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Paul Ryan's Plan to Change Medicare Looks A Lot Like Obamacare

NPR Health Blog - Sat, 11/26/2016 - 1:01pm

House Speaker Paul Ryan, R-Wis., speaks to the media during a briefing on Capitol Hill in September.

Mark Wilson/Getty Images

President-elect Donald Trump and House Speaker Paul Ryan agree that repealing the Affordable Care Act and replacing it with some other health insurance system is a top priority.

But they disagree on whether overhauling Medicare should be part of that plan. Medicare is the government-run health system for people age 65 and older and the disabled.

Trump said little about Medicare during his campaign, other than to promise that he wouldn't cut it.

Ryan, on the other hand, has Medicare in his sights.

"Because of Obamacare, Medicare is going broke," Ryan said in an interview on Fox News on Nov. 10. "So you have to deal with those issues if you're going to repeal and replace Obamacare."

In fact, the opposite appears to be true — Obamacare may actually have extended the life of Medicare.

This year's Medicare trustees report says the program would now be able to pay all its bills through 2028, a full 11 years longer than a 2009 forecast — an improvement Medicare's trustees attribute, in part, to changes in Medicare called for in the Affordable Care Act and other economic factors.

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And the irony of the Ryan Medicare plan, say some health policy analysts, is that it would turn the government program into something that looks very much like the structure created for insurance plans sold under the ACA.

"The way it works is comparable to Obamacare," says physician and conservative policy analyst Avik Roy, founder of the Foundation for Research on Equal Opportunity.

Ryan's plan would set up "Medicare exchanges" where private insurance companies would compete with traditional government-run Medicare for customers. Obamacare exchanges sell only private insurance plans.

People would get "premium support" from the government to pay for their insurance under the Ryan Medicare plan.

The subsidy would be tied to the price of a specific plan offered by an insurer on the exchange, much like the Affordable Care Act subsidy is tied to the second-cheapest "silver" plans.

And the payment would be linked to a recipient's income, so lower-income people would get a bigger subsidy. The subsidy would rise as beneficiaries get sicker, to ensure access to insurance. As with Obamacare, people who choose plans that cost more than the government subsidy would have to pay the balance.

Insurers would have to agree to issue policies to any Medicare beneficiary, to "avoid cherry-picking," and to ensure that "Medicare's sickest and highest-cost beneficiaries receive coverage."

The changes would start in 2024, when people who are now about 57 become Medicare eligible.

Roy agrees with Ryan that Medicare is going broke and that a program structured in this way would save money through "the magic of competition."

"If you have 10 insurers competing for that business, you're going to negotiate a better deal," he said.

Medicare is already a dual public-private program. Most seniors today are enrolled in what's known as traditional Medicare, where the government pays for medical appointments, tests and hospital stays on a fee-for-service basis.

Alongside that program is Medicare Advantage, an insurance plan provided by a private insurer that may offer seniors additional services like dental care at the same price.

The government pays a fixed monthly fee to the insurer for each Medicare Advantage patient, rather than paying for every service separately, as it does in traditional Medicare.

About half of Medicare's new enrollees choose Medicare Advantage plans, says Henry Aaron, a health care economist at the Brookings Institution.

Aaron says Ryan's proposal aims to move almost all seniors into Medicare Advantage-style insurance by making traditional Medicare too expensive for the consumer.

But, he says, there are risks to that approach.

"The real question here is whether the requisite safeguards are in place to ensure that the elderly and people with disabilities would be able to maneuver in such a system," he says.

That's because the health care and health insurance systems are very complex. Doctors move in and out of networks, copayments can vary and plans can change.

Millions of people on Medicare are also eligible for Medicaid, meaning they are poor and vulnerable, Aaron says. And at least 8 million Social Security beneficiaries have been declared financially incompetent and are assigned a representative to manage their money.

"What you've got here is a group of people who are very sick, poor, and often cognitively impaired one way or the other," Aaron says. "Tossing people like that into a health care marketplace and saying, 'Here, go buy some insurance,' is a recipe for problems."

Seniors may feel the same way. Researchers at Brown University last year found that as people get older and sicker, they tend to drop Medicare Advantage and opt for traditional Medicare.

Ryan has been working on his plan to change Medicare for many years. A version of his "premium support" plan was included in several budget proposals he put forth when he was chairman of the House Budget Committee.

The Congressional Budget Office says the proposals would reduce federal spending on Medicare.

At this point it's unclear whether Trump shares Ryan's ambitions to upend the current Medicare system. Trump didn't include Medicare reform on his campaign website. But since his election, "modernize Medicare" has been included on the list of health care priorities on his transition site.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Worries About Health Insurance Cross Political Boundaries

NPR Health Blog - Sat, 11/26/2016 - 6:00am

Keely Edgington and her daughter, Lula, pose inside their family-owned restaurant, Julep, in Kansas City, Mo. Lula was diagnosed with a neuroblastoma when she was 9 months old. She's now 16 months old.

Alex Smith / KCUR

This month's election results could have big implications for those who now have insurance because of the Affordable Care Act — either through the exchanges or Medicaid expansion. President-elect Trump and Republicans in Congress have made it clear they want to scrap the law, but it's unclear what may replace it. That gap between repeal and replacement has left many unsure of what will happen with their medical care. We have these reports from around the country from people who could be affected by changes.

Little Lula's Preexisting Condition Is Cancer

If you stop by Julep, a Kansas City, Mo., bar and restaurant, you might catch a glimpse of Lula — the blond, blue-eyed toddler daughter of the owners, Keely Edgington and Beau Williams. They let her inspect the customers a bit before the place gets too busy.

"She likes to go out there and essentially just stare everybody down and smile at them," Edgington says.

She's so smiley you'd never guess how much she's been through in her short life. "She happens to have 4S non-amplified neuroblastoma," Edgington says. It's a cancer in her adrenal gland that doctors discovered when Lula was 9 months old. She needed emergency surgery because of the size and location of the tumor.

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The cost was enormous. Edgington says she stopped looking at bills after they topped $350,000, and that was before the surgery. The vast majority of the cost was paid for through the insurance the family gets through HealthCare.gov, the federal health insurance marketplace created under the Affordable Care Act. They say, as small business owners, the exchange and subsidies they received because of the law were their only way they could get covered.

Even with coverage, the family was still on the hook for $10,000.

Lula has responded well to the treatment. She's been in remission for a few months, but the family still faces high medical costs. At a minimum, Lula will need intensive, expensive screenings and scans for a few years, then she'll have to be monitored for health conditions that might come up as a result of chemotherapy.

Shots - Health News Trump Can Kill Obamacare With Or Without Help From Congress

Since the election, the family says they've been on eggshells waiting to see what will happen with their insurance. They fear possibly losing subsidies. And, before the Affordable Care Act insurance companies could deny coverage to people with preexisting medical conditions like Lula's, and the companies could set lifetime limits on the amount they'd pay for someone's care. Insurers could also take into account an individual's health history, so that someone with a chronic disease might pay many times more than a healthier person.

The family has been thinking about how they might cope with huge medical or insurance costs that might come if Obamacare is repealed. They've pondered a second mortgage, selling their business or even more desperate measures.

"Do we have to move to Canada and hope we get coverage there? That's really extreme, but what wouldn't you do for your child's life?" says Edgington

Trump has said he'd make sure insurance companies couldn't deny coverage to a person with a preexisting condition, but he has provided no formal plan, and much of what happens next is in Congress's hands. Insurance and legal analysts are also unclear about what will happen, although most think the biggest changes probably wouldn't go into effect until at least 2018. — Alex Smith, KCUR, Kansas City, Mo.

Obamacare Choices Are Dwindling For Some

Michael Cluck and his wife Nancy live in Edwardsville, Ill., just outside St. Louis. Cluck, 62, and his wife, Nancy, 58, bought insurance through HealthCare.gov in 2015, and it, "actually saved us $300 a month, and we were really happy with it," he says.

But two providers, including his own insurer, Coventry, dropped out of the health insurance exchange in his county and two adjacent ones for 2017. There's now just one choice there: Blue Cross Blue Shield of Illinois.

"Premiums were not that bad. Deductibles were not that bad," Cluck says of Blue Cross. "But the problem was, they would not cover any doctors or hospital stays on the Missouri side of the river."

Mike Cluck and his wife, Nancy, of Edwardsville, Ill., were happy with Obamacare until their insurer dropped out.

Durrie Bouscaren / St. Louis Public Radio

Cluck had prostate cancer. He is now free of cancer, but he still needs regular checkups and he fears the cancer may return. It takes him about 30 minutes to drive to oncology appointments now, but the in-network providers Blue Cross Blue Shield of Illinois shows in its directory are farther away.

"That's where the problem came in. Because all of my cancer doctors, and Siteman Cancer Center, are in St. Louis, Mo.," Cluck says.

To Cluck, it's a frustrating display of flaws in the Affordable Care Act.

"This was not supposed to happen," he says. "When they put the Affordable Care Act in place, we were promised we could keep our doctors. We were promised it would cost $2,500 less than what we were currently paying. And nothing's come true."

On Nov. 8, when faced with a choice between Democratic presidential nominee Hillary Clinton and Donald Trump, he voted for the Republican.

"For a lot of reasons, not just Obamacare," he says. But while he hopes that there's a good replacement plan ready for any changes to Obamacare, he's is frustrated by the insurance companies' narrow networks.

"I don't understand why, when the health care companies are recording record profits that they're not staying in the Affordable Care Act. That's the one thing that just boggles my mind."

So, he hopes Trump follows through on his promise to repeal and replace.

"There's a lot of things they need to fix, because there's a lot of people who are reliant upon medical care and health care. I think this should really be fixing, dismantling—however you want to call it—the Affordable Care Act, I think that needs to really be a priority for the new administration." — Durrie Bouscaren, St. Louis Public Radio.

Fears About Losing Insurance Limited Job Options

Leigh Kvetko relies on health insurance she bought through the federal marketplace to pay for the expensive medications that keep her alive after two organ transplantations.

Lauren Silverman / KERA News

Leigh Kvetko, 46, of Dallas, has to take 10 medications twice a day because she's had two organ transplants to replace her pancreas and kidney in 2003. Several of the pills she takes cost nearly $1,000 each per month. For years, Kvetko stuck with a job she hated in large part because it offered health insurance. When the Affordable Care Act passed, insurers could no longer discriminate against people like Kvetko, who have diagnosed health problems, and she and her husband finally felt free.

"It gave me hope and [my husband and I] decided to sell our house, to downsize, and to start our own businesses and start a new chapter of our lives."

In this new chapter, Kvetko is retail manager at a busy Dallas coffee shop. She struts through the store in cowboy boots, her long red hair framing green-speckled eyes. She looks happy — and healthy. But her pancreas is failing, and she's terrified about President-elect Trump's promise to dismantle the Affordable Care Act. She fears it will put health care out of reach for her, and another 1.2 million Texans who rely on subsidized plans. — Lauren Silverman, KERA, Dallas.

These reports come to us as part of a partnership with NPR, local member stations and Kaiser Health News.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Legislation That Would Shape FDA And NIH Triggers Lobbying Frenzy

NPR Health Blog - Fri, 11/25/2016 - 6:00am

Lobbyists seeking to influence the 21st Century Cures Act descended on lawmakers.

Susan Walsh/AP

The 21st Century Cures Act now being refined by the lame duck Congress is one of the most-lobbied health care bills in recent history, with nearly three lobbyists working for its passage or defeat for every lawmaker on Capitol Hill.

More than 1,455 lobbyists representing 400 companies, universities and other organizations pushed for or against a House version of a Cures bill this congressional cycle, according to federal disclosure forms compiled by the Center for Responsive Politics.

The legislation would give the Food and Drug Administration new powers to more rapidly approve drugs and medical devices. The measure would also include additional funding for the agency as well as more money for the National Institutes of Health.

Work is now underway on a compromise expected to come up for a vote soon. While final details are still being negotiated, the House version that passed in June 2015 provided the NIH with $1.75 billion in additional annual funding over five years. The bill would keep generics off the market longer for drugs treating rare diseases and speed the drug and device approval process.

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The Cures Act garnered more lobbying activity than all but a few of the more than 11,000 bills proposed in the 114th Congress, an analysis of the CRP data shows. It's also the second most-lobbied health care bill since 2011, surpassed only by the Medicare Access and CHIP Reauthorization Act of 2015, which, among other things, overhauled Medicare payments to health providers.

Shots - Health News A Look At How The Revolving Door Spins From FDA To Industry

Putting a precise price tag on the lobbying is difficult because spending reports don't break down spending by specific measures. The reports show that interested groups spent as much as half a billion dollars from 2015 through the second quarter of 2016 on all lobbying disclosures that included the 21st Century Cures Act.

"In a bill of this importance and consequence, a lot of groups have a lot of interest in every line in that bill, and they're going to put as much pressure as they can on legislators — and maybe some executive branch people as well — to get favorable language in that bill to support their interests," said former Rep. Lee Hamilton, who founded the Indiana University Center on Representative Government after spending more than three decades in the House of Representatives. "The more intense the lobbying, the more money is at stake."

Senate Majority Leader Mitch McConnell identified the legislation as a priority after a 2016 election that has cast doubt on the future of the Affordable Care Act. President-elect Donald Trump has vowed to eliminate "red tape" at the FDA but hasn't specifically commented on the Cures Act.

"Absolutely this has gained a lot of attention on K Street" said Tim LaPira, a political science professor at James Madison University. Every Congress, he said, a few dozen bills spark a "feeding frenzy."

Even so, the bill hasn't spurred as much lobbying as the Affordable Care Act in 2009, which brought out more than 1,200 organizations, according to CRP data.

The Pharmaceutical Researchers and Manufacturers of America, or PhRMA, the main trade group for brand-name drugmakers, applauded the House bill's passage. The group's lobbying reports naming the bill accounted for $24.7 million in spending by the group, which spent $30.3 million overall.

Its spokesperson Allyson Funk said in a statement the trade group "appreciate[s] Congress' continued interest in improving biomedical innovation and accelerating new treatments for patients."

Several nonprofit patient advocacy and research groups have opposed the bill, citing concerns about endangering patients with simplified drug and device approvals.

Beyond the pharmaceutical industry, the bill's supporters include universities, medical schools and groups representing them, as well as patient groups funded by drug and device companies, said Diana Zuckerman of the nonprofit National Center for Health Research, which has not lobbied the bill, but has launched a campaign to convince congress to "fix" it.

"It really is a David and Goliath issue of where the money is," Zuckerman said.

Rep. Fred Upton, a Michigan Republican, (left) and Rep. Diana DeGette, D-Colo., hold thank you signs made by Max Schill, 6, from Williamstown, N.J., after the House of Representatives voted in favor of the 21st Century Cures Act in 2015.

Congressional Quarterly/CQ-Roll Call, Inc.

AbbVie, the maker of Humira, a drug used to treat arthritis, ulcerative colitis and Crohn's disease, reported $7.7 million in lobbying expenditures in disclosures listing the bill as an issue. The company's total lobbying was $9.5 million this cycle.

Hospitals and medical schools, which oppose rising drug costs, supported the bill because the NIH funding could propel grants to medical and research institutions, Zuckerman said.

Johns Hopkins Medicine called enhanced biomedical research funding "long overdue." Spokeswoman Jania Matthews said in an email that the bill would also "provide new tools at the FDA to accelerate the approval of new therapies and medical devices."

The U.S. Chamber of Commerce generally supports the bill and reported $87.1 million in expenditures in disclosure reports that cited the Cures Act, with overall spending of $136.5 million through the second quarter of 2016.

The U.S Oil and Gas Association, with lobbying expenditures of $293,000, lists the Cures Act as a legislative issue. Funding for the bill would partly come from selling crude oil from the U.S. Government's Strategic Petroleum Reserve.

According to the House Committee on Energy and Commerce, money from oil sales would go toward funding NIH "because just as energy reserves are a national resource designed to protect and serve our citizens, so too is an investment in health innovation and research."

The U.S. Oil and Gas Association declined to comment.

Additional lobbyists may be working on the bill under the radar. LaPira said that lax lobbying disclosure requirements mean that some lobbyists may not disclose work on the bill, H.R. 6. That's what he saw when the Affordable Care Act was passed, too.

"The clerk's office is supposed to list the bill number if they know it, but nobody ever checks," he said. "That's another sort of trick of the trade: to hide in plain sight."

The bill is considered a swan song for sponsor Rep. Fred Upton, Republican from Michigan, whose tenure as chair of the House Committee on Energy and Commerce is nearing an end, said Paul Heldman, an analyst at Heldman Simpson Partners, a research firm that provides health policy analysis to investors. Upton garnered broad support from device makers, drug manufacturers, researchers and patient advocacy groups. He's received more than half a million dollars in campaign contributions from pharmaceutical and health product groups in the last two election cycles.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Sydney Lupkin on Twitter:@slupkin.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Give Thanks For Siblings: They Can Make Us Healthier And Happier

NPR Health Blog - Thu, 11/24/2016 - 5:00am
Katherine Streeter for NPR

Somehow we're squeezing 18 people into our apartment for Thanksgiving this year, a year when too many people are worrying about fraught post-election conversations. My relatives, who luckily are all cut from the same political cloth, range in age from my mother, aged 92, to my 32-year-old nephew (my 17-month-old granddaughter's political leanings are still unfolding.)

I love them all, but in a way the one I know best is the middle-aged man across the table whose blue eyes look just like mine: my younger brother Paul.

Paul and I irritated each other when we were kids; I would take bites out of his precisely made sandwiches in just the spot I knew he didn't want me to, and he would hang around the living room telling jokes when he knew I wanted to be alone with the boy on the couch.

But as adults we've always had each other's backs, especially when it comes to dealing with our mother's health crises, which have become more frequent in the past few years. Paul is the first person I want to talk to when there's something that worries me about Mom; I know he'll be worried, too.

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There's probably a biological explanation for the intensity of the sibling bond. Siblings share half their genes, which evolutionary biologists say should be motivation enough for mutual devotion. "I would lay down my life," British biologist J.B.S. Haldane once said, applying the arithmetic of kin selection, "for two brothers or eight cousins." Siblings are a crucial part of a child's development, too, teaching one another socialization skills and the rules of dominance and hierarchy, all part of the eternal struggle for parental resources.

When psychologists study siblings, they usually study children, emphasizing sibling rivalry and the fact that brothers and sisters refine their social maneuvering skills on one another. The adult sibling relationship has only sporadically been the subject of attention. Yet we're tethered to our brothers and sisters as adults far longer than we are as children; our sibling relationships, in fact, are the longest-lasting family ties we have.

Most such relationships are close — two-thirds of people in one large study said a brother or sister was one of their best friends. One thing that can scuttle closeness in adulthood is a parent who played favorites in childhood; this sense of resentment can last a lifetime.

Jill Suitor, a sociologist at Purdue University, and her colleagues polled 274 families with 708 adult children (ages 23 to 68) in 2009 and found that the majority had good feelings toward their siblings. Most didn't remember much favoritism when they were kids, but those who did reported feeling less loved and cared for by their siblings. It didn't matter whether they felt themselves to be the favored or the unfavored child. The simple perception of parental favoritism was enough to undermine their relationship.

That's one thing Paul and I have going for us: We're pretty sure our parents treated us the same when we were growing up. Yet we're very different people. Paul is gregarious while I'm shy, funny while I'm not, a terrific amateur saxophonist while I can't read music or carry a tune. This isn't unusual. In families with more than one child, every sibling seems to get a label in contrast to every other sibling.

So if your kid sister is the queen bee in any social gathering, you might get labeled "the quiet one" even if you're not especially quiet, just quiet in comparison. And if you're a bright child who always gets good grades, you might not get much credit for that if your big brother is a brilliant child with straight A's. There's only room for one "smart one" per family — you'll have to come up with something else. (I was smart, but Paul was smarter; I ended up being the "good one.")

The very presence of siblings in the household can be an education. When a new baby is born, writes psychologist Victor Cicirelli in the 1995 book Sibling Relationships Across the Life Span, "the older sibling gains in social skills in interacting with the younger" and "the younger sibling gains cognitively by imitating the older."

They learn from the friction between them, too, as they fight for their parents' attention. Mild conflict between brothers and sisters teaches them how to interact with peers, co-workers and friends for the rest of their lives.

The benefits can carry into old age. The literature on sibling relationships shows that during middle age and old age, indicators of well-being — mood, health, morale, stress, depression, loneliness, life satisfaction — are tied to how you feel about your brothers and sisters.

In one Swedish study, satisfaction with sibling contact in one's 80s was closely correlated with health and positive mood — more so than was satisfaction with friendships or relationships with adult children. And loneliness was eased for older people in a supportive relationship with their siblings, no matter whether they gave or got support.

That's why it's so sad when things between siblings fall apart. This often happens when aging parents need care or die — old feelings of rivalry, jealousy and grief erupt all over again, masked as petty fights ostensibly over who takes Mom to the doctor or who calls the nursing home about Dad.

Many families get through their parents' illnesses just fine, establishing networks where the workload is divided pretty much equally. So far, Paul and I have done fine, too. But about 40 percent of the time, according to one study, there is a single primary caregiver who feels like she (and it's almost always a she) is not getting any help from her brothers and sisters, which can lead to serious conflict.

And because of the particular intensity of sibling relationships, such conflict cuts to the bone. People grieve for the frayed ties to their siblings as though they've lost a piece of themselves.

Throughout adulthood, the sibling relationship "is powerful and never static," said Jane Mersky Leder, author of The Sibling Connection. Whether we are close to our siblings or distant, she writes, they remain our brothers and sisters — for better or for worse.

So let this all percolate as you sit down to turkey with your sometimes-complicated family. And remember the immortal words of folksinger Loudon Wainwright III, in a song called Thanksgiving. It's about spending the holiday with a brother and a sister he rarely sees but still has intense feelings about:

On this auspicious occasion, this special family dinner

If I argue with a loved one, Lord, please make me the winner.

Science writer Robin Marantz Henig is a contributing writer for The New York Times Magazine and the author of nine books. This is an updated version of an article that we originally published on Nov. 27, 2014.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Your Dog Remembers Every Move You Make

NPR Health Blog - Wed, 11/23/2016 - 1:03pm
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November 23, 20161:03 PM ET Heard on Morning Edition

Comparative psychologist Claudia Fugazza and her dog demonstrate the "Do As I Do" method of exploring canine memory.

Mirko Lui/Cell Press

You may not remember what you were doing a few minutes ago. But your dog probably does.

A study of 17 dogs found they could remember and imitate their owners' actions up to an hour later. The results, published Wednesday in Current Biology, suggest that dogs can remember and relive an experience much the way people do.

That's probably not a big surprise to people who own dogs, says Claudia Fugazza, an author of the study and an animal behavior researcher at Eotvos Lorand University in Budapest. Fugazza owns a Czechoslovakian Wolfdog named Velvet.

"Most dog owners at least suspected that dogs can remember events and past experiences," she says.

But demonstrating this ability has been tricky.

Fugazza and her colleagues thought they might be able to test dogs' memory of events using a training method she helped develop called "Do As I Do." It teaches dogs to observe an action performed by their owner, then imitate that action when they hear the command: "Do it."

Do As I Do Training

This video shows episodic-like memory in dogs, using the "Do As I Do" method.

This video shows episodic-like memory in dogs, using the "Do As I Do" method.

Credit: Claudia Fugazza, Akos Pogany, and Adam Milkos / Current Biology 2016

"If you ask a dog to imitate an action that was demonstrated some time ago," Fugazza says, "then it is something like asking, 'Do you remember what your owner did?' "

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In the study, a trained dog would first watch the owner perform some unfamiliar action. In one video the team made, a man strides over to an open umbrella on the floor and taps it with his hand as his dog watches.

Then the dog is led behind a partition that blocks a view of the umbrella. After a minute, the dog is led back out and lies on a mat. Finally, the owner issues the command to imitate: "Do it."

The dog responds by trotting over to the umbrella and tapping it with one paw.

In the study, dogs were consistently able to remember what their owners had done, sometimes up to an hour after the event.

Shots - Health News Their Masters' Voices: Dogs Understand Tone And Meaning Of Words

The most likely explanation is that the dogs were doing something people do all the time, Fugazza says. They were remembering an event by mentally traveling back in time and reliving the experience.

Even so, the team stopped short of concluding that dogs have full-fledged episodic memory.

"Episodic memory is traditionally linked to self-awareness," Fugazza says, "and so far there is no evidence of self awareness in dogs and I think there is no method for testing it."

For a long time, scientists thought episodic memory was unique to people. But over the past decade or so, researchers have found evidence for episodic-like memory in a range of species, including birds, monkeys and rats.

Dogs have been a special challenge, though, says Victoria Templer, a behavioral neuroscientist at Providence College.

"They're so tuned into human cues, which can be a good thing," Templer says. "But it also can be a disadvantage and make it very difficult, because we might be cuing dogs when we're totally unaware of it."

The Budapest team did a good job ensuring that dogs were relying on their own memories without getting any unwitting guidance from their owners, says Templer, who wasn't involved in the study.

She says the finding should be useful to scientists who are trying to understand why episodic memory evolved in people. In other words, how has it helped us survive?

One possibility, Templer says, is that we evolved the ability to relive the past in order to imagine the future.

So when we're going to meet a new person, she says, we may use episodic memories of past encounters to predict how the next one might go.

"If I can imagine that I'm going to interact with some individual and that might be dangerous, I'm not going to want to interact with them," she says.

And that could help make sure the genes that allow episodic memories get passed along to the next generation.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Pence Expanded Medicaid As Governor, Now He May Be Part Of Cutting It

NPR Health Blog - Wed, 11/23/2016 - 12:40pm

In 2015, Indiana Gov. Mike Pence announced that the Centers for Medicaid and Medicare Services had approved the state's waiver to try a different approach for Medicaid.

Michael Conroy/AP

Chris Cunningham was so thrilled with Indiana Gov. Mike Pence's Medicaid expansion under the Affordable Care Act that she readily accepted his invitation to an event celebrating its first anniversary in January.

After eight years without health insurance, Medicaid coverage paid for treatment of her thyroid problem and lung disease and prescription drugs to help both. "It was a game changer for me," the Indianapolis woman said.

Election Day's results are on her mind now.

Indiana Gov. Mike Pence was one of 10 Republican governors to expand Medicaid under Obamacare, but as President-elect Donald Trump's running mate, Pence is now calling for the health law's repeal and replacement.

If that happens, millions of low-income people around the country added to the state-federal insurance program since 2014 under the health law are at risk of losing their health insurance. Thirty-one states and the District of Columbia have expanded Medicaid, extending coverage to at least 10 million Americans.

"I don't see how a compassionate human being can rip health care away from millions of people," Cunningham said.

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What Pence did with Indiana's Medicaid program may place him in the middle ground of political battles to come over Obamacare's future. He called for the law's repeal even before joining Trump, but also pushed Medicaid's expansion in a conservative direction by advocating for stricter eligibility requirements on low-income people receiving government-paid health care.

Neither Trump nor any other top Republican has spelled out what a replacement would look like. Trump has said he supports Medicaid block grants to states — a way of stabilizing federal funding that could ultimately raise states' costs and force them to cut benefits or eligibility.

Shots - Health News In Depressed Rural Kentucky, Worries Mount Over Medicaid Cutbacks

The health law allowed states to open Medicaid to all adults with incomes at or below 138 percent of the federal poverty level, with all the extra costs paid by the government for the first three years, 2014 through 2016.

Pence took the federal money but won the Obama administration's approval to add features that set Indiana apart from other expansion states. For example, recipients are required to pay money — $1 a month for many — into special accounts that Pence contends will make them more conscious of the costs associated with health care.

Healthy Indiana Plan 2.0 pushed Medicaid's traditional boundaries, which is why it has captured attention in conservative states. The plan demands something from all enrollees, even those below the poverty level. Individuals who fail to keep up their contributions lose dental and vision coverage and face copayments. Those above the poverty level can temporarily lose all coverage if they fall behind on contributions.

Proponents, including Pence, have said the strategy makes Medicaid recipients share financial responsibility for their care and that it will save Indiana money by reducing unnecessary services and inappropriate emergency room use.

Pence has said Indiana's program has lowered ER use, led to recruitment of more physicians by paying them more and succeeded in getting most recipients to contribute monthly payments.

"This is an innovative, fiscally responsible program," Pence said at the expansion's first anniversary event that Cunningham attended in Indianapolis. "We are improving outcomes, improving lives and improving the fortunes of Hoosiers."

Cunningham said last week she remembers that day well and the personal connection Pence made with her and other new enrollees.

"It does give me hope that Gov. Pence started Medicaid expansion here and talked highly of it," she said. "When I met him that day, it gave me a sense that even though I didn't agree with 75 percent of what he stood for, I found him to be a really good man [who] really wanted to improve the health situation for people of Indiana."

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Indiana hospitals are also hoping Pence will be an advocate for preserving the expansion.

The expanded Medicaid program pumped millions of dollars into the state's hospital industry by providing them more paying patients and increasing their Medicaid reimbursements.

Brian Tabor, executive vice president of the Indiana Hospital Association, said the election results have him worried about the future of Medicaid and Obamacare. But knowing Pence will have Trump's ear could make a difference.

Pence "understands that with some flexibility, states can be successful at expanding coverage and that bodes well for states like Indiana," he said. "He is passionate about the health and security that Medicaid provides to Hoosiers. I am confident that he will have a significant policy role in the White House and will use that in a way to preserve what we have in Indiana."

Tabor said that while block grants or a per capita limit for Medicaid would give states more autonomy in running the program, he worries it would mean cuts in federal funding that would hurt recipients and providers.

Medicaid's expansion in Indiana has provided vital funding to hospitals, particularly those in rural areas that have struggled to stay open. "It's been a lifeline to many rural providers," he said.

Susan Jo Thomas, executive director of Covering Kids & Families of Indiana, an advocacy group, seems less hopeful for the future of Medicaid expansion and the program overall even with Pence as vice president.

"It's scary to us," she said of the prospect of losing Obamacare and Medicaid becoming a block grant program. While Republicans have proposed the block grant idea since the 1980s, she noted it could find stronger support because Congress has turned more conservative and most states have conservative governors.

For Cunningham, Medicaid expansion in 2015 came at the right time. She had been managing several group homes for the disabled in 2008 when she ended her career to care for her own disabled husband.

"I was in a desperate situation and I've been very grateful for the help," she said.

For her at least, worries about not having insurance will fade next May.

That's when she will turn 65 and enroll in Medicare.

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. You can follow Phil Galewitz on Twitter: @philgalewitz.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Spike In Demand For Long-Acting Birth Control Strains Clinic Budgets

NPR Health Blog - Wed, 11/23/2016 - 12:31pm

Under the Affordable Care Act, insurers are required to cover birth control with no copay. It's unclear what will happen to coverage if the act is repealed or amended.

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In the two weeks since the election, Planned Parenthood Federation of America has seen a huge increase in volunteers and donations – over 200,000 donations in a single week. But this surge in support hasn't reached many other reproductive health organizations. And many of these centers are already struggling to meet a spike in demand for long-acting contraception after the election of Donald Trump.

Susie Markus, executive director of the Wyoming Health Council, says that she's heard people in Wyoming say they're going to donate to Planned Parenthood. "But there's only one Planned Parenthood in Wyoming." Her organization is the umbrella group for 15 publicly funded family planning centers in Wyoming. She's been hoping for donations, but none have come in.

The nonprofit Wyoming Health Council is funded in part by Title X, a 46-year-old federal law that helps provide family planning services to the poor by distributing funds to regional grantees. They in turn support 3,951 facilities, including local health departments, federally qualified health centers, independent clinics and hospital outpatient units. About 13 percent of the facilities are run by Planned Parenthood. Title X doesn't just cover birth control; it also covers breast and cervical cancer screenings, pregnancy counseling, and testing and treatment for sexually-transmitted diseases and other services, but not abortion. Centers funded by Title X are required to see all patients, regardless of insurance coverage, and charge them on a sliding scale based on income. Clinics cover the difference between the cost of the visit and what patients can pay.

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In states like Indiana, funding is already so tight that the post-election rush on IUDs and other long-lasting contraceptives like implants has left clinics scraping for money. IUDs come with a high up-front cost – up to $1,000 for the device and insertion. "At the end of the day, we've decided that if a woman wants an IUD, we will get it for her," says Kristen Adams, president and CEO of the Indiana Family Health Council, a nonprofit that distributes funds to 26 clinics in the state. "That means a lot of budget shifting."

Because the clinics provide same-day services, Adams says they typically have a few IUDs in stock. "But can we afford to keep 20 on our shelves? No."

Family planning organizations in other states say they can handle a brief spike in patients, but if the rush of women seeking IUDs and other reproductive services continues, things might get difficult.

"Our demand for IUDs has about doubled, but we don't know if that's a short term spike or not. I think it would take a more consistent increase for it to begin to be an issue," says Kate Brogan, Maine Family Planning's vice president for public affairs. She says that Maine Family Planning has also seen a slight increase in donations.

This sentiment is echoed in California, which is served by Essential Access Health, the largest Title X-funded network in the country, with more than 340 clinics. According to Amy Moy, their vice president of public affairs, California's network serves about 1 million people, or one quarter of the people eligible for Title X services nationwide. She says that the state has additional programs that fund family planning for people with low incomes.

One of those centers, the Women's Community Clinic in San Francisco, has received some election-related donations, but "not like the increase Planned Parenthood has seen," says Carlina Hansen, their executive director. If the demand for long-acting contraceptives continues, she says her clinic will need to open up more appointments and possibly increase staffing. "We already operate at a loss, and donations help us carry that loss. If we need to increase our staff, balancing our budget gets difficult."

Even in states like California, Title X grantees are worried about the future. The Affordable Care Act and Medicaid expansion have increased the number of patients whose family planning visits are covered by insurance. If those expansions are rolled back, state programs and clinics will be pressed to take on the additional cost. And advocates are worried Title X will find itself on the chopping block.

It's not an unfounded concern.

In the last several years, numerous bills have been introduced in Congress to block Title X funds from organizations that also provide abortions, like Planned Parenthood. In 2011, the House voted to defund Title X in its entirety, but the measure didn't pass the Senate. Still, for the last several years Title X funding has decreased, from $317.5 million in 2010 to $286.5 million in 2016. Under a Trump administration and with a Republican Congress, those numbers could shrink even more.

"If we lost Title X funding — oh, gosh, given the history of Title X battles in Congress, I think that's a real question," says Brogan in Maine. "Right now we have over 50 clinics. There's no way we'd be able to maintain that without Title X."

Copyright 2016 NPR. To see more, visit NPR.
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Infectious Diseases Keep Delivering Surprises To The U.S.

NPR Health Blog - Tue, 11/22/2016 - 2:14pm
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Infectious diseases are no longer the major killers in the U.S. that they once were, but they still surprise us.

According to a report published Tuesday in JAMA, the journal of the American Medical Association, deaths from infectious disease accounted for 5.4 percent of deaths from 1980 to 2014.

That's a big change from 1900, when infectious diseases like pneumonia, tuberculosis and diarrhea accounted for almost half of all deaths. The historical decline represents great progress in sanitation, antibiotic discovery and vaccination programs, says Heidi Brown, an assistant professor of public health at the University of Arizona and an author of the research letter. "We've done phenomenal and amazing things with respect to infectious diseases," she says.

But if you dig into the data a bit, she says, you can see where new diseases make an appearance, sometimes a deadly and dramatic one. For example, between 1980 and 1995, the number of deaths per 100,000 people from HIV/AIDS rose by an average of more than 85 percent per year. Then when new antiretroviral drugs became available, that rate fell by an average of more than 10 percent annually from 1995 to 2014.

"We went from not understanding [the disease] to being able to do something about it in a relatively short period of time," says Brown. (To be sure, even with the gains we've made, the epidemic is not over.)

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West Nile virus also shows how new diseases can pop up. The disease, which is transmitted by mosquitoes, arrived in the U.S. in 1999 and "very quickly became endemic," says Brown. In 2014 it killed about 3 people for every 10 million in the population. (This chart, from the Centers for Disease Control and Prevention, shows the impact of the disease through 2015.)

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Now public health officials are warning about the threat from other vector-borne viruses like Zika and chikungunya. Just last week, the World Health Organization said Zika was no longer a public health emergency, but that it has become is a chronic problem, here to stay.

The emergence of new public health threats shows the need for vigilance, despite the reassuring statistics, says Brown. "Infectious diseases still not conquered," she says. "There's still that vulnerability."

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson.

Copyright 2016 NPR. To see more, visit NPR.
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Dementia Risk Declines, And Education May Be One Reason Why

NPR Health Blog - Mon, 11/21/2016 - 5:46pm
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November 21, 20165:46 PM ET Heard on All Things Considered

Education may help brains cope with cognitive decline, and treatments for high blood pressure and other health problems may decrease dementia risk.

Alfred Pasieka/Science Photo Library/Getty Images

Some encouraging news in the battle against Alzheimer's disease and other forms of dementia: The rate at which older Americans are getting these conditions is declining. That's according to a study published Monday in JAMA Internal Medicine. Researchers say one reason for the improved outlook is an increase in education.

The study used data gathered in two snapshots, one in 2000 and another in 2012, that each looked at more than 10,000 Americans who were at least 65 years old. In the first snapshot, 11.6 percent of them had some form of dementia. In the second snapshot, it was 8.8 percent.

Put in more human terms, "that's well over a million people who don't have dementia, who would have had it if the rates had stayed the same as 2000 rates," says John Haaga, who directs the Division of Behavioral and Social Research at the National Institute on Aging, which funded the study.

While the prevalence of dementia cases dropped, the average amount of education in the study population increased. In 2000, the average amount of education was 11.8 years, just shy of the 12 years it usually takes to graduate from high school. In 2012, the average amount of education was 12.7 years — in other words, high school plus a little bit of college.

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Researchers don't know why education should be a protector against dementia, says Dr. Kenneth Langa, a professor of medicine at the University of Michigan and the lead author of the study. But they have some theories.

"One is that education might actually change the brain itself," Langa says. "We think that it actually creates more, and more complicated, connections between the nerve cells so that you're able to keep thinking normally later into life."

Education can not only change the brain, it can change your whole life, says Haaga.

"It affects what kind of work you do, of course. It also affects who your friends are, who you're married to, whether you're married. All aspects of life are affected by educational attainment," he says.

But the study doesn't say that education alone is the "X factor" in preventing dementia. There are medical factors, too.

Cardiovascular conditions believed to increase the risk of dementia — things like high blood pressure, high cholesterol, obesity, diabetes — are becoming more common, says Haaga. But they're also being treated more aggressively.

"So it could well be that we're getting better at managing the bad effects of these risk factors," he says. "But they are still risk factors."

This study fits a recent trend. In the past decade or so, other researchers have found similar declines in dementia risk in wealthier nations. But the populations they examined haven't been very diverse. This study is different. It draws on the ongoing Health and Retirement Study that follows about 20,000 older Americans of all backgrounds nationwide.

Langa says the ethnic, geographic and economic diversity of the subjects makes the trend shown in all these studies more convincing. "The fact that our study also shows a decline [in the prevalence of dementia], provides additional evidence that this phenomenon seems to be going on across the United States and not in one particular geographic region."

But while the risk of dementia is declining, the number of cases is still expected to rise. That's because the population of older adults in this country is increasing. The number of people 65 and older is expected to nearly double by 2050.

Copyright 2016 NPR. To see more, visit NPR.
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If Republicans Repeal Obamacare, Ryan Has Replacement Blueprint

NPR Health Blog - Mon, 11/21/2016 - 10:59am
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November 21, 201610:59 AM ET Heard on Morning Edition

House Speaker Paul Ryan, R-Wis., discussed a Republican alternative to Obamacare upon its release at the American Enterprise Institute in June.

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Donald Trump and Republicans in Congress are vowing to repeal and replace the Affordable Care Act, the signature health care overhaul of President Obama.

Trump has offered a few ideas of where he'd like to see a health care overhaul go, such as a greater reliance on health savings accounts, but he hasn't provided a detailed proposal.

The absence of specifics on health care from the president-elect makes the 37-page plan that Speaker of the House Paul Ryan has released the fullest outline of what Republicans would like to replace Obamacare. Some health policy analysts say it looks a bit like Obamacare light.

"Republicans through this plan have embraced, I think rightfully so, the basic idea that everybody in the U.S. should have health insurance," says Jim Capretta, a health policy fellow at the American Enterprise Institute. "And people who are outside the employer system should get some level of financial help through a tax credit, because, frankly, that's similar to the tax break that is available through employer coverage."

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Republicans had been criticized for years for promising to repeal the ACA and offering nothing as a replacement. Ryan unveiled the proposal at AEI in June.

The Wisconsin Republican's comments at the time reflected that: "Well, here it is, a real plan, in black and white, right here. We are officially putting it on the table."

The Ryan report details what he says is wrong with Obamacare and how Republicans could fix it.

The upshot?

"Don't force people to buy insurance," Ryan told the crowd. "Make insurance companies compete for our business."

"And, yes," he added, "we're going to help you buy insurance."

While the Ryan plan gets rid of the mandate to buy insurance, it otherwise has many provisions that will be familiar to people who know Obamacare. It would offer tax credits to help people pay for insurance. And it would protect people with existing illnesses and medical conditions from being dropped by their health plans.

The main difference from the Affordable Care Act reflects the conservative view that a market approach could make health care more efficient, and cheaper.

While the Ryan proposal is more detailed than many, it does lack some key information. Most importantly, the size of the subsidies that would be offered is unknown, as is the level of insurance that would be tied to them.

Obamacare bases its financial assistance on a policy that pays a set percentage of a person's health care costs and that carries a minimum set of benefits. Ryan has only hinted at what level of insurance coverage his subsidies are expected to buy.

But a major aim of his overhaul is to move people to insurance policies that carry high deductibles. To pay those deductibles and other health care costs, people would have tax-free health savings accounts. The individual, government or employer could contribute to such an account. That could keep premium costs down for young, healthy people, says Paul Howard, director of health policy at the conservative Manhattan Institute.

"Most of the care that most people need for most of their adult lives can be very inexpensive," Howard says.

So rather than spending a lot of money on premiums for insurance they don't need, people could save that money for when they do get sick. Howard says people could start young and save for major health problems over time.

"By the time you're 40, ideally, you would have built up a health savings plan that would be partly funded by government sources, plus your own sources, a significant nest egg," he says.

Ryan also wants to limit the tax breaks for employer-based insurance to nudge companies into buying cheaper, high deductible, policies for their employees too. The idea is similar to the so-called Cadillac tax in Obamacare that levies a tax surcharge for expensive health insurance policies.

Howard says workers might prefer a high-deductible plan, especially if they were aware of how much of their compensation goes to health insurance. He says companies should ask their employees the following.

"Do you know that $20,000 of your wages are going every year to insurance?" he asks. "Would you rather have $10,000 in your pocket, put $5,000 into a high-deductible plan or something like that, and then put some aside for a rainy day that will accumulate over time?"

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Conservatives argue that making people buy their own health care — even with money provided by the government or their employer — will get them to shop around for the best quality and price, and lower overall health care costs in the long run.

Ryan wants to launch his new system with a single open enrollment period, rather than the annual sign-up windows offered under Obamacare.

People with ongoing medical conditions who maintain their coverage continuously can't be cut off, or see their prices raised. But what if you let your coverage lapse?

"You could be denied a policy because you have diabetes, and the next time you could get coverage again would be when you turn 65 and become eligible for Medicare," says Sabrina Corlette, a professor at the Georgetown Center for Health Policy Reform. "The effect of it could be to lock a lot of people out who have pre-existing conditions."

For people in that situation, Ryan has proposed creating high risk pools — special government subsidized coverage for hard to insure people like those with cancer or other chronic illnesses.

Corlette, however, says high-risk pools have been tried already, in 35 states, and failed.

"When you put people into this insurance ghetto, which is these high risk pools, the cost is going to be extraordinarily high," she says.

Corlette says Ryan's plan covers fewer people and offers fewer benefits.

"What Paul Ryan has called for is a much skimpier set of protections so that tax credit buys you a lot less than it would have under the ACA," she says.

A key feature of Obamacare is that it spreads the cost of insurance across generations. So healthy young people subsidize older sicker people who use more health care.

Ryan's plan would change that.

Copyright 2016 NPR. To see more, visit NPR.
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Hospital Companions Can Ease Isolation For Older People

NPR Health Blog - Mon, 11/21/2016 - 4:53am
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November 21, 20164:53 AM ET Heard on Morning Edition

Volunteer Julia Torrano helps Estelle Day, 79, style her hair while she's a patient at UCLA Medical Center.

Ina Jaffe/NPR

Loneliness can be a problem for older people, especially when they're in the hospital. Their children may have moved away. Spouses and friends may themselves be too frail to visit. So a California hospital is providing volunteer companions in the geriatric unit.

One of the volunteers at the UCLA Medical Center in Santa Monica is 24-year-old Julia Torrano. She hopes to go to medical school. Meanwhile, her twice-weekly volunteer shifts give her a lot of practice working with patients.

One of them is Estelle Day. She's 79 years old, a slender woman with a wild mane of hair that is still mostly red. Torrano peppers her with questions.

"Where were you originally from?" asks Torrano. Day replies that she grew up on Long Island in New York. Torrano also wants to know how Day met her husband, where she learned to play the harp, where her travels have taken her.

Day is happy to answer everything. She says she likes people and describes herself as "windbaggy." That's especially true if she's talking about playing music. She is a lifelong musician and retired music teacher. She plays harp and guitar, but her favorite instrument is the pipe organ. "To be able to rock a building under your hands and your feet is exciting," she says.

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This was Day's fifth day as a patient in the geriatric unit. She says multiple chronic conditions brought her here, but she didn't want to name them. Visible were a bulky back brace she wears for her osteoporosis, an IV drip and a heart monitor.

When that heart monitor suddenly began beeping, Torrano was out of the room like a shot. She returned seconds later with a nurse who solved the problem with the push of a button.

Torrano and the other volunteer companions aren't just candy stripers, bringing snacks and magazines. She knew what to do when the heart monitor started beeping because, like all of the volunteers in this program, she's been trained. As Dr. David Reuben, chief of geriatrics at the Geffen School of Medicine at UCLA explains: "Just because you're willing to do something doesn't mean you know how to do it."

Volunteers learn about medical confidentiality, what to do in an emergency, and how to interact with patients, including patients with dementia. Reuben says they go through a "vigorous training process and vetting process before we allow them to be with patients." There are nearly three dozen volunteers so far. The program started just a few months ago, and the hospital plans to expand it.

Loneliness is a legitimate medical issue. There are a number of studies linking loneliness and social isolation in old people to poorer health and earlier death, including one published earlier this month in JAMA Psychiatry associating loneliness, social isolation and brain changes typical in Alzheimer's. Reuben cautions that those studies weren't done in a hospital setting. Nevertheless, he says, "you might suspect that being more engaged, more energized ... might promote a speedier recovery."

So now the hospital is designing studies to find out if the volunteer companionship improves medical outcomes, or at least improves the patient's experience in the hospital.

Torrano says she'll sometimes spend her entire four-hour shift with a single patient. Like Estelle Day, many are happy to share their life stories. She remembers one man in particular who had been a political prisoner in Iran. He'd run an underground newspaper. "He was in jail so much," she recalls, yet he told her he also misses Iran. "Even though it was very traumatic, he still wishes he was there," Torrano says.

Estelle Day says she's not especially lonely, but she has been alone much of the time since she was admitted to the geriatric unit. So it helps to have a companion who will not only listen to her life story, but can also troubleshoot the little problems that can make life in a hospital such a challenge. "Somebody who is sensitive and tuned-in and is very helpful," explains Day, the way Torrano was when Day's heart monitor started acting up.

And companionship can take many forms. On the day of Torrano's visit, one of Day's most pressing issues was fixing her hair. It had been shoved up in a rubber band since she was admitted.

So with Day's encouragement, Torrano picks up a comb and gently begins detangling. Whatever it takes to make the patient look good and feel better.

Copyright 2016 NPR. To see more, visit NPR.
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Older Patients Can Benefit From Lung Cancer Surgery

NPR Health Blog - Mon, 11/21/2016 - 4:52am
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November 21, 20164:52 AM ET Heard on Morning Edition

When Morton Pollner was diagnosed with lung cancer at age 76, he thought it was a death sentence.

Michael Rubenstein for NPR

Every year when Morton Pollner had his checkup, he worried that doctors would find something on his lung. For years, they didn't. Then his luck ran out.

"My reaction was, 'Well, you smoked for 30 years. You got away with it for another 30 years and this is it.' I thought it was a death sentence," he says.

Pollner, who lives in Monroe, N.Y., was 76 when he was diagnosed with lung cancer. Like many patients his age, he didn't expect there would be any effective treatment. Lung cancer is the second most common cancer in men and women. And it is mainly a disease of older people. Only about 2 percent of lung cancer patients are under 45 and the average age at diagnosis is about 70.

Older patients are frequently not offered curative treatment like surgery, because they and their families and even their doctors often think they won't be able to tolerate it. So they are referred for supportive care to control symptoms, rather than surgery to remove the cancer.

It's been seven years since Pollner had surgery for lung cancer. He's now 82 and takes Tai Chi classes three times a week at the local synagogue.

Michael Rubenstein for NPR

But many patients can survive and even thrive after surgery, says Dr. Prasad Adusumilli, a thoracic surgeon at Memorial Sloan Kettering Cancer Center in New York. He was senior author of a study published in the Journal of Clinical Oncology in October. The study looked at more than 2,000 patients with Stage 1 non-small cell lung cancer who had surgery to remove their tumor. About 70 percent of the patients were 65 years old or older and about 30 percent were at least 75.

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And he found that a surprising number of these older patients did quite well. One year after surgery, more people had died from other causes than died from lung cancer. And, after five years, almost 9 out of 10 patients were alive and cancer free.

"They did well and beat their lung cancer," Adusumilli says, proving that when it comes to surgery for early stage lung cancer, age should not be a limiting factor.

This was the case for Morton Pollner, who is one of Adusumilli's patients. His cancer had not spread, and Adusumilli told him there was a good possibility the cancerous tissue could be completely removed and he could go back to leading a normal life. That was seven years ago. Today, Pollner is 82, cancer free and enjoying life.

Morton and his wife Joan Pollner are both enjoying life.

Michael Rubenstein for NPR

"Whatever I get from here on, it's like gravy," he says.

Surgery isn't the answer for all older lung cancer patients, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. Patients with heart or other health problems may not be candidates. At the same time, he says it's important to recognize that patterns of aging have changed over the past two decades.

Seventy today is not the same as it was 20 years ago, Lichtenfeld says. Older adults are more functional, both physically and mentally, than ever before, and he says the medical community needs to adjust its thinking about what treatments older cancer patients can tolerate.

"We shouldn't allow numerical age to be the deciding factor," Lichtenfeld says.

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Florida Keys Approves Trial Of Genetically Modified Mosquitoes To Fight Zika

NPR Health Blog - Sun, 11/20/2016 - 9:11am
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November 20, 20169:11 AM ET Heard on Weekend Edition Sunday

Protest signs at the Florida Keys Mosquito Control District board's meeting Saturday in Marathon, Fla.

Greg Allen/Greg Allen

In the Florida Keys on Election Day, along with the presidential race, one of the most controversial items on the ballot dealt with Zika. In a nonbinding vote countywide, residents in the Florida Keys approved a measure allowing a British company to begin a trial release of genetically modified mosquitoes. Armed with that approval, local officials voted Saturday to try out what they hope will be a new tool in the fight against Zika.

For months now, state and local authorities in Florida have struggled to control the spread of Zika. But although there have been more than 200 cases of locally transmitted Zika statewide, none have been reported in the Keys. And that's one reason why residents like Megan Hall oppose the new technology. At a meeting of the Florida Keys Mosquito Control District board in Marathon on Saturday, Hall made a personal appeal to the board. "I am going to ask you, beg you, plead with you," she said, "not to go forward with this."

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An Aedes aegypti mosquito feeds on the arm of Emilio Posada, the Upper Keys supervisor for the Florida Keys Mosquito Control District, in Key Largo, Fla.

Wilfredo Lee/AP

For five years now, the district has been working with the British company Oxitec to get federal approval for a trial release of the mosquitoes in the Keys. The company releases genetically modified male Aedes aegypti mosquitoes into the wild. When they mate with female Aedes aegypti, their offspring die.

In trials in Brazil, the Cayman Islands and other countries, Oxitec has shown its GM mosquitoes can reduce the population of Aedes Aegypti by 90 percent or more. But after five years, a small but vocal group of residents is not convinced the mosquitoes are safe. Opponent Dina Schoneck told the board, there are still too many unanswered questions about the new technology. She said, "I believe there are a lot of risks that are not being considered."

Although it doesn't have any cases of local Zika transmission yet, Monroe County, which includes the Keys, has had big problems in the past with dengue, another disease carried by the same mosquito. The head of the county's health department, Bob Eadie, supports the trials. Just because the county hasn't had any local Zika cases yet doesn't mean the disease isn't a threat, he said. Eadie went on, "There is a tool available for the people of Monroe County that can help control mosquitoes that carry a very, very, very serious disease."

In August, the Food and Drug Administration gave its approval for the trial, saying it found no potential adverse impact on human health or the environment. Because of the vocal opposition, the Mosquito Control District's Board of Commissioners decided to submit the trial to the voters in the form of two nonbinding resolutions. One was for the residents of Key Haven, the community where the trials were proposed. The other referendum went before voters in the rest of the county.

Because Key Haven voters rejected it, commissioners say trials won't be conducted there. But in Saturday's meeting, the board approved trials elsewhere in the Keys at a location still to be determined. Jill Cranney-Gage is a commissioner who represents Key West. "This is a tool mosquito control needs. When you're sworn into office," Cranney-Gage said,"your main goal is to kill mosquitoes and to protect the residents and the county."

Containers hold genetically modified Aedes aegypti mosquitoes before being released in Panama City, Panama.

Arnulfo Franco/AP

Officials in the Keys say the announcement by the World Health Organization that Zika is no longer a "public health emergency" is in no way an indication the threat is lessening but that instead, it's a disease that's here to stay

Florida Keys Mosquito Control District staff and Oxitec are now working now to identify a new neighborhood to conduct trials. Derric Nimmo with Oxitec is hopeful that identifying a new location and receiving federal approval will be a matter of a few months, and releases could start next year. Nimmo says he's encouraged that the GM mosquito technology gained the approval of a large majority — 58 percent of county residents. "So there is very strong support for use of this technology in Monroe County," he says. "And hopefully, they'll move forward with this trial."

After months of struggling with Zika, health officials and mosquito control authorities elsewhere in Florida are eager to begin their own trials of the GM mosquitoes. Oxitec says if things go well in the Keys, it could begin trials next year in Miami.

Copyright 2016 NPR. To see more, visit NPR.
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Heavy Screen Time Rewires Young Brains, For Better And Worse

NPR Health Blog - Sat, 11/19/2016 - 8:07am
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November 19, 20168:07 AM ET Heard on Weekend Edition Saturday Ippei Naoi/Getty Images

There's new evidence that excessive screen time early in life can change the circuits in a growing brain.

Scientists disagree, though, about whether those changes are helpful, or just cause problems. Both views emerged during the Society for Neuroscience meeting in San Diego this week.

The debate centered on a study of young mice exposed to six hours daily of a sound and light show reminiscent of a video game. The mice showed "dramatic changes everywhere in the brain," said Jan-Marino Ramirez, director of the Center for Integrative Brain Research at Seattle Children's Hospital.

"Many of those changes suggest that you have a brain that is wired up at a much more baseline excited level," Ramirez reported. "You need much more sensory stimulation to get [the brain's] attention."

So is that a problem?

On the plus side, it meant that these mice were able to stay calm in an environment that would have stressed out a typical mouse, Ramirez explained. But it also meant they acted like they had an attention deficit disorder, showed signs of learning problems, and were prone to risky behavior.

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Overall, the results add to the evidence that parents should be very cautious about screen time for young children, Ramirez said. "I would minimize it."

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A more optimistic interpretation came from Leah Krubitzer, an evolutionary neurobiologist at the University of California, Davis. "The benefits may outweigh the negative sides to this," Krubitzer said, adding that a less sensitive brain might thrive in a world where overstimulation is a common problem.

The debate came just weeks after the American Academy of Pediatrics relaxed its longstanding rule against any screen time for kids under two. And it reflected an evolution in our understanding of how sensory stimulation affects developing brains.

Researchers learned many decades ago that young brains need a lot of stimulation to develop normally. So, for a long time parents were encouraged to give kids as many sensory experiences as possible.

"The idea was, basically, the more you are exposed to sensory stimulation, the better you are cognitively," Ramirez said.

Then studies began to suggest that children who spent too much time watching TV or playing video games were more likely to develop ADHD. So scientists began studying rats and mice to see whether intense audio-visual stimulation early in life really can change brain circuits.

Studies like the one Ramirez presented confirm that it can. The next question is what that means for children and screen time.

"The big question is, was our brain set up to be exposed to such a fast pace," Ramirez said. "If you think about nature, you would run on the savanna and you would maybe once in your lifetime meet a lion."

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In a video game, he said, you can meet the equivalent of a lion every few seconds. And human brains probably haven't evolved to handle that sort of stimulation, he said.

Krubitzer, and many other scientists, said they aren't so sure. It's true this sort of stimulation may desensitize a child's brain in some ways, they said. But it also may prepare the brain for an increasingly fast-paced world.

"Less than 300 years ago we had an industrial revolution and today we're using mobile phones and we interact on a regular basis with machines," Krubitzer said. "So the brain must have changed."

Krubitzer rejected the idea that the best solution is to somehow turn back the clock.

"There's a tendency to think of the good old days, when you were a kid, and [say], 'I didn't do that and I didn't have TV and look how great I turned out,' " Krubitzer said.

Gina Turrigiano, a brain researcher at Brandeis University, thinks lots of screen time may be fine for some young brains, but a problem for others.

"Parents have to be really aware of the fact that each kid is going to respond very, very differently to the same kinds of environments," she said.

Copyright 2016 NPR. To see more, visit NPR.
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In Depressed Rural Kentucky, Worries Mount Over Medicaid Cutbacks

NPR Health Blog - Sat, 11/19/2016 - 6:00am

Freida Lockaby says she has benefited from access to health care coverage through Medicaid.

Phil Galewitz/Kaiser Health News

For Freida Lockaby, an unemployed 56-year-old woman who lives with her dog in an aging mobile home in Manchester, Ky., one of America's poorest places, the Affordable Care Act was life altering.

The law allowed Kentucky to expand Medicaid in 2014 and made Lockaby – along with 440,000 other low-income state residents – newly eligible for free health care under the state-federal insurance program. Enrollment gave Lockaby her first insurance in 11 years.

"It's been a godsend to me," said the former Ohio school custodian who moved to Kentucky a decade ago.

Lockaby finally got treated for a thyroid disorder that had left her so exhausted she'd almost taken root in her living room chair. Cataract surgery let her see clearly again. A carpal tunnel operation on her left hand eased her pain and helped her sleep better. Daily medications brought her high blood pressure and elevated cholesterol level under control.

But Lockaby is worried her good fortune could soon end. Her future access to health care now hinges on a controversial proposal to revamp the program that her state's Republican governor has submitted to the Obama administration.

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Next year will likely bring more uncertainty when a Trump administration and a GOP-controlled Congress promise to consider Obamacare's repeal, including a potential reduction in the associated Medicaid expansion in 31 states and the District of Columbia that has led to health coverage for an estimated 10 million people.

Shots - Health News What Happens If Kentucky Dismantles Its Health Insurance Exchange?

Kentucky Gov. Matt Bevin, who was elected in 2015, has argued his state can't afford Medicaid in its current form. Obamacare permitted states to use federal funds to broaden Medicaid eligibility to all adults with incomes at or below 138 percent of the federal poverty level, now $11,880 for individuals. Kentucky's enrollment has doubled since late 2013 and today almost a third of its residents are in the program. The Medicaid expansion under Obamacare in Kentucky has led to one of the sharpest drops in any state's uninsured rate, to 7.5 percent in 2015 from 20 percent two years earlier.

Kentucky's achievement owed much to the success of its state-run exchange, Kynect, in promoting new coverage options under the health law. Kynect was launched under Bevin's Democratic predecessor, Steve Beshear, and dismantled by Bevin this year.

Bevin has threatened to roll back the expansion if the Obama administration doesn't allow him to make major changes, such as requiring Kentucky's beneficiaries to pay monthly premiums of $1 to $37.50 and require nondisabled recipients to work or do community service for free dental and vision care.

Budget pressures are set to rise next year in the 31 states and the District of Columbia where Medicaid was expanded as the federal government reduces its share of those costs. States will pick up 5 percent next year and that will rise gradually to 10 percent by 2020. Under the health law, the federal government paid the full cost of the Medicaid expansion population for 2014-2016.

In a state as cash-strapped as Kentucky, the increased expenses ahead for Medicaid will be significant in Bevin's view — $1.2 billion from 2017 to 2021, according to the waiver request he's made to the Obama administration to change how Medicaid works in his state.

Trump's unexpected victory may help Bevin's chances of winning approval. Before the election, many analysts expected federal officials to reject the governor's plan by the end of the year on the grounds that it would roll back gains in expected coverage.

A Trump administration could decide the matter differently, said Emily Beauregard, executive director of Kentucky Voice for Health, an advocacy group that opposes most waiver changes because they could reduce access to care.

"I think it's much more likely that a waiver could be approved under the Trump administration," she said. "On the other hand, I wonder if the waiver will be a moot point under a Trump administration, assuming that major pieces of the [Affordable Care Act] are repealed."

Lockaby is watching with alarm: "I am worried to death about it."

Life already is hard in her part of Kentucky's coal country, where once-dependable mining jobs are mostly gone.

In Clay County where Lockaby lives, 38 percent of the population live in poverty. A fifth of the residents are disabled. Life expectancy is eight years below the nation's average.

Clay's location places it inside an area familiar to public health specialists as the South's diabetes and stroke belt. It's also in the so-called "Coronary Valley" encompassing the 10-state Ohio/Mississippi valley region.

About 60 percent of Clay County's 21,000 residents are covered by Medicaid, up from about a third before the expansion. The counties uninsured rate for nonelderly adults has fallen from 29 percent to 10 percent.

Still, the increase in insurance coverage hasn't made Clay's people healthier yet. Local health officials here say achieving that will take a decade or more. Instead, they cite progress in smaller steps: more cancer screenings, more visits to mental health professionals and more prescriptions getting filled. Harder lifestyle changes that are still ahead — such as eating better, quitting smoking and regular exercise — will take more than a couple years to happen, said Aaron Yelowitz, associate professor of economics at the University of Kentucky.

At the Grace Community Health Center in Manchester, Ky., psychologist Joan Nantz meets with patient Ramiro Salazar, who gained Medicaid under the expansion.

Phil Galewitz/Kaiser Health News

One hopeful spot is the Grace Community Health Center in downtown Manchester, where patient visits are up more than 20 percent since 2014. Those without insurance pay on a sliding scale, which can mean a visit costs $50 or more.

That was too much for Ramiro Salazar, 47, who lives with his wife and two children on a $733 monthly income. With Medicaid, he sees a doctor for his foot and ankle pain, meets regularly with a psychologist for anxiety and gets medications — all free to him. Medicaid even covers his transportation costs to doctors, vital because a specialist can be 40 miles away.

Salazar is worried about Bevin's plans, especially the additional costs. "I probably couldn't afford it as I'm unemployed," he said. "It would hurt me pretty bad."

Any development that could take away health coverage from people with mental health issues worries Joan Nantz, a psychologist who works part time at Grace and whose appointment calendar is booked three weeks out because of patient demand. More than 90 percent of her clients are on Medicaid.

"If something happens to this program, I can't begin to think what impact it would have on society," she said. Without counseling, people with mental health issues will resort to illegal drugs and be more likely to commit crimes and domestic violence, Nantz said.

Just five primary care doctors in Manchester treat adults in Clay and surrounding counties. Manchester Memorial Hospital has tried to recruit more without success.

"We had a painful primary care shortage here five years ago and now it's worse," said Dr. Jeffrey Newswanger, an emergency room physician and chief medical officer at the hospital. "Just because they have a Medicaid card doesn't mean they have doctors."

The emergency room is busier than ever seeing patients for primary care needs, he said.

Newswanger sees both sides to the debate over Medicaid. The hospital gained because more patients are now covered by insurance, and the ER's uninsured rate dropped to 2 percent from 10 percent in 2013.

"Eliminating the expansion altogether would be painful for the hospital and a disaster for the community," he said.

But, Newswanger also appreciates some of Bevin's proposals.

"No one values something that they get for free," he said, and incentives are needed to make people seek care in doctors' offices instead of expensive ERs.

Christie Green, public health director of the Cumberland Valley District Health Department that covers Clay County, said making the poor pay more or scrapping Medicaid's expansion would be a setback to improving people's health.

Last year, Green helped Manchester build a three-mile trail along a park and install a swinging bridge across a small creek. Both additions were intended to promote physical fitness in a place where more than a third smoke — both far above national averages.

Progress is slow. The path is used regularly. But drug addicts congregate daily by the bridge and it rarely gets traffic.

"There is a lot to overcome here," Green said.

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. You can follow Phil Galewitz on Twitter: @philgalewitz.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Deaths Involving Fentanyl Rise As Curbing Illicit Supply Proves Tough

NPR Health Blog - Fri, 11/18/2016 - 3:27pm
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November 18, 20163:27 PM ET Heard on All Things Considered

From

Anthony Salemi, of Everett, Mass., holds a photo of his brother Joe, who died from an overdose of fentanyl-laced heroin earlier this year.

Jesse Costa/WBUR

In mid-August, an affable, 40-year-old man from Everett, Mass., overdosed at his mom's home after almost 25 years of heroin use. Joe Salemi had overdosed before, but this time couldn't be revived. Salemi's brother, Anthony, says he was pretty sure when his brother died that there must have been something besides heroin in the syringe. The medical examiner later confirmed it.

"I knew, deep in my mind, it was going to be the stuff that everyone's talking about now — fentanyl," Anthony says. "Because I never thought straight heroin would kill him."

Anthony Salemi was familiar with fentanyl. He'd been prescribed the powerful painkiller after surgery in 2006. Anthony had warned his younger brother about reports that dealers were adding an illicit version of the drug to heroin, sometimes promising a more intense high. Fentanyl is more than 50 times more potent than heroin, according the Centers for Disease Control and Prevention.

But people like Joe rarely know for sure if there is fentanyl in the tiny plastic bags of illegal powder they buy — or how much. Just a few grains of pure fentanyl, doctors say, is enough to kill most users. In Massachusetts, 75 percent of the people who overdosed this year tested positive for the drug.

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"It just seems like the dealers and the drugs are ravaging the whole country, says Anthony Salemi. "The supply just keeps coming in, no matter how many cops you put at the border, it just keeps coming in. This is scary."

The Obama administration agrees that the increasing supply of fentanyl on the street is a major challenge and says agencies are doing a lot. But reducing the supply is complicated.

Fentanyl is a synthetic opioid, constructed with lab chemicals — unlike heroin or morphine, which start with the opium sap of a poppy plant. Drug enforcement agents say clandestine labs across China are the main source of the illegally sold fentanyl.

Producers then ship the drug to Mexico, where drug cartels mix it into heroin or press it into blue, pink or white tablets that look like prescription pills for anxiety or pain. The powder or pills are delivered to dealers, or directly to users, via the Internet or darknet, an online area used for illegal purchases.

"Synthetic drugs are a real winner because they are easy to make, and they're cheap to produce," says Kara McDonald, director of policy, planning and coordination at the international narcotics and law enforcement bureau of the U.S. Department of State.

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"They're not dependent on a season or the weather like a plant-based drug," McDonald says. "And with the distribution system — through mail order — they can be delivered directly to the door in some cases. Like a pizza."

The profit margin is huge, says Drug Enforcement Administration spokesperson Russ Baer. He says it costs from $3,000 to $4,000 to produce a kilo — 2.2 pounds — of fentanyl. The fentanyl is then cut with cheap fillers to make pills, or mixed into bags and fraudulently sold as pure heroin.

"Drug traffickers involved in the wholesale distribution of those products can yield close to $1.5 million off that one kilogram," says Baer.

The DEA has six agents who operate out of Beijing and work closely with China's Ministry of Public Security, Baer says. Chinese officials established controls on 116 new chemicals last year, including 19 that have much the same molecular structure as fentanyl. Baer says that helped reduce the supply of some of these designer analogs of the drug. (Though each analog drug has a slightly different chemical structure from fentanyl, they work much the same way in the body.)

And in September, the DEA moved to declare another fentanyl analog called U-47700 illegal. But the producers always seem to be one step ahead of enforcement agencies, Baer says.

"Once we control a substance, whether here in the U.S. or in China, for example," he says, "the drug manufacturers simply change a molecule, tweak a molecule, in an attempt to circumvent the law."

Keeping up with the inventive chemists sounds nearly impossible.

"We're identifying one to two new synthetic substances every week," Baer says.

If a drug compound is similar to fentanyl, or if it produces the same physiological effect, the DEA can file trafficking charges here in the U.S. But these variations are not illegal in many countries. McDonald says the State Department is working, through the United Nations and with individual nations, to make sure police everywhere can identify new drugs and prosecute dealers.

The international control system is only able to detect, process and outlaw about 10 new psychoactive substances a year, McDonald says. "It doesn't take a mathematician to identify that we have a real challenge here."

To get in front of production, the State Department and a group of U.S. senators asked the United Nations in October to add to the list of tightly controlled substances two key ingredients used to make fentanyl. A decision is expected next year.

Shots - Health News Surgeon General Murthy Wants America To Face Up To Addiction

McDonald and Baer at the DEA say slowing demand for illicit uses of fentanyl and other opioids has become an urgent priority. The office of the U.S. Surgeon General this week also issued a report on the growing problem of substance abuse and the need for more widespread implementation of well-recognized, evidence-based treatment programs to address the problem.

In an interview with NPR's Steve Inskeep on Morning Edition Thursday, Surgeon General Vivek Murthy called addiction "a chronic disease of the brain."

"We need to treat it with the same urgency and compassion that we do any other illness," Murthy told Inskeep.

But some lawmakers, physicians and families who've lost loved ones say the Obama administration has done too little too late to tackle the epidemic.

U.S. Sen. Ed Markey, a Democrat from Massachusetts, says it's time to make the illegal production and trafficking of fentanyl the top policy issue in relations with China and Mexico.

"Many more people are going to die from this than [from] any threat from nuclear weapons or any devastation that's caused by an imbalance in trade," Markey says.

Baer says trying to stop the supply of opioids is part of the solution, but so is tackling demand by addressing addiction as a disease.

"The community needs to embrace these folks, create treatment opportunity," Baer says. "We need to educate the public. It's the No. 1 priority and it represents a public health crisis that all of us must work together to try to resolve."

The CDC offers a sobering perspective. While about 78 Americans will die today after an overdose, another 580 will try heroin — or what they think is heroin — for the first time.

This story is part of NPR's reporting partnership with WBUR and Kaiser Health News.

Copyright 2016 WBUR. To see more, visit WBUR.
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Will Legal Marijuana Lead To More People Smoking Tobacco?

NPR Health Blog - Fri, 11/18/2016 - 11:36am

Is marijuana a gateway drug to smoking cigarettes?

PhotoAlto/Katarina Sundelin/Getty Images

California's decision to legalize marijuana was touted as a victory for those who had argued that the state needed a system to decriminalize, regulate and tax it.

But the new law, approved by voters on Nov. 8, also could be a boon to the tobacco industry at a time when cigarette smoking is down and cigarette companies are looking for ways to expand their market, according to researchers in Los Angeles County and around the state.

They warn that unless the state proceeds carefully, the legalization of marijuana for recreational use could roll back some of the gains California has made in reducing the use of tobacco.

"There is a concern that there could be a potential renormalization of smoking," says Michael Ong, an associate professor at UCLA's David Geffen School of Medicine.

Ong says it will depend on how the initiative is implemented, whether officials follow through on the regulation, and how involved public health officials are with it. "It will be important to make sure that we don't have a setback in terms of what we have done for clean air in California ... and what we have done to reduce tobacco's harms," he says.

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Ethan Nadelmann, executive director of the Drug Policy Alliance, which supports marijuana legalization, defended the measure, saying there is no evidence that legalization leads to increased cannabis consumption — or tobacco smoking.

California's adult smoking rate is the second-lowest in the country, at 11.6 percent, according to the California Department of Public Health. The smoking rate dropped by more than 50 percent between 1988 and 2014, cutting health care costs and reducing tobacco-related diseases, according to the department.

The headway against smoking over the past few decades is due to a combination of factors, including tobacco taxes, laws restricting where people can smoke, and broad-based media campaigns and programs to help people quit. Despite the decline in smoking, the use of e-cigarettes has increased dramatically over the past few years, with nearly 10 percent of adults ages 18 through 24 now using them, according to the department.

Another ballot initiative passed by voters last week could push the smoking rate even lower. Prop. 56 will add $2 per pack to the tax on cigarettes and increases taxes on electronic cigarettes that contain nicotine and other tobacco products. The money will help pay for health care and increase funding for tobacco control and prevention.

The marijuana initiative, Prop. 64, allows adults ages 21 and over to grow, buy and possess small amounts of marijuana for personal use. It also regulates recreational marijuana businesses and imposes taxes that will help pay for drug education and prevention programs.

Bonnie Halpern-Felsher, a pediatrics professor at the Stanford University School of Medicine, says she is concerned that there may not be enough education and prevention written into the proposition, especially targeted at youth.

Marijuana is already the most widely used illegal drug among adolescents. Many young people consider marijuana and blunts, which are marijuana rolled with a tobacco leaf wrapper, to be more socially acceptable and less risky than cigarettes, according to a recent study co-authored by Halpern-Felsher. The study also found that youths who saw messages about the benefits of marijuana were more likely to use it.

Blunts are particularly worrisome because they contain nicotine as well as marijuana, Halpern-Felsher says. Many young people may not understand the risk of blunts or marijuana, she notes, and once they start thinking that smoking one product is acceptable, they may believe it's OK to smoke other things as well. "That's my concern," she says. "I do think people are going to generalize."

From the tobacco industry's point of view, marijuana could serve as a "smoke inhalation trainer," and thus become a gateway to tobacco use, says Robert K. Jackler, a professor at the Stanford School of Medicine who researches tobacco advertising. He says tobacco and marijuana are marketed in similar ways — as products to help people relax and ease their stress. "There is tremendous overlap potential," he says.

Tobacco companies could easily try to exploit that similarity to enter the marijuana market, Jackler says. They already have enormous influence on state laws and regulations, and could try to set up small dispensaries and make marijuana another one of their products.

"The tobacco industry is always looking for replacement products because, at least in America, smoking is down," he says. "This will give them a new entry into the market. They are best equipped to exploit this market opportunity."

In fact, the tobacco industry considered getting into the marijuana market in the 1960s and 70s and could easily do so, says Stanton Glantz, a professor at University of California, San Francisco School of Medicine. Glantz believes that even as the newly approved tobacco tax reduces California's smoking rate further, legalized marijuana will help sustain the tobacco market. He says he expected to see mass marketing and branding of marijuana over time.

Along with some therapeutic benefits of marijuana, there are also health risks, Glantz says. "The likely costs that are going to be incurred by all the marijuana-induced diseases don't come close to being covered by the taxes that are written into Prop. 64," he warns.

The initiative should have included higher taxes, graphic warning labels, provisions to keep demand low and a broad-based education campaign like there is on tobacco, Glantz argues. "The ideal situation is where it's legal so nobody is thrown in jail, but nobody wants to buy it."

Election Buzz: Recreational Marijuana On The Ballot Legalizing Marijuana: It Changes Policing, But May Leave Racial Disparities

Legalization supporters said they don't believe the tobacco industry will get involved in the marijuana market until and unless federal prohibition ends. Marijuana is still illegal under federal law.

Nadelmann, of the pro-marijuana Drug Policy Alliance, says it is misguided to conflate the two products. Young people can distinguish between the effects of cigarettes and marijuana, he says.

"Teenagers are actually smarter than most of the adult propaganda," Nadelmann says. "They know smoking cigarettes is really stupid and that smoking marijuana is not such a major issue."

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Texas Parents Have Unanswered Questions About School Vaccination Rates

NPR Health Blog - Fri, 11/18/2016 - 9:59am

When Georgia Moore (second from left) was diagnosed with leukemia in 2010, her parents, Trevor and Courtney Moore, worried about the germs her younger sister, Ivy, would bring home from school.

Courtesy of the Moore family/Kaiser Health News

Georgia Moore was diagnosed with leukemia the day after her 10th birthday. The fourth-grader began an intense chemotherapy regimen, which left her immune system vulnerable and kept her from attending her small, private Montessori school in Austin, Texas.

But her younger sister Ivy was in kindergarten at the same school, where a handful of families opted out of vaccinating their children. That meant 6-year-old Ivy might bring home germs that could pose a risk to Georgia.

"She would go to school, come home and immediately we'd put clothes in the washer to keep a healthy environment," the girls' mother, Courtney Moore, said of the family's after-school routine.

Georgia, now 16, had very few hospitalizations during the course of her treatment and is now cancer-free, five years out from treatment. But Georgia's battle against cancer made Courtney Moore a vocal advocate for immunizations in Texas — where an increasing number of parents are opting against vaccinating their children.

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After Georgia Moore (left) was diagnosed with leukemia, she underwent chemotherapy that depressed her immune system. She had to stay home from her small, private school in 2010, when the photo was taken.

Courtesy of the Moore family/Kaiser Health News

Texas is one of 18 states that allow nonmedical exemptions to the vaccines required for school attendance. California had a similar law allowing nonmedical exemptions, until last year when it enacted a law that has one of the strictest requirements in the country after a 2014 outbreak of measles traced to the Disneyland theme park infected more than 100 people around the country.

Many of the parents opting out of the immunizations, which are widely recommended by doctors, say they fear a link between the vaccines and health problems such as autism. But studies that they cite have been widely debunked by public health officials.

"Year after year we've seen a steady increase in the number of students with a conscientious exemption from vaccination in Texas," said Christine Mann, a spokeswoman for the Texas Department of State Health Services. "But overall, the numbers are small."

Even though statewide levels of vaccinations remain high, at over 98 percent, what concerns public health officials are the growing geographic clusters of geographic areas with high rates of unvaccinated children. Texas went from just 2,314 "conscientious exemptions" in 2003 to 44,716 this year, according to the Texas Department of State Health Services.

Shots - Health News A Boy Who Had Cancer Faces Measles Risk From The Unvaccinated

Data about the number of unvaccinated kids in individual public schools aren't available. Currently, exemption rates are available for individual private and charter schools, but only districtwide for public schools.

Some parents are pressing state officials to let them know how many of their children's peers are unvaccinated.

Jinny Suh, who has a 4-year-old son, is helping spearhead a petition drive asking legislators to change state law so that the number of school exemptions is public. As a parent, there are lots of things that people get very passionate about," Suh said. "But for some reason, in my experience, vaccinations remain an almost taboo topic besides a few passionate people."

At least two bills were introduced during the past legislative session that would require Texas schools to notify parents about vaccination rates at the school level, but none were approved.

As is the case across the country, areas where kids aren't receiving vaccinations in Texas tend to be places with more highly educated and higher-income residents. The school with the highest percentage exemption rate in the state is the Austin Waldorf School, where more than 40 percent of students are unvaccinated and tuition exceeds $13,000 a year. Regents Academy, a private school in east Texas, was the second-highest exemption rate, at almost 38 percent of the school.

"If one of those kids is incubating an infectious disease and the other kids aren't vaccinated, then it's going to spread like wildfire," said Catherine Troisi, an infectious disease epidemiologist at the University of Texas Health Science Center at Houston.

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Troisi explains that for a disease like measles, you want "herd immunity" to be at 95 percent to prevent an outbreak. If healthy children aren't receiving vaccines, they are putting children who are too young to receive the vaccine and people with compromised immune systems at a much greater risk of infection.

Dr. Peter Hotez, a professor in the department of pediatrics and molecular virology and microbiology at the Baylor College of Medicine in Houston, called the growing numbers "extremely troubling" in a commentary last month in the PLOS Medicine, an online journal. He noted that some counties were getting close to that 95 percent marker, such as Gaines County in the western part of the state where the exemptions are now at 4.83 percent and Briscoe County in the Texas Panhandle with 3.55 percent. And Hotez, who has an adult daughter with autism, highlighted the situation in Austin, where the public school rate for exemptions is 2 percent but many of the private schools exceed 20 percent.

The American Academy of Pediatrics in September issued a policy statement encouraging pediatricians to be more vocal about the importance of vaccines for children healthy enough to receive them.

But some parents are leery of the public health efforts on vaccinations. "We believe parents should make medical decisions for their children, not the state," said Jackie Schlegel, director of Texans for Vaccine Choice, a political action committee that was formed partially in opposition to 2015 legislation to do away with the state's nonmedical vaccine exemptions.

"We campaigned, we block-walked and we'll do it again for anyone else who would like to trample on our parental rights," said Schlegel. When asked if she supported a parent's right to know the number of unvaccinated children at a given public school, Schlegel said "informed consent and privacy are very big concerns and need to be evaluated on both sides of the coin."

As a mother who has seen the issue up close, Moore says she hopes parents understand how their decision not to vaccinate their children could have far-reaching consequences.

"It's a very personal decision ..." Moore said. "But you have to recognize that if you choose not to [vaccinate], there's a good possibility that that personal decision will impact a lot of people."

An earlier version of this story ran on Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, and The Texas Tribune.

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Chemists Re-Create Deadly Frog Poison In The Lab

NPR Health Blog - Thu, 11/17/2016 - 2:02pm
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November 17, 20162:02 PM ET Heard on All Things Considered

The skin of the golden poison dart frog, Phyllobates terribilis, secretes a deadly poison that might lead to a better understanding of how to treat malfunctions of the human nervous system.

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The golden poison dart frog is about an inch long and banana yellow. By some estimates, the skin of one little frog contains enough toxin to kill 10 adult men.

"Oh yeah, it's one of the more lethal poisons on the planet," says Justin Du Bois, a synthetic chemist at Stanford University.

The substance is called batrachotoxin (buh-TRAK-uh-TOX-in), and tiny amounts of it can be deadly if it makes it into a victim's bloodstream. It's what some indigenous groups in Colombia's lowland rain forest would use to tip their blow darts.

And, as Du Bois and his colleagues write Thursday in the journal Science, they figured out how to make it in the lab in 24 steps. Why on Earth would anyone want to do that?

"Well, it turns out it's a fantastic research tool for figuring out how nerves conduct electricity," Du Bois says, "and we're very interested in that fundamental process."

Once inside a victim, the compound embeds itself in certain proteins that are responsible for conducting electrical impulses through the nerves and muscles, including the heart. By disrupting that process, it can cause paralysis and a heart attack. But studying the poison's mode of action could also lead to a deeper understanding of the role electrical impulses play in fundamental processes like heart function and the sensation of pain.

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"There are very few molecules like this that we're aware of," Du Bois says, "and we would like to really understand how it works."

And maybe — just maybe — some version could be developed into a useful drug. Du Bois points out a few rare diseases that involve malfunction in the same proteins that this toxin acts on; one such disorder prevents a person from feeling any pain at all.

"You could literally run a knife through their hand and they wouldn't feel a thing," Du Bois says. Some of the same proteins are involved in a condition that's sometimes called "Man on Fire syndrome," because people who have it experience frequent pain and burning.

"Molecules like batrachotoxin are essentially a key into mechanisms of how our nervous system works," says Toto Olivera, a biochemist and neuroscientist with the Howard Hughes Medical Institute who is based at the University of Utah. The more specific the compound is, and the more potent, he says, then "sometimes, the greater the insight that you can gain."

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There's a long list of nasty toxins that, with a few tweaks in the lab, have proved useful for human health, Olivera points out. Take curare, for example. The poison from tropical plants is now used as a muscle relaxant during some kinds of surgeries.

Olivera's lab found that the venom that certain sea snails — Conus magus — use to paralyze fish also acts on an important mechanism in the human body's communication of pain. That led to the development of a painkiller that is now used in patients who have become tolerant to morphine.

"Sometimes, you can add one atom to a compound and totally change how it acts," says Becca Tarvin, a doctoral student in evolutionary biology at the University of Texas, Austin. She studies the toxins of poison dart frogs and just got back from a trip to Colombia.

Tarvin says the various species of poison dart frogs contain at least 500 different toxins. She knows firsthand how some of these toxins feel once they're in your system; she and a field assistant once licked a few of the milder frogs, to see how they differed.

"One just tasted like sushi, like raw fish," she says. "The other one had kind of a bitter flavor that stayed in your mouth. But the last one I tasted, it tasted bitter at first. And then I could tell on my tongue the area that had touched the frog and the feeling kept spreading until my mouth was kind of numb."

Out of those 500 toxins, scientists know the biological activity of about 60.

"So, being able to synthesize any of these compounds is super important in figuring out how they work and how they could be developed as drugs," Tarvin says.

But another reason it's important to synthesize these compounds, the scientists say, is that they are getting harder and harder to find in nature. A lot of these frogs are endangered.

"Because of that," Tarvin says, "our chances of finding these toxins and these frogs before they're gone is low."

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Surgeon General Murthy Wants America To Face Up To Addiction

NPR Health Blog - Thu, 11/17/2016 - 5:14am
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November 17, 20165:14 AM ET Heard on Morning Edition

Addiction to opioids and heroin is a major public health problem, but so is alcohol abuse.

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In 1964, the U.S. surgeon general released a report on the health impacts of smoking, and it shaped the public and government's attitudes toward tobacco for years to come. On Thursday, another surgeon general's report was issued, this time tackling a much broader issue: addiction and the misuse and abuse of chemical substances. The focus isn't just one drug, but all of them.

Though little in the report is new, it puts impressive numbers to the problem, and some surprising context: More people use prescription opioids than use tobacco. There are more people with substance abuse disorders than people with cancer. One in five Americans binge drink. And substance abuse disorders cost the U.S. more than $420 billion a year.

Dr. Vivek Murthy, who is closing in on his second year as surgeon general, told NPR's Steve Inskeep Thursday on Morning Edition that he hopes putting all the data together will help Americans understand that these problems share a common solution. And it starts with kids. Their conversation has been edited for length and clarity.

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On the prevalence of substance abuse in the United States

U.S. Surgeon General Vivek Murthy says there is evidence for what works to prevent substance abuse, but it's often not applied.

Charles Dharapak/AP

An estimated 20.8 million people in our country are living with a substance use disorder. This is similar to the number of people who have diabetes, and 1.5 times the number of people who have all cancers combined. This number does not include the millions of people who are misusing substances but may not yet have a full-fledged disorder. We don't invest nearly the same amount of attention or resources in addressing substance use disorders that we do in addressing diabetes or cancer, despite the fact that a similar number of people are impacted. That has to change.

We now know from solid data that substance abuse disorders don't discriminate. They affect the rich and the poor, all socioeconomic groups and ethnic groups. They affect people in urban areas and rural ones. Far more people than we realize are affected. It's important for us to bring people out from the shadows, and get them the help that they need.

On the economic impact of substance use disorders

The impact this is having on the health and well being of our country, as well as our economy, is quite staggering. These substance use disorders cost over $420 billion a year in the form of health care costs, lost economic productivity, and cost to the criminal justice system. We measure numbers like this for other illnesses, too, and the cost for substance abuse disorders far exceeds the cost of diabetes.

On shifting views of substance disorders

For far too long people have thought about substance abuse disorders as a disease of choice, a character flaw or a moral failing. We underestimated how exposure to addictive substances can lead to full blown addiction.

Opioids are a good example.

Now we understand that these disorders actually change the circuitry in your brain. They affect your ability to make decisions, and change your reward system and your stress response. That tells us that addiction is a chronic disease of the brain, and we need to treat it with the same urgency and compassion that we do with any other illness.

The opioid crisis has certainly received a lot of attention, and it is certainly tearing apart families and costing us in terms of lives lost and health care dollars. But in terms of actual cost, we lose the most lives and suffer the most costs from alcohol related disorders and alcohol related addiction. In 2015, about 66 million people reported that they'd engaged in at least one episode of binge drinking in the previous month. That's a pretty astounding number. And in 2015, roughly 28 million people reported that they had driven under the influence of drugs and alcohol.

On what we can do to curb the addiction epidemic

There are prevention strategies and treatment strategies that can address multiple substance use disorders. Some of these programs are school-based, college-campus-based, and community-based, some online and some in person. Many — particularly the school-based programs — teach children how to manage stress in a healthy way, because stress is one of the reasons people turn to substances like alcohol, illicit drugs and prescription painkillers. The programs also teach them about substances of misuse, and teach them how to refuse tobacco and alcohol and other illicit substances when they're offered.

The problem that we have right now is that we're not implementing many of these evidence-based interventions.

While we're calling people's attention to some pretty stark statistics, I also want to recognize that there are reasons to be hopeful. All across our country we have examples of communities that are starting to step up and implement prevention programs and treatment programs. And peoples' lives are changing as a result of that. We've been dealing with substance disorders for centuries. What's different now is that we have solutions that work.

On continuing this work under the Trump administration

People on both sides of the aisle state clearly and in unequivocal terms that substance use disorders are a problem that we have to address now, because they are tearing apart our communities. So I am hopeful that we are all on the same page when it comes to addressing this crisis — and addressing it urgently. I'm looking forward to working with the next administration to do so.

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