higher risk groups,” Weiner told PNN in an email.

“For patients in the higher risk groups, particularly those with diagnosis of substance use disorders, I would counsel the patient and inform them of their elevated risk and come up with a game plan for safety. I am only unwilling to prescribe to anyone when I don't believe an opioid is indicated for their condition.”  

Obamacare Prevented Thousands of Opioid Overdose Deaths

By Pat Anson, PNN Editor

The expansion of Medicaid under the Affordable Care Act – widely known as Obamacare -- was associated with a six percent lower rate of opioid overdose deaths, according to a new study that estimates thousands of overdoses may have been prevented by expanding access to healthcare for millions of Americans.

Researchers also found a significant and unexpected increase in overdoses involving methadone, an addiction treatment drug sometimes used to treat chronic pain.

Thirty-two states and the District of Columbia opted to expand Medicaid eligibility under the Affordable Care Act (ACA), providing healthcare coverage to uninsured low-income adults. ACA requires that individuals who receive coverage be provided with mental health and substance use disorder treatment.

Researchers at the NYU Grossman School of Medicine and University of California, Davis looked at death certificate data from 49 states and the District of Columbia between 2001 and 2017— looking for changes in overdose rates in counties that expanded Medicaid under ACA compared to those that did not.

Their findings, published online in JAMA Network Open, suggest that Medicaid expansion prevented between 1,678 and 8,132 opioid overdose deaths from 2015 to 2017.

Overall, there was a 6% lower rate of opioid overdose deaths, an 11% lower rate of heroin overdoses, and a 10% lower rate of death involving fentanyl and synthetic opioids other than methadone in states that adopted the ACA.

"The findings of this study suggest that providing expanded access to health care may be a key policy lever to address the opioid overdose crisis," said senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the Department of Population Health at NYU Langone Health.

Methadone Overdoses Rose

Cerdá and her colleagues also found a concerning 11% increase in methadone overdose rates in states that expanded Medicaid under the ACA. Methadone is an opioid that has long been used to treat addiction, but it is also prescribed by some doctors to treat chronic pain.

“Although the rate of methadone-related mortality is relatively low compared with other opioid classes, our finding that Medicaid expansion was associated with increased methadone overdose deaths deserves further investigation,” researchers said.

“Past research has found high rates of methadone use to treat pain among Medicaid beneficiaries and that the drug is disproportionately associated with overdose deaths among individuals in this population, underscoring the importance of ongoing local, state, and federal actions to address safety concerns associated with methadone for pain in tandem with Medicaid expansion.”

In 2014, the methadone prescribing rate among Medicaid patients was nearly twice that of commercially insured patients. Medicaid patients were also slightly more likely to be prescribed methadone for pain (1.1% vs. 0.85%) as opposed to addiction.

Expansion Reduced Opioid Deaths

The ACA became law at a time when opioid overdose deaths were rising sharply. Some critics of Obamacare claimed that expanding access to low-cost opioid pain relievers would create an incentive for low-income Medicaid beneficiaries to sell their drugs.

“It stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem,” a 2018 report by Sen. Ron Johnson (R-WI) claimed. “The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014. Drug overdose deaths have risen rapidly, at a much faster pace than before expansion.”

The NYU and UC Davis study found that theory to be false.

"Past research has found Medicaid expansion is associated with not only large decreases in the number of uninsured Americans, but also considerable increases in access to opioid use disorder treatment and the opioid overdose reversal medication naloxone," said lead author Nicole Kravitz-Wirtz, PhD, an assistant professor in the Department of Emergency Medicine at UC Davis.

"Ours was the first study to investigate the natural follow-up question: Is the expansion associated with reductions in local opioid overdose deaths? On balance, the answer appears to be yes." 

Many Alternative Therapies for Back Pain Not Covered

By Pat Anson, PNN Editor

A new study by the Johns Hopkins Bloomberg School of Public Health has confirmed what many back pain sufferers already know: Public and private health insurance plans often do not cover non-drug alternative pain therapies.

Bloomberg researchers looked at dozens of Medicaid, Medicare and commercial insurance coverage policies for chronic lower back pain and found that while most plans covered physical therapy and chiropractic care, there was little or no coverage for acupuncture, massage or counseling.

"This study reveals an important opportunity for insurers to broaden and standardize their coverage of non-drug pain treatments to encourage their use as safer alternatives to opioids," says senior author Caleb Alexander, MD, a professor of epidemiology at the Bloomberg School.  

Alexander and his colleagues examined 15 Medicaid, 15 Medicare Advantage and 15 major commercial insurer plans that were available in 16 states in 2017.

Most payers covered physical therapy (98%), occupational therapy (96%), and chiropractic care (89%), but coverage was inconsistent for many of the other therapies.

Acupuncture was covered by only five of the 45 insurance plans and only one plan covered therapeutic massage.

Nine of the Medicaid plans covered steroid injections, but only three covered psychological counseling.

"We were perplexed by the absence of coverage language on psychological interventions," Alexander says. "It's hard to imagine that insurers wouldn't cover that."  

Even for physical therapy, a well-established method for relieving lower back pain, insurance coverage was inconsistent.

"Some plans covered two visits, some six, some 12; some allowed you to refer yourself for treatment, while others required referral by a doctor," Alexander says. "That variation indicates a lack of consensus among insurers regarding what model coverage should be, or a lack of willingness to pay for it.”  

The Bloomberg study is being published online in the journal JAMA Network Open.  It was funded by the U.S. Department of Health and Human Services, National Institutes of Health and the Centers for Disease Control and Prevention.  

Lower back pain is the world’s leading cause of disability, but there is surprisingly little consensus on the best way to treat it. A recent series of reviews by an international team of experts in The Lancet medical journal found that low back pain is usually treated with bad advice, inappropriate tests, risky surgeries and painkillers.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” said lead author Rachelle Buchbinder, PhD, a professor at Monash University in Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

The authors recommend counseling, exercise and cognitive behavioral therapy as first-line treatments for short-term low back pain, followed by spinal manipulation, massage, acupuncture, meditation and yoga as second line treatments. They found limited evidence to support the use of opioids for low back pain, and epidural steroid injections and acetaminophen (paracetamol) are not recommended at all.

Medicaid Expansion Did Not Fuel Opioid Crisis

By Pat Anson, PNN Editor

A new study is debunking claims that increased access to healthcare and pain management helped to fuel the opioid crisis. If anything, the opposite appears to be the case.

The study, published in the Journal of General Internal Medicine, found that early Medicaid expansions in Arizona, Maine and New York may have led to lower overdose rates in those states.

"These findings suggest that Medicaid expansions were unlikely to have contributed to the subsequent rise in drug overdose deaths, and may even have been protective," said lead author Atheendar Venkataramani, MD, PhD, an assistant professor of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania.

Venkataramani and co-author Paula Chatterjee, MD, looked at state-level data on drug overdoses from 1999 to 2008, comparing overdose mortality rates in the three Medicaid-expansion states to those in other states.

By 2008, Arizona, Maine and New York had about 7 fewer overdose deaths per 100,000 people compared to the other 47 states.

The differences were even greater when the three states were only compared to adjacent states: They had 17 fewer deaths per 100,000 people.

Overall, the study suggests that drug overdose deaths were nearly 20 percent lower in the early expansion states.

"The results should provide reassurance to policymakers who are concerned that state Medicaid expansions, including the recent expansions implemented as part of the Affordable Care Act, promote rises in drug overdose mortality," said Venkataramani.

The Affordable Care Act (ACA) – widely known as Obamacare – greatly expanded Medicaid coverage for millions of poor Americans, starting in 2014. But some critics have claimed the ACA made the opioid crisis worse by giving patients easier access to opioids.

“The Medicaid expansion may be fueling the opioid epidemic in communities across the country,” Wisconsin Sen. Ron Johnson (R) wrote in a 2017 letter to the Health and Human Services inspector general. “Because opioids are so available and inexpensive through Medicaid, it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

The Penn Medicine study wasn't designed to determine why Medicaid expansion appeared to lower overdose death rates in New York, Arizona and Maine. But it does suggest that better access to healthcare was a factor.

“Improving people’s access to health care could have a number of effects. It may be that people had better access to substance use disorder treatment or better access to mental health or pain management. Or it may be that providing health insurance reduced the risk of financial ruin, which helped downward socioeconomic spirals that could lead to substance use disorder,” Venkataramani wrote in an email to PNN.

“If Medicaid expansions did increase access to opioids, then the effect of doing so was far outweighed by other forces that actually reduced mortality rates from drug use order. The mechanisms again are not known because of data limitations in this study, but access to regular health care, access to substance use disorder treatment, and improved socioeconomic circumstances all may have contributed to the slower growth in drug overdose mortality in Medicaid expansion states.”

The Affordable Care Act expanded Medicaid coverage to about 12 million Americans in the 31 states and the District of Columbia that opted to receive it. A recent study found that opioid prescriptions decreased slightly in those states, while prescriptions for addiction treatment drugs like Suboxone rose significantly.

Oregon Health Official Defends Opioid Plan

By Pat Anson, Editor

The head of Oregon’s Health Authority is defending a controversial plan that would force many of the state’s Medicaid patients off opioids.

In an op/ed this week in the Wall Street Journal, Patrick Allen wrote that patients deserve “safe, effective choices to relieve pain -- not just a pill.” He suggested physical therapy, exercise and massage would be better alternatives.

At issue is a task force recommendation to limit Medicaid coverage of opioids to just 90-days for five broad chronic pain conditions – including fibromyalgia and chronic pain caused by trauma.  Patients already on opioids longer than 90 days would be given one year to taper off the medications and switch to alternative therapies that would be covered by Medicaid.

The plan has drawn criticism nationwide from chronic pain patients, advocates and pain management experts. Drs. Sally Satel and Stefan Kertesz wrote in another WSJ op/ed that the plan would “exacerbate suffering for thousands of patients.”

Allen disagrees, saying opioids are too risky to use long-term.

“This new proposal would expand evidence-based options for chronic pain management, allowing Oregonians to find a care plan that works for them,” Allen wrote.  “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function.

“Offering only one pain-management option that continues to kill Americans at alarming rates is a tragedy we can’t accept.”

According to his LinkedIn profile, Allen does not hold a medical degree and has spent most of his career working in the banking industry and as a state regulator in consumer and business affiars. He was appointed last year as director of the Oregon Health Authority, which operates the state’s Medicaid program and purchases health insurance for over 400,000 public employees and teachers.

PATRICK ALLEN

Oregon’s Health Evidence Review Commission held a public hearing on the opioid proposal earlier this month, but has not given final approval. If adopted, the opioid restrictions would not go into effect until 2020.

Opioid prescribing in Oregon has been declining for years – as it has nationwide – but the state has the highest rate of non-medical use of prescription opioids in the country. About three Oregonians die every week from an opioid overdose.

Oregon Opioid Plan Would Do 'Substantially More Harm'

By Pat Anson, Editor

A proposed change in Oregon’s Medicaid program would result in the forced tapering of many pain patients off opioid medication and do “substantially more harm than good,” according to a group of pain physicians, academics and patient advocates.

At issue is a recommendation by a task force to limit Oregon Health Plan coverage of opioids to just 90-days for five broad chronic pain conditions – including fibromyalgia and chronic pain caused by trauma.  Medicaid patients with those conditions taking opioids beyond 90 days would lose coverage for the pain relievers and be encouraged to use alternative pain therapies such as yoga, acupuncture and physical therapy, which would be covered under the plan.

“We recently learned of efforts by the Oregon Medicaid Pain Task Force to deny coverage of opioids beyond 90 days for most chronic pain conditions and, effectively, to mandate the taper of current patients receiving opioid therapy. We believe that such efforts risk doing substantially more harm than good,” wrote Kate Nicholson, a civil rights attorney and pain patient, in a letter to Oregon health officials. The letter was co-signed by over a dozen  physicians, academics and advocates.

“An across-the-board denial of opioid therapy for the huge umbrella category of chronic pain is as destructive as is liberally prescribing opioids for all types of chronic pain,” the letter warns. “The denial of coverage to the Medicaid population, in particular, is likely to have a disproportionate impact on individuals with disabilities, on the sickest patients and those with multiple chronic conditions.”

Oregon’s Health Evidence Review Commission will review the proposal at its August 9th meeting. The commission could give final approval as early as October, but the opioid restrictions would not go into effect until 2020, according to the Bend Bulletin.

“Individuals with chronic pain really face debilitating conditions that impact quality of life, yet we’re faced with this significant opioid epidemic where we know there’s a lot of misuse and overprescribing,” Dr. Dana Hargunani, chief medical officer for the Oregon Health Authority, told the Bulletin. “We’re trying to use evidence to guide us, but we really welcome public input into the process. I know it’s a really significant issue for many individuals.” 

Opioid prescribing in Oregon has been declining for years – as it has nationwide – yet the state has “one of the highest rates of prescription opioid abuse in the nation,” according to the Oregon Health Authority. An average of three Oregonians die every week from an opioid overdose. However, many of those deaths involve the “non-medical” use of opioid pain relievers by drug abusers, not patients.

The 2013 National Survey on Drug Use and Health found Oregon to have the highest rate of non-medical use of prescription pain relievers in the country.

“I’m very sad for the people who OD’d,” pain patient Steve Hix told the Bulletin. “But what’s that got to do with me?”

Fewer Opioids Prescribed in Medical Marijuana States

By Pat Anson, Editor

The availability of medical marijuana has significantly reduced opioid prescribing for Medicaid and Medicare patients, according to two large studies published in the Journal of the American Medical Association (JAMA).

In one study, researchers at the University of Georgia looked at Medicare Part D prescription drug data from 2010 to 2015. They found that the number of daily doses prescribed for morphine (-14%), hydrocodone (-10.5%) and fentanyl (-8.5%) declined in states with medical marijuana laws. However, daily doses for oxycodone increased (+4.4%) in those same states.

The drop in opioid prescribing was most pronounced in states that have medical marijuana dispensaries, as opposed to those that only allow home cultivation of cannabis for medical purposes.

“We found that prescriptions for hydrocodone and morphine had statistically significant negative associations with medical cannabis access via dispensaries,” wrote lead author W. David Bradford, PhD, Department of Public Administration and Policy at the University of Georgia.

“Combined with previously published studies suggesting cannabis laws are associated with lower opioid mortality, these findings further strengthen arguments in favor of considering medical applications of cannabis as one tool in the policy arsenal that can be used to diminish the harm of prescription opioids.”

The second study, by researchers at the University of Kentucky, looked at Medicaid prescriptions from 2011 to 2016, and found a 5.88% decline in opioid prescribing in states with medical marijuana laws.  Opioid prescribing for Medicaid patients fell even more -- by 6.38% -- in states where the recreational use of marijuana is legal.

“These findings suggest that medical and adult-use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose,” wrote lead author Hefei Wen, PhD, University of Kentucky College of Public Health.

One weakness of both studies is that they did not determine if Medicaid and Medicare patients reduced their use of opioid medication because they were using cannabis.  They also only included patients that were elderly, poor or disabled. And they were conducted during a period when nationwide opioid prescribing was in decline.

A recent study by the RAND corporation found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioid medication. RAND researchers believe some pain patients may be experimenting with marijuana, but their numbers are not large enough to have a significant impact on prescribing. 

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids," the RAND study found. "Either the patients are continuing to use their opioid pain medications in addition to marijuana, or this patient group represents a small share of the overall medical opioid using population." 

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law.

Prescriptions Plummet in Medical Marijuana States

By Pat Anson, Editor

Medical marijuana is giving some serious competition to the prescription drug industry. A new analysis of Medicaid claims found that prescriptions to treat pain, nausea, seizures, psychosis and depression plummeted in the 23 states and District of Columbia where medical marijuana was legal in 2014.

If all 50 states had medical marijuana laws that year, researchers say the potential savings to Medicaid and taxpayers would have been over a billion dollars.

“We found statistically and economically meaningful reductions in prescription drug use associated with the laws. This finding suggested that patients in states with such laws were substituting medical marijuana for prescription drugs,” W. David Bradford and Ashley Bradford, a father-daughter team of researchers at the University of Georgia, reported in the journal Health Affairs.

Previous studies have shown that prescriptions for opioid pain medication have fallen in states where medical marijuana is legal.

The new study was more comprehensive and included nine clinical areas that cannabis could be used to treat: anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders, and spasticity (muscle spasms).

Five of the nine clinical areas had significant drops in prescribing where medical marijuana was legal:

• 17% decline in anti-nausea medication
• 13% decline in antidepressants
• 12% decline in psychosis medication
• 12% decline in anti-seizure drugs
• 11% decline in pain medication

The study found no significant association between medical marijuana laws and drugs used to treat anxiety, glaucoma, sleep disorders or spasticity.

“There is no question that we see patients constantly turning to cannabis, to get off their other medications, mainly to eliminate the side effects they are experiencing.  At this time, this is a huge advantage to us all -- we get a healthier solution to help us with our medical issues and Medicare and Medicaid are seeing a reduction of costs,” said Ellen Lenox Smith, a PNN columnist, medical marijuana user and caretaker in Rhode Island.

“However, until we are able to receive insurance reimbursement like Germany started providing in March, we have to still pay out of pocket. So until we are treated fairly like this in the U.S., we will continue to be paying more for this safer help than if we went to the pharmacy to purchase medication with our co-pays. For me, however, the cost is worth the quality of life I have been able to achieve using cannabis.”

In the current study, researchers cautioned that using fewer prescription drugs is not necessarily a good thing for every marijuana user.

“Our findings do raise important questions about individual behavior. For example, it is plausible that forgoing medications with known safety, efficacy, and dosing profiles in favor of marijuana could be harmful under some circumstances,” said the Bradfords. “In addition, patients who switch from a prescription drug that requires regular physician monitoring to marijuana may interact with their doctor less often, and their adherence to other important treatment regimens could suffer.”

Previous studies have found a significant decline in use of opioid medication by patients who use marijuana and that marijuana users are not at greater risk of alcohol and drug abuse.

Currently medical marijuana is legal in 29 states and the District of Columbia.