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California Whooping Cough Infections Run High Among Latino Babies

NPR Health Blog - Thu, 12/18/2014 - 11:49am
California Whooping Cough Infections Run High Among Latino Babies December 18, 201411:49 AM ET


April Dembosky

Nurse Julietta Losoyo gives Derek Lucero a whooping cough vaccination at the San Diego Public Health Center on Dec. 10.

Chris Carlson/AP

California is battling the worst whooping cough epidemic in 70 years.

Nearly 10,000 cases have been reported in the state so far this year, and babies are especially prone to hospitalization or even death.

California's Whooping Cough Epidemic 5 min 34 sec   Shots - Health News Calif. Vaccination Gap And Whooping Cough

Six of 10 infants who have become ill during the current outbreak are Latino. There's no conclusive explanation, but there are a few theories that range from Latino cultural factors to a lack of health insurance.

"Hispanics have larger household sizes, and there may be cultural practices around visiting new infants that increase the number of contacts," says Dr. Gil Chavez, deputy director of California's department of public health.

Babies can't get their first dose of the vaccine until they are two months old. Some adults may be infected and not know it. The more siblings and extended family members that babies live or visit with, the more exposure they may have to whooping cough.

"Aunts, uncles, grandparents who may not have had a booster shot, they may be passing it on that way," says Michael Rodriguez, a family physician at UCLA.

However, he points out that several other ethnic groups have large family sizes or live together because financial resources are limited. These factors alone can't explain why Latino babies are disproportionately affected, he says.

"It really speaks to the lack of access to health insurance that's particularly predominant within the Latino community," says Sarah de Guia, executive director of the California Pan-Ethnic Health Network, an advocacy group.

Latinos make up 62 percent of the uninsured, she says, either because they can't afford to pay for health insurance, or because they're afraid that signing up for coverage will expose family members who aren't lawfully present in the U.S.

Many parents who entered the country illegally are afraid they will be discovered and deported if they enroll their children, who are legal immigrants or citizens, into government coverage, such as Medicaid.

"That's the primary reason why people are not getting the preventive care that they need," she says. "And then that impacts everyone."

Public health officials attribute the ongoing epidemic to several factors.

Whooping cough is cyclical in nature and tends to peak every three to five years. The last outbreak of the disease in California was in 2010.

But doctors are discovering that immunity from the current vaccine may be wearing off on a similar timeline. Medical recommendations suggest booster shots after eight years, but doctors are seeing kids who received a booster three years ago getting sick. Public health officials are considering an update to the recommendations to account for the dip in immunity seen after three years.

Plus, many kids in some areas aren't getting vaccinated at all. The highest rates of whooping cough are found in the Bay Area counties of Sonoma, Napa and Marin, which also have some of the highest rates of parents who opt out of vaccinating their children.

Doctors believe these kids are the root of the current and recent epidemics.

"We had a lot of unvaccinated children that acted as the kindling to start an outbreak," said Dr. Paul Katz, a pediatrician at Kaiser Permanente in San Rafael. "Those children were able to infect all the other children who were vaccinated but were too early for a booster –- they became the rest of the wood to start the fire."

All of these factors combine to put babies at risk, especially babies who are not old enough to be vaccinated.

And if Latino children and adults don't have health coverage, they are less likely to be visiting the doctor regularly and getting their booster shots, says Rodriguez.

California's public health department has done some outreach to encourage pregnant women to get vaccinated in the third trimester, in order to pass immunity on to the fetus. But little outreach has been done in Spanish, and most materials are distributed directly to doctors' offices. Latinos aren't likely to see that information if they don't have insurance and aren't going to the doctor.

Advocate Sarah de Guia says more work needs to be done so pregnant women –- and adults -– in Latino communities know they need to update their vaccinations.

"It's important for public officials to provide culturally and linguistically appropriate outreach to make sure people are getting the message in their language, and in a way they will understand," she says.

Copyright 2014 KQED Public Media. To see more, visit
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Is Your State Ready For The Next Infectious Outbreak? Probably Not

NPR Health Blog - Thu, 12/18/2014 - 10:30am
Is Your State Ready For The Next Infectious Outbreak? Probably Not December 18, 201410:30 AM ET $(function() { var pymParent = new pym.Parent( 'responsive-embed-state-outbreak-preparedness', '', {} ); });

Ebola may have slid off the nation's worry list, but that doesn't mean the United States is ready to handle an outbreak of Ebola or another infectious disease, an analysis says. That includes naturally occurring outbreaks like dengue fever, tuberculosis and measles, as well as the use of bioterrorism agents like anthrax.

Goats and Soda Endless Ebola Epidemic? That's The 'Risk We Face Now,' CDC Says

The report issued Thursday gives half of the states and the District of Columbia failing grades on 10 measures of preparedness, which include maintaining funding for public health services from 2012; getting half the population vaccinated for flu; reducing the number of bloodstream infections caused by central lines for people in the hospital; testing the response time for emergency laboratory tests; and testing 90 percent of suspected E. coli 0157 infections within four days.

Maryland, Massachusetts, Tennessee, Vermont and Virginia did the best, scoring eight out of 10, while Arkansas, Idaho, Kansas, Kentucky, Louisiana, New Jersey, Ohio and Wyoming scored at or near the bottom.

That's not so good, considering that infectious diseases are the leading cause of death in people under age 60 worldwide, and cost the United States more than $120 billion a year. The list of diseases is long and growing, with old foes like tuberculosis and influenza, and newer threats like West Nile virus and Middle East Respiratory Syndrome.

Shots - Health News Is Enterovirus D68 Behind The Mysterious Paralysis In Children?

It doesn't take rocket science to combat infectious disease; the public health strategies required have been used successfully for decades. But public health preparedness often loses out in state and federal budgets, unless there's been a recent Ebola outbreak or anthrax attack.

An up-to-speed public health system will be able to manage these challenges:

  • Quickly diagnosing outbreaks with laboratory testing and investigators who can trace contacts. Testing and contract tracing were used to contain the Ebola cases in Texas, and are used routinely by state and local health departments to combat outbreaks of foodborne illness.
  • Containing outbreaks with vaccines, medications and other countermeasures, including quarantine.
  • Train hospitals so they can respond quickly and safely when a novel infection presents itself, whether it's Ebola or the mysterious enterovirus D68, which sickened hundreds of children this fall.
  • Reporting systems that can help investigators quickly recognize an outbreak in the making, whether with everyday infections like flu and West Nile virus or rarer pathogens like Ebola and chikungunya.
  • Communicate swiftly and clearly among health workers, government agencies and the public.
  • Rapidly develop new vaccines or medical treatments, which multiple companies and countries are attempting now with Ebola.

The report was issued by the Trust for America's Health and the Robert Wood Johnson Foundation (which also provides funding to NPR.)

Goats and Soda Experimental Vaccine For Chikungunya Passes First Test

"Infectious disease control requires constant vigilance," the report concludes. "This requires having systems in place and conducting continuous training and practice exercises. The Ebola outbreak is a reminder that we cannot afford to let our guard down or grow complacent when it comes to infectious disease threats."

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Worries About Unusual Botulinum Toxin Prove Unfounded

NPR Health Blog - Thu, 12/18/2014 - 9:47am
Worries About Unusual Botulinum Toxin Prove Unfounded December 18, 2014 9:47 AM ET

A culture of Clostridium botulinum, stained with gentian violet.


Remember that worrisome new form of botulinum toxin we told you about in late 2013, the one that supposedly had to be kept secret out of fear it could be used as a bioweapon that would evade all of our medical defenses?

Well, as it turns out, it's not that scary after all. The antitoxin stored in the government's emergency stockpile works and would neutralize the toxin just fine.

That's the conclusion of some recent studies done by folks at the Centers for Disease Control and Prevention, which after two years of waiting finally received the strain of Clostridium botulinum bacteria from the public health department that identified it.

Shots - Health News Who's Protecting Whom From Deadly Toxin? Shots - Health News Why Scientists Held Back Details On A Unique Botulinum Toxin

Botulinum toxin is one of the most poisonous substances known, and for a long time scientists knew of seven different types. Then researchers at the California Department of Public Health announced that they'd discovered the first new form of the toxin to turn up in over 40 years.

They called it "type H" and described their find in a medical journal. But here's the unusual and worrying part: The editors of the journal allowed the researchers to withhold key genetic details that would allow others to make or study this toxin. The reason given was that "no antitoxins as yet have been developed to counteract the novel C. botulinum toxin."

As NPR reported, however, other botulism researchers soon raised serious concerns. They said the California lab wasn't sharing the genetic information, and was also keeping the novel strain under lock and key. No one could independently confirm the claims that this was a new and potentially lethal toxin — or consider how to protect the public, if the concerns were valid.

When other scientists finally got the strain, they were relieved. "We don't think it poses a new, novel threat," says Robert Tauxe of the CDC's division of foodborne, waterborne and environmental diseases. "It appears to be a hybrid, that is a naturally occurring combination of two other existing toxins."

Tauxe explains that the botulinum toxin is a protein with two different parts. "I think of it as being like the scissors on a Swiss Army knife," he says. "There is the scissors part that actually does cut a piece of protein on a nerve cell. And that is held in a larger handle. And the larger handle is really how the immune system recognizes the toxin and reacts to it."

He says the newly discovered hybrid toxin has a "scissors" part that cuts like a type F toxin, but the "handle" is very similar to a type A toxin.

"What this means is that our medical countermeasures, our antisera that we have produced in quantity and have stocked in the national stockpile and that we use to treat botulism routinely, contain antibodies that protect against this novel toxin," says Tauxe.

At the CDC, scientists did experiments with mice showing that the current antitoxin offers protection. Other studies using cultures of nerve cells came to the same conclusion.

NPR asked the California Department of Public Health how it responds to criticism over the decision not to make the genetic sequence and strain available to others earlier, given that other labs were able to quickly ascertain that the current defenses would work. In reply, a spokeswoman sent a statement from James Watt, chief of its division of communicable disease control.

He said that discovery of the new strain was unusual for the department:

"The department does not typically identify agents that are potentially novel and/or of national security significance. Since there was no immediate threat, we chose to proceed carefully and deliberately to prevent any possible threat to public health and security."

The department has transferred governance over the new strain to the feds, he said, adding, "any decision regarding both releasing the sequence and the strain will be made by them now."

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What Happens After You Get That Mammogram

NPR Health Blog - Wed, 12/17/2014 - 3:47pm
What Happens After You Get That Mammogram December 17, 2014 3:47 PM ET

This graphic lays out the possible outcomes for 10,000 women if they start getting annual screening mammograms at age 50 and continue that for 10 years.

Courtesy of JAMA

Women and their doctors have a hard time figuring out the pluses and minuses of screening mammograms for breast cancer. It doesn't help that there's been fierce dissent over the benefits of screening mammography for women under 50 and for older women.

To make it easier to grasp the big picture, Dr. Jill Jin, an associate editor of JAMA, the journal of the American Medical Association, put together this graphic on the odds of various outcomes from screening mammography. It's based on a review of studies on the risks and benefits of mammography earlier this year and was published Wednesday in JAMA.

Because mammograms aren't perfect screening tests, they can miss some cancers and falsely diagnose cancer that's not there. Those false positives can lead to more testing, including biopsies, and needless anxiety.

Mammograms can also lead to overdiagnosis, when a scan finds something that would never become life-threatening but can lead to surgery, radiation and chemotherapy. Some studies estimate that 20 percent of cancers found on mammograms are overdiagnosed and lead to unnecessary treatment, according to Jin.

The graphic looks at the odds of false positives, overdiagnoses and breast cancer diagnosis for 10,000 women over 10 years, if each started getting annual mammograms at age 50, the age recommended by the U.S. Preventive Services Task Force. About 3,568 women will have normal exams, while 6,130 will have at least one false positive result. About 302 will be diagnosed with cancer, and 10 deaths will be averted because of screening.

Bottom line: Mammograms are the best tool we have for early detection of breast cancer, but they're not perfect. It's best to know the likelihood of possible harms, as well as the benefits.

Copyright 2014 NPR. To see more, visit
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Managed Care Plans Make Progress In Erasing Racial Disparities

NPR Health Blog - Wed, 12/17/2014 - 1:30pm
Managed Care Plans Make Progress In Erasing Racial Disparities December 17, 2014 1:30 PM ET


Lisa Aliferis

A nurse checks a man's blood pressure during a health clinic In Los Angeles.

Patrick Fallon/Bloomberg via Getty Images

Years of efforts to reduce the racial disparities in health care have so far failed to eliminate them. But progress is being made in the western United States, due largely to efforts by managed care plans to identify patients who were missing out on management of chronic diseases like diabetes and heart disease.

While management of blood pressure, cholesterol and blood sugar improved nationwide, African-Americans still "substantially" trailed whites everywhere except the western U.S., an area from the Rocky Mountains to the Pacific as well as Alaska and Hawaii.

"We were certainly hoping we would see indications of progress in eliminating disparities in the country as a whole," said Dr. John Ayanian, who heads the Institute for Healthcare Policy and Innovation at the University of Michigan and was lead author of the study. While it was "disappointing" that disparities persisted, he said, "it's also heartening to see that ... in the West, the disparities had been eliminated, and that was both surprising and encouraging."

To find that out, Ayanian and his colleagues looked at 100,000 Medicare patients who were enrolled in HMOs, called "Medicare Advantage" plans, from 2006 to 2011. The study was published last week in the New England Journal of Medicine.

Shots - Health News African-Americans Remain Hardest Hit By Medical Bills

Disparities in health care have long been noted in American health care. The researchers wrote that, in 2008, "life expectancy was 5.4 years shorter for black men and 3.7 years shorter for black women than for white men and white women." Heart disease and diabetes — diseases that can be better managed by controlling blood pressure, cholesterol and blood sugar, the risk factors measured in the study — accounted for 38 percent of the gap in mortality between black and white men, and 54 percent of the gap among women, the researchers said. That's why closing the racial gap on these measures is so critical.

"It's one of the first large studies to show that it's possible to eliminate deeply ingrained racial disparities in important risk factors," Ayanian said. He said that outcomes for Hispanics, and Asians and Pacific Islanders were "also encouraging."

Nationwide, black enrollees in the study were substantially less likely than white enrollees to have adequate control of blood pressure, cholesterol and blood sugar, trailing whites by about 10 percent.

Hispanics were 1 to 3 percent less likely than whites to have blood pressure, cholesterol or blood sugar under control. Asians and Pacific Islanders were more likely than whites to have good control of blood pressure and cholesterol. Blood sugar control was about the same.

Specifically, the researchers pointed to Kaiser Permanente health plans as being successful in eliminating disparities. Kaiser includes "nearly half" of Medicare HMO enrollees in the western region of the U.S., Ayanian said.

"Our findings in the West of nearly identical control of three major risk factors among black Medicare enrollees and white Medicare enrollees in Kaiser health plans and control of (blood sugar) in other health plans show the potential to achieve equity in these key health outcomes," the researchers wrote.

Kaiser representatives said they did not have any advance knowledge of the publication of the study.

Dr. Joseph Young, who leads Northern California Kaiser's clinical hypertension program, said that Kaiser adopted a population management approach to managing chronic conditions in 2006. Kaiser has created registries for people with various kinds of conditions, so that patients who might be missing preventive care or better management of disease can be easily identified.

In the area of blood pressure control, Kaiser changed its drug formulary to allow a "combined pill — a single pill that includes two drugs, to make it easier for patients to take their medication.

These population-based strategies resulted in big improvements in overall outcome for Kaiser patients. Young said that during the 2000s, very serious heart attacks ... fell by 62 percent, and our stroke mortality fell by 42 percent.

Kaiser does have some remaining racial disparities in its non-Medicare population, and Young said they are "actively focusing" on closing those remaining gaps.

"We want clinicians to do what Kaiser is doing and take seriously to provide high quality race-blind clinical care," says Dr. Anthony Iton, who leads the Healthy Communities initiative at the California Endowment. "Kaiser is showing it can be done." He called the study "very hopeful" and believes that Kaiser's approaches are replicable elsewhere.

"Any other system that says it's not doable has to explain how they can justify not providing the same high-quality care to everyone that comes in the door," Iton said.

California probably has "less of a socioeconomic spread between whites and blacks than you do in the southeastern United States," Iton noted. "It's a heavier lift in the Southeast than in the West. But despite that, it's clearly doable."

This story is part of partnership that includes NPR, KQED, and the Kaiser Family Foundation.

Copyright 2014 KQED Public Media. To see more, visit
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Behind The Scenes At The Lab That Fingerprints Microbiomes

NPR Health Blog - Wed, 12/17/2014 - 12:06pm
Behind The Scenes At The Lab That Fingerprints Microbiomes December 17, 201412:06 PM ET Katherine Harmon Courage

Rob Knight, co-founder of the American Gut Project at the University of Colorado in Boulder, works in the lab where the samples are processed.

The American Gut Project

The gut microbiome may soon reveal important answers to questions about our health. But those answers aren't yet easy to spot or quick to obtain.

The week after I mailed off my family's microbial samples to be analyzed for the American Gut Project, I followed them down the road from my home to the University of Colorado, Boulder. They — and I — came to a massive, futuristic science complex there. Daniel McDonald, a doctoral student studying quantitative biology and computer science, greeted me and brought me up to the workspace, where rows of researchers worked on computers outside of a small lab room.

Shots - Health News Poo And You: A Journey Into The Guts Of A Microbiome Shots - Health News To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo

Inside the lab, where the sealed samples were received, a lone technician sorted through new arrivals, snipping off intentionally fouled swab heads. Each sample kit contains two cotton swabs. One swab head goes directly to the freezers for safe keeping (in case the first sample doesn't provide clear results or for the near future, when sequencing technology is better). The other gets dissolved in a solution so its contents can be carefully analyzed for genetic traces of microbes.

Just down the hall is one of the lab's boxed-in robots, charged with loading samples into individual wells on a tray that will later get fed through the sequencers. The task might seem mundane for such a high-tech tool, but the bot works much faster and more accurately than a human lab helper can.

Still, this is where some of the work can be slow going. The team must wait for hundreds of fecal, oral or skin samples to process together. A single sample could go through the full analysis process in a week, but it would cost thousands of dollars, Rob Knight, a co-founder of the project, estimates, rather than the $99 members of the study pay. For the project to be cost-effective for participants, the research team must wait to collect large groups of samples and analyze them together. (Little did I know then just how long I would be waiting for my family's samples to be processed.)

This robot in the Knight lab can handle many samples simultaneously. To avoid contamination, the lab only processes the same kind of samples at the same time together (fecal with fecal, skin with skin and pet with pet).

Katherine Harmon Courage for NPR

Most of the human microbiome is uncharted territory because many of the microbes that live in our guts can't be grown easily in the lab. Oxygen is toxic to them. Using the tools of genetics to probe the human microbiome has already uncovered many new species, each of which has a full genome of its own.

We're still far from getting quick full genomes from each of the inhabitants. Instead, scientists rely on microbes' telltale 16S gene, a marker that helps identify bacteria from one another. Finding the base pairs —the As, Cs, Ts and Gs — for this gene can help scientists sort out which species are present.

This is where a nifty machine that performs PCR (polymerase chain reaction) comes in. It makes thousands of copies of the genetic material so that the pattern in the genetic code is easier for the sequencers to find.

These sequencers are located on a lower floor of the building in a room that smells a bit like a photography darkroom. Here, each tray of samples takes about 20 hours to process. On a nearby screen, I see a readout of bright genetic points against a dark background, which looks more like a telescopic image of a night sky than the code to microbial life from someone's stomach.

This supercomputer, affectionately known as "Compy," crunches massive amounts of microbiome data at the University of Colorado, Boulder.

Katherine Harmon Courage for NPR

Deciphering this code is just the first step in understanding what is going on in the jungle of your gut. Like many things in biology, it is not just the organisms present — plants, animals or bacteria — but how these organisms interact that is important.

The dynamics among the characters make a play — not just the cast.

For instance, research has shown that many of us are walking around with E. coli in our guts but show no ill effects. In much the same way that weeds or hungry insects might not harm a thriving field or forest but could wreak havoc on an unbalanced ecosystem, we depend on a healthful mix of good microbes to keep the bad ones from taking over.

And to see what our intestinal forests are composed of, we need more than just a few points of genetic data. So after the sequencer spits out the genetic code it has assembled, the data needs to get turned back into intelligible (or at least semi-intelligible) patterns.

To do this, our microbial code gets run through a supercomputer nicknamed Compy, which hums safely in the building's basement beyond two sets of doors and a sticky, dust-collecting floor mat. When I meet her, Compy is busy crunching away on base pairs with her 1,000 processors.

From there, the microbe sequences get reunited with their human host's information from the questionnaires. But figuring out the best way to do this is still a work in progress.

The research group is testing using new software to analyze and display these many layers of information. One colorful display that we examine back up in McDonald's fourth-floor office shows a 3-D plot of microbe species and their sites on the human body. It looks a little like an explosion of Dippin' Dots caught in midair — only the brown blobs don't indicate chocolate.

But these dots aren't our microbes. Our samples are still standing by in a freezer for their turn with the robots and whirring sequencing machines. With our samples in the hopper and the process of turning a messy, poop-swab into a sterile, color-coded microbiome chart a bit demystified, it was now time to wait to see what our swipes would turn up.

This is the third story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

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Too Little, Too Late For Many New Yorkers Seeking Hospice

NPR Health Blog - Wed, 12/17/2014 - 5:04am
Too Little, Too Late For Many New Yorkers Seeking Hospice December 17, 2014 5:04 AM ET


Fred Mogul Listen to the Story 6 min 2 sec  

Sandra Lopez (left) and her dog, Coco, greet hospice nurse Heather Meyerend last fall. In the weeks before Lopez died, Meyerend stopped by weekly to check her physical health, pain levels and medications.

Amy Pearl/WNYC

Sandra Lopez and her Chihuahua, Coco, were inseparable. He followed her everywhere, and kept Lopez's mood up when she was in pain — which was often.

On Oct. 15, 2014, Lopez died at age 49 of melanoma that had slowly spread throughout her body over the course of two years.

“ If you're referred to hospice, it means no one expects you to get better. And that is, in my mind, a threshold that's difficult for people to step over.

Lopez was in and out of the hospital in 2014, but during the months she was home, a hospice nurse from the Metropolitan Jewish Health System visited once a week to help manage the pain, backed up by a 24-hour, nurse-staffed phone line that Lopez called often.

"Some days the pain is so excruciating," Lopez told me in August from the couch in her Brooklyn apartment, "that the pain overrides the medication."

But despite evidence that hospices can greatly relieve discomfort, extend life and save money, and despite a generous hospice benefit available through both Medicare and Medicaid, relatively few people in New York take advantage of it, compared with elsewhere in the country.

The reasons for this local gap are complicated, but Jeanne Dennis, senior vice president of hospice and palliative care at the Visiting Nurse Service of New York, says one place to start is with patients' fears. "If you're referred to hospice, it means no one expects you to get better," Dennis says. "And that is, in my mind, a threshold that's difficult for people to step over."

Experts also focus on what they call medical culture, which can vary dramatically from region to region. According to this theory, physicians in the metropolitan area are specialists and sub-specialists, and institutions put a premium on treatments and tests. Even more than in other places, the goal in New York City is to cure patients rather than simply care for them. Treating and testing is just what they do — letting go isn't, says Dennis.

Physicians put off the conversation, she says, with rationalizations like, " 'It's a little too soon'; 'It's a little too early'; 'I don't have enough time today'; 'I'm not sure they're ready for it.' "

New York has 7 out of the 10 hospitals in the country with the fewest hospice referrals. Local academic medical centers — national leaders in research — do better, but still lag behind the rest of the country in their referral rates. It's a big contrast to some hospitals around the country, particularly several in Arizona, Utah and Florida, where more than 75 percent of dying patients take advantage of Medicare's hospice benefit.

Shots - Health News Terminally Ill, But Constantly Hospitalized

Further, most hospice referrals in New York are for brief stays — a week or less — 2.5 times shorter than the national average. Szoa Geng, a health care consultant from the firm Strategy&, says when hospitals move people to hospice with just a few days left to live, the patients don't get the full hospice experience.

"They're not getting the psychosocial support, and their families are not," Geng says. "It can be a time of closure, and coming to peace with a lot of things in your life, and none of that can happen if you come onto hospice with a day left."

Hospice care mostly takes place at home, but it can also occur in freestanding hospices, nursing homes or designated areas of hospitals. To receive the care, a doctor must predict a patient is in the last six months of life without hope of improving. There's no penalty for outliving that prediction; some patients stabilize and go off hospice care, then return later when they start declining again.

About 25 percent of people in the New York metropolitan area use hospice care in their last six months of life, compared with close to 50 percent nationally. Statewide, the rate is closer to 30 percent. But that still makes New York 49th out of 50 states and the District of Columbia, according to the 2012 Dartmouth Health Atlas, the most recent statistics available.

Sandra Lopez said that before her oncologist told her about hospice care, she frequently called 911 to request an ambulance to take her to the hospital, where she would be admitted and spend days at a time. That happened "dozens and dozens of times" in a year, Lopez said.

At around $210 a day, Lopez's hospice care cost Medicaid tens of thousands of dollars — probably less than her revolving-door trips to the hospital (with all their multinight stays), but still a lot of money.

For Lopez, hospice helped her get ready to walk down the final road.

"I stopped worrying — like the worry box I used to be," she told me in August. "I just live my life normally, like everybody else, because worrying will just probably get me more sick."

Lopez knew that at some point her body would start shutting down, but she would never say how much time her doctors estimated she had remaining, because she didn't dwell on that, she said. She was at peace as she faced death and knew she could stay that way — as long as someone was with her at home, at her bedside, helping to subdue her pain.

This story is part of an NPR reporting partnership with WNYC and Kaiser Health News. Special thanks to WYNC's Data Team.

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When You Burn Off That Fat, Where Does It Go?

NPR Health Blog - Tue, 12/16/2014 - 3:58pm
When You Burn Off That Fat, Where Does It Go? December 16, 2014 3:58 PM ET

Lose weight and those pounds shuffle off, unmourned. Good riddance. Please don't come back soon.

But where does weight go when we lose it?

We talk about burning off fat, and it does burn in a way, going through a complex biochemical process. But mass can't be created or destroyed, so the atoms that made the triglycerides that plumped up the love handles have got to be somewhere.

The Salt Cutting Back On Carbs, Not Fat, May Lead To More Weight Loss

That mystery was bedeviling Ruben Meerman, an Australian and former physicist turned TV personality and science educator. Meerman had recently lost 15 kilos (33 pounds), and he was wondering where the fat went.

So he teamed up with Andrew Brown, a lipid researcher at the University of New South Wales, to figure it out. Their results were published Tuesday in the lighthearted Christmas edition of The BMJ, formerly the British Medical Journal.

The adipose sleuths started with this chemical formula, which describes what happens when you burn a molecule of triglyceride, the predominant fat in a human body:

C55H104O6+78O2 —> 55CO2+52H2O+energy.

If you remember your high school chemistry, you've already figured out that when you metabolize fat you end up with carbon dioxide, water and energy.

Oxidizing 10 kilos of human fat requires inhaling 29 kilos of oxygen to produce 28 kilos of carbon dioxide and 11 kilos of water, the authors figure.

The Salt Rethinking Fat: The Case For Adding Some Into Your Diet

That's based on the work of other scientists. Meerman and Brown then fired up their calculators to figure out the proportion of mass that ends up as CO2 versus H2O — 84 percent compared to 16 percent.

Carbon dioxide is a common gas in the atmosphere, so it's pretty obvious where it would go.

Yes, we exhale lost fat. There it helps plants photosynthesize (if you're feeling noble) and contributes to global warming (if you're feeling guilty).

Exhale more CO2, and you'll lose more weight — especially if you're exhaling more frequently because you're running.

The relatively small amount of water produced by fat metabolism could be disposed of through urine, sweat or other bodily fluids, the authors note.

Many people think that fat metabolites are disposed of in feces or converted to muscle, Meerman and Brown write, but that's not correct. "We recommend these concepts be included in secondary school science curriculums and university biochemistry courses to correct widespread misconceptions about weight loss."

And let your fat drift away on the breeze.

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Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab

NPR Health Blog - Tue, 12/16/2014 - 1:19pm
Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab December 16, 2014 1:19 PM ET

The coronavirus responsible for Middle East respiratory syndrome (green particles) seen on camel cells in a scanning electron micrograph.

NIAID/Colorado State University

Imagine that scientists wanted to take Ebola virus and see if it could ever become airborne by deliberately causing mutations in the lab and then searching through those new viruses to see if any spread easily through the air.

Would that be OK?

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The question was posed by David Relman, a microbiologist at Stanford University, at a two-day meeting being held at the National Academy of Sciences in Washington, D.C., to discuss whether some experiments with germs are so risky that the dangers aren't worth the potential benefits.

Researchers call these "gain-of-function" experiments. Take a bug that's bad and give it some genes that just might give the microbes new abilities.

The work has split the scientific community. Some of the most prominent figures in this saga showed up at the historic National Academy of Sciences building this week to have another go at it.

The controversy started a few years ago, with some experiments that took a bird flu virus and altered it so that it spread easily between ferrets, the lab stand-in for people. Critics said the scientists had created a superflu that could cause a pandemic in people if it ever got out of the lab, but the researchers said their work was essential to understanding how flu viruses can jump from animals into people and start devastating flu pandemics.

This disagreement rumbled along until this summer, when some high-profile lab mishaps with other infectious agents prompted the government to temporarily halt certain federally funded research projects that might make three viruses — influenza, SARS and MERS — more pathogenic or contagious.

Officials said they wanted to reassess the risks and benefits, and the meeting that started Monday is part of that effort. "We want to provide a neutral venue for open discussion," said Victor Dzau, president of the Institute of Medicine of the National Academy of Sciences.

The one thing that almost everyone seemed to agree on is that they hate the term "gain-of-function," saying that it doesn't meaningfully describe the kinds of experiments that have some people worried.

"I think the term 'gain-of-function' is being misused more than the viruses," said Michael Imperiale, a microbiologist with the University of Michigan Medical School. "I'd rather that we just take each individual case and call it what it is." Kanta Subbarao of the National Institutes of Health, whose lab works on all three pathogens, said the term is "vague and unsatisfactory."

Virologist Yoshihiro Kawaoka of the University of Wisconsin, Madison, whose lab did one of the flu experiments that caused such controversy, said his work convinced government agencies that they needed to spend the money to replenish the emergency vaccines that have been stockpiled for this particular bird flu virus, because it does indeed seem capable of mutating in ways that could start a pandemic. "This information is important for policymakers," he said, adding that such experiments allow scientists "to obtain information that we could not obtain by other methods unless it actually occurred in nature."

Relman, in response, said that "we already knew enough to be very concerned and motivated to do something" and suggested that if additional motivation was needed, it could have been achieved through experimental approaches that carried less risk.

Meanwhile, scientists who study MERS and SARS, like the University of North Carolina's Ralph Baric, came to the meeting and argued that they weren't doing anything worrisome with these viruses. But they had been dragged into the discussion and had their work halted only because they study respiratory viruses that can be highly pathogenic in people.

The government's review process is expected to last about a year, with another conference planned at the National Academies to discuss draft recommendations on how the government should weigh the risks and benefits of this type of work. Those recommendations will be developed by an advisory committee called the National Science Advisory Board for Biosecurity, which will also be holding public meetings.

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Few Employers Cover Egg Freezing For Women With Cancer

NPR Health Blog - Tue, 12/16/2014 - 8:22am
Few Employers Cover Egg Freezing For Women With Cancer December 16, 2014 8:22 AM ET

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Michelle Andrews

As some companies add egg freezing to their list of fertility benefits, they're touting the coverage as a family-friendly perk.

Women's health advocates say they welcome any expansion of fertility coverage. But they say that the much-publicized changes at a few high-profile companies such as Facebook and Apple are still relatively rare, even for women with serious illnesses like cancer who want to preserve their fertility.

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News stories about company-paid egg freezing for female employees have focused on whether the benefit truly gives women and men more options for balancing work and family life or instead sends a message that they're expected to put off having a family if they want to get ahead on the job.

But career advancement isn't the main concern for some women who, because of illness or age, are worried that time is running out for them to have children. After their mid-30s, women can still carry a pregnancy, but their eggs are less viable. Egg freezing allows women to extend their fertile years.

Brigitte Adams, 42, became the face of oocyte cryopreservation, as egg freezing is called technically, when Bloomberg BusinessWeek put her on its cover for a story on the subject last spring.

Divorced in her mid-30s, she froze her eggs three years ago, paying for the $12,000 egg retrieval procedure with personal savings and help from her parents. Adams pays $300 annually to store her eggs, and she's pondering becoming a single mother. Her marketing job at a tech startup in Los Angeles doesn't provide any coverage for egg freezing and storage or the in vitro fertilization that will be required if she decides to go ahead.

Adams is keenly aware that there is no guarantee that the 11 eggs she's storing will result in a pregnancy. "It's not a silver bullet," Adams says, "but it gave me the sense I'd done everything I could, and that has helped me tremendously to just move on."

Two years ago, the American Society for Reproductive Medicine declared that it no longer considered egg freezing to be experimental. Research shows that fertilization and pregnancy rates using frozen eggs are similar to those using fresh eggs, and children born using frozen eggs don't have higher levels of chromosomal abnormalities or birth defects, the ASRM said in its revised practice guideline.

Yet insurance coverage for egg freezing and other infertility treatments remains spotty, says Richard Reindollar, executive director at the ASRM. "Of all the disease processes, insurance coverage is available for essentially all of them, but not for infertility," he says.

America's Health Insurance Plans hasn't surveyed insurers specifically about egg-freezing coverage, says Susan Pisano, a spokesperson for the trade group. However, she said her understanding is that many plans cover egg freezing when there's a diagnosed fertility problem or when an individual is at risk for infertility because of treatments like radiation therapy or chemotherapy. Coverage for nonmedical reasons is much less common, Pisano says.

Roughly a third of companies with 500 or more workers provide no coverage for infertility services, according to benefits consultant Mercer's annual survey of employer health benefits.

High-tech companies are more likely to cover fertility services than other firms, according to Mercer. Forty-five percent of high-tech companies cover in vitro fertilization, and 27 percent cover other advanced reproductive procedures, such as egg freezing, for example. The comparable figures for companies not in the technology sector were 26 percent and 14 percent, respectively.

Infertility advocates would like to see more companies adopt egg freezing policies, especially for women who have cancer, for example, and are likely to become infertile as a result of chemotherapy.

"I think it's amazing for people at these companies, but can we also get this covered for women with cancer?" says Barbara Collura, president and CEO of Resolve, an infertility advocacy group.

Copyright 2014 Kaiser Health News. To see more, visit
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Alaska's Governor Eager To Expand Medicaid

NPR Health Blog - Tue, 12/16/2014 - 3:28am
Alaska's Governor Eager To Expand Medicaid December 16, 2014 3:28 AM ET


Annie Feidt Listen to the Story 2 min 54 sec  

Valerie Davidson was appointed health commissioner by Alaska's Gov. Bill Walker to help him expand Medicaid in the state. She'll look for middle ground with Republicans to get it done, she says.

Lori Townsend/Alaska Public Media

Alaska's new governor won his election in one of the tightest races in the country, a race that was too close to call even a week after election night. Bill Walker, who ran as an independent (unaffiliated with the Republicans or Democrats), took office on Dec. 1, after campaigning on the promise that he would expand Medicaid as one of his first orders of business.

Environment Republican Sweep Highlights Climate Change Politics In Alaska

To make good on that, he'll have to face a Republican-controlled legislature that hasn't been willing to even consider the idea.

But for Walker, it's a no-brainer: Around 40,000 low-income Alaskans would receive health benefits under Medicaid expansion; most of those affected would be childless adults. The federal government would pay 100 percent of the costs until the end of 2016, and after that the state's share would only slowly increase to 10 percent by 2020.

Plus, Walker points out, Alaskans already pay taxes that fund the expansion.

"I always will default back to what is best for Alaskans," he says, "and it's best for Alaskans to have the health care coverage we've already paid for."

The Alaska Chamber of Commerce, the Alaska State Hospital and Nursing Home Association and the Alaska Native Tribal Health Consortium, all support the Medicaid expansion. So far 28 states have expanded their coverage, and most of those governors have had legislative support says Laura Snyder, a policy analyst with the Kaiser Family Foundation.

“ I always will default back to what is best for Alaskans, and it's best for Alaskans to have the health care coverage we've already paid for.

"There have been a few states where the governor has acted on his own through executive authority," she says, "but most states have generally incorporated it into state budgets which usually require legislative signoff."

In the case of Alaska, Gov. Walker will probably need the legislature because the state has to pay some administrative costs that would add up to as much as $10 million per year. Those millions could be a tough sell for the Republican legislature. Republican Sen. Anna MacKinnon says Walker will have to make a strong case.

"It will be a lively debate," MacKinnon says, "but I look forward to working with him to the best of my abilities within the financial constraints that this state is currently facing."

To help his case, Walker has appointed Valerie Davidson as Health Commissioner. She's been a leader in the Alaska Native health care system and a determined advocate for Medicaid expansion since the health law passed. She says she'll rely on a cooperative work ethic as she negotiates with lawmakers over expansion. Davidson's confident Alaska can get it done.

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"It may not be something everyone's 100 percent happy with," she says, "but we may be able to find middle ground that we can all live with.

"I think that's what makes Alaska so great," Davidson adds. "We don't back down just because things get difficult. If it's 40 below we go about our day and get things done. That's just what we do. And we do that with policy issues as well."

Beyond any opposition by the legislature, Alaska faces big technical hurdles before Medicaid expansion can work. The state's payment and enrollment systems aren't functioning properly right now, and Davidson wants to address those issues before any expansion.

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

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To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo

NPR Health Blog - Mon, 12/15/2014 - 3:58pm
To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo December 15, 2014 3:58 PM ET Katherine Harmon Courage

After a quick swipe and online registration, these test tubes were ready to ship back to the lab at the University of Colorado in Boulder for sequencing and analysis.

Katherine Harmon Courage for NPR

Understanding the human microbiome takes much more work than just identifying the organisms that live in a person's gut. A genetic census of these microbes is really only the start of figuring out what they have to do with health and disease.

To find helpful patterns in the microbe populations, researchers also need to gather a host (no pun intended) of information from the people providing the samples. As participants in the American Gut Project, that means we — myself, my mom, my husband and our dog — answered questions about our life history. (Well, we helped the dog with his.)

Katherine Harmon Courage with her husband, David, and their dog, Raz.

Courtesy of Daylene Wilson

Some of the basic questions were like the things I've answered to get a passport:

In what country were you born? U.S.

Some that I find on so many user surveys:

What is your race? Caucasian.

Then there were the questions about health that reminded me of a trip to the doctor's office:

Do you have asthma? No.

Were you born via cesarean section? Yes.

Have you had your appendix removed? Nope.

But the lifestyle questions were all over the map:

Do you take a multivitamin? No.

Do you bite your fingernails? No way.

Do you use fabric softeners? Why, yes, I do, the "natural" type.

For all of us, including the dog, we provided detailed dietary information. We tracked our food intake for a week, which, as anyone who has ever tried this for diet or health purposes knows, is no small task.

So my husband and I diligently logged the contents of our breakfasts (toast, almond butter and fruit), salad (kale, avocado and tahini-and-vinegar dressing), smoothies (oranges, protein powder and bananas), and splurge dinners (chicken tacos, margaritas and ice cream). We also logged our exercise as we trained for our second New York City Marathon together.

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My mother back on the East Coast kept a diary of her diet. On a typical day she had kefir and granola for breakfast, homemade chicken soup for lunch, lasagna and red wine for dinner. The dog diligently chomped his usual kibble, making him the easiest of the bunch to report on.

But as a science journalist, I couldn't help but focus on the missing details.

There was no way to specify whether our toast was made from regular, whole or sprouted grains. Did our salad greens come from the farmer's market or pre-rinsed in a bag from the supermarket.

These factors, I thought, must have some effect on gut flora. Maybe there were extra nutrients from the sprouted grains and perhaps odd organisms lived on recently picked, hand-washed greens.

I asked Rob Knight, at the University of Colorado, Boulder and one of the leaders on the American Gut Project, if there were a million other questions he would like to ask study participants. Had he wondered if skipping details would mean he was going to miss some potentially big lessons about diet and gut health later.

But he had a pragmatic outlook. For now, he said, It's about opening the project to as large a population as possible, not gathering every possible piece of data. A 30-page questionnaire might turn up a few more correlations, but it would undoubtedly deter people, too.

The current eight-page version was, in truth, plenty long. And since these are still the early days of microbiome research, painting the broad strokes — more veggies versus fewer — and trends — chronic gut disease versus good health—is the initial goal. Perhaps future studies will be able to drill down on specific populations to find these more minute differences, he said.

The other trouble, of course, is relying on self-reported data. You can believe me. Honest. But can you rely on what other people say about what they ate and how much they exercised or flossed their teeth?

But, since Knight and the other researchers can't send out monitors to follow each participant around, information provided by the volunteers is the only feasible option. And other validation studies have found that questions like the ones they used result in answers that are close enough at this point in the research.

Our diets tracked, our surveys answered, it was time for the event some of us had been waiting for (me, my mother) — and others had been dreading (my husband) or oblivious to (our dog). It was sample time.

So I ripped into the plain white envelope that had arrived in the mail. Inside there were four clear tubes with two cotton swabs each. I ventured out into the backyard to find a fresh sample from our dog. The other two awaited private time at home.

The trick for collecting fecal samples, according to Knight, is to avoid overloading the swabs with, er, material. That'll just clog the lab's processing machines, he says. The slightest swipe from a used piece of toilet paper captures enough microbial genetic material to paint a detailed picture of your gut's full microbiota.

Samples discreetly taken, we wrote the dates and times on the tubes, wrapped them in clean tissue as instructed, and placed them back in the mail to the American Gut Project's lab at the University of Colorado, Boulder, where I caught up with them and the ones my mom sent from Connecticut the next week.

This is the second story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

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Prolific Prescribers Of Controlled Substances Face Medicare Scrutiny

NPR Health Blog - Mon, 12/15/2014 - 12:00pm
Prolific Prescribers Of Controlled Substances Face Medicare Scrutiny December 15, 201412:00 PM ET

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Charles Ornstein Ryann Grochowski Jones Listen to the Story 3 min 51 sec  

Number of providers by state who wrote at least 3,000 prescriptions for Schedule 2 controlled substances in 2012 in Medicare Part D.


Despite a national crackdown on prescription drug abuse, doctors churned out an ever-larger number of prescriptions for the most-potent controlled substances to Medicare patients, new data show.

In addition, ProPublica found, the most prolific prescribers of such drugs as oxycodone, fentanyl, morphine and Ritalin often have worrisome records.

In 2012, the most recent year for which data is available, Medicare covered nearly 27 million prescriptions for powerful narcotic painkillers and stimulants with the highest potential for abuse and dependence. That's up 9 percent over 2011, compared to a 5 percent increase in Medicare prescriptions overall. Even taking into account an increase in the number of Medicare enrollees, the prescribing rate rose slightly for these drugs, which are classified as Schedule 2 controlled substances by the Drug Enforcement Administration.

Twelve of Medicare's top 20 prescribers of Schedule 2 drugs in 2012 have faced disciplinary actions by their state medical boards or criminal charges related to their medical practices, and another had documents seized from his office by federal agents.

The No. 1 prescriber — Dr. Shelinder Aggarwal of Huntsville, Ala., with more than 14,000 Schedule 2 prescriptions in 2012 — had his controlled substances certificate suspended by the state medical board in March 2013. He surrendered his medical license four months later. (Aggarwal could not be reached for comment.)

Prescribing high volumes of Schedule 2 drugs can indicate a doctor is running a pill mill, said Dr. Andrew Kolodny, chief medical officer of Phoenix House, a New York-based drug treatment provider. Government regulators should do more to monitor prescribing patterns and intervene proactively if they appear aberrant, he said.

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"We wait 'til these doctors kill people," said Kolodny, founder of Physicians for Responsible Opioid Prescribing, which advocates for tighter regulation of painkillers. "It doesn't make any sense."

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Medicare's drug program, known as Part D, now covers about 38 million seniors and disabled people and pays for more than one of every four prescriptions dispensed in this country. Concerns about oversight of controlled substances date back to at least 2011, when the Government Accountability Office highlighted abuse of opioids in Part D and called on Medicare to take action.

Within the past year, Medicare has started to use prescribing data to identify potentially problematic doctors, as have some state medical boards. Beginning in mid-2015, Medicare will have the authority to kick doctors out of the program if they prescribe in abusive ways.

"It's a real area of concern for us," said Dr. Shantanu Agrawal, director of the Center for Program Integrity within the federal Centers for Medicare and Medicaid Services.

The 2012 data shows the upward trend line for prescriptions of controlled substances before these initiatives took hold.

The Drug Enforcement Administration classifies certain potent drugs based on their potential for abuse and sets limits on prescribing for each group. Drugs classified as Schedule 2 require written prescriptions and cannot be refilled.

ProPublica reported in 2013 that Medicare did not proactively analyze its prescribing data or take action against providers whose patterns were troubling, even if they had been charged with Medicare fraud or kicked out of state Medicaid programs.

Shelinder Aggarwal's Medicare prescribing history had plenty of red flags. The pain medicine specialist has consistently shown up in Medicare's data as a top prescriber of narcotics. By 2012, the year before he stopped practicing, more than 80 percent of his Medicare patients received at least one prescription for a Schedule 2 drug, in many cases oxycodone.

It took complaints from pharmacies near Aggarwal's office to alert the Alabama Board of Medical Examiners to his unusual prescribing habits, said Larry Dixon, the board's executive director. Board investigators subsequently made undercover visits to the doctor's office and videotaped him prescribing drugs without an exam.

"If you paid $1,200 in cash, they would put a VIP stamp on your medical records and you didn't ever have to have an appointment," Dixon said.

Medicare's Part D data draws a roadmap to the doctors who prescribe controlled substances most frequently.

In 2012, 269 providers wrote at least 3,000 prescriptions for Schedule 2 drugs, ProPublica's analysis shows. They were concentrated in a handful of states. Florida led the country with 52 providers, followed by Tennessee with 25. (Look up your doctor using our Prescriber Checkup tool.)

About one in five doctors who wrote at least 3,000 prescriptions for Schedule 2 drugs have faced some kind of sanction or investigation, ProPublica found.

In September, Medicare sent 760 letters to doctors who prescribed far more Schedule 2 drugs than others in their medical specialty and state. Officials hope the initiative will cause doctors to examine their prescribing and make changes.

"Simply being an outlier doesn't establish that you're doing something wrong," said CMS' Agrawal. "What we are trying to do is give physicians the ability to assess themselves, given their comparative data."

Medicare also has sent information on 71 prescribers for possible investigation to the inspector general of the U.S. Department of Health and Human Services, and on one doctor to a state medical board.

Some medical licensing boards are also expanding their efforts to use data to spot problematic prescribing. North Carolina's medical board has proposed new regulations allowing the agency that runs the state's prescription drug monitoring program to share data with the board. The board currently can only access the data when it is pursuing an active investigation into a particular physician.

Similarly, Alabama's legislature recently authorized its medical board to regulate pain medicine clinics and proactively access data from its prescription monitoring database.

Dixon, the Alabama board's executive director, and Henderson said their states' changes are not meant to impede legitimate care by doctors.

"Most of these people are just as genuine as you could possibly hope," Dixon said.

Data, alone, can be misleading. Dr. Mark Ellis, a pain specialist in Athens, Ga., was the third-highest prescriber of Schedule 2 drugs in the country in 2012, with more than 10,000 prescriptions. But unlike many states, Georgia does not allow nurse practitioners and physician assistants to write prescriptions for these controlled substances on their own, requiring them to be signed by a physician. As a result, Ellis said he was credited with the prescribing of four other professionals in his practice. (Ellis was fined by Georgia's medical board in July 2005 for working with a physician assistant without consent from the board.)

With scrutiny of painkiller prescribing on the rise, Ellis said he attempts to ensure that patients are taking, not selling, their pills by requiring frequent drug testing.

Rules put in place by several states have reduced prescribing of narcotics, experts say. New York, Kentucky and Tennessee now require that doctors check databases that track every controlled substance prescription in their states before prescribing such drugs to patients for the first time and at certain intervals afterward. Other states are considering or are in the process of implementing similar rules.

Mandatory checks are "the most-effective single tool we've found yet to address this problem," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

ProPublica is a nonprofit investigative reporting newsroom based in New York.

Copyright 2014 ProPublica. To see more, visit
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Small Businesses Drop Coverage As Health Law Offers Alternatives

NPR Health Blog - Mon, 12/15/2014 - 11:01am
Small Businesses Drop Coverage As Health Law Offers Alternatives December 15, 201411:01 AM ET Jay Hancock

Where are the health insurance deals? On the exchanges, many small businesses have concluded.

Bjorn Rune Lie/Ikon Images/Getty Images

For two decades Atlanta restaurant owner Jim Dunn offered a group health plan to his managers and helped pay for it. That ended Dec. 1, after the Affordable Care Act made him an offer he couldn't refuse.

Subsidies under the health law for workers to buy their own coverage combined with years of rising costs in the company plan made dropping the plan an obvious — though not easy — choice.

"I had a lot of regrets going into it," Dunn, who owns three Italian Oven restaurants in suburban Atlanta, said of his decision. "I don't think I have as many now — only because I've seen the affordability factor for my managers improve."

Dunn and five managers are now covered under individual plans bought on How many other owners make the same decision will help set the future of small-business health insurance. Although the evidence so far is mixed, brokers expect more firms to follow in the next few years.

Companies like Dunn's — those with fewer than 50 workers — provide medical coverage to roughly 20 million people. Unlike larger employers, they have no obligation under the health law to offer a plan. Now they often have good reason not to.

If employees qualify for government subsidies, like the managers who switched from Italian Oven's corporate insurance to individual Obamacare coverage, everybody can win.

Owners don't have to pay premiums, meaning they can give workers raises, invest in equipment or add to profits instead. And employee take-home pay can rise if subsidies — available even to families with middle-class incomes — are worth more than what a company was contributing.

Whether to cancel a company plan and let workers buy insurance on or another online exchange "is something that I would say comes up in every conversation with a small-group" employer, said Adam Berkowitz, a consultant with Caravus, a benefits firm based in St. Louis.

"I just had another [small] business call in today and say, 'You know, we can't do it. We're packing it in,' " said Roger Howell, head of Howell Benefit Services in Wilkes-Barre, Pa.

Anthem, the largest seller of small-business health insurance, lost almost 300,000 members in such plans — many more than expected — in the first nine months of the year. That was 15 percent of the enrollment. Many of those consumers are presumably switching to individual plans sold through exchanges, including those offered by Anthem, officials said.

It's far from clear, however, that most companies will take the same steps as Italian Oven.

Many small employers see health coverage as an essential piece of compensation. They note that premiums in company-sponsored plans are tax-deductible — for workers as well as employers — while the tax advantages of individual plans are limited.

"I feel like we have to have a medical plan in order to hire people and keep them employed," said Dan Allen, head of a 15-worker engineering firm in Decatur, Ill. Allen Engineering renewed its Coventry Health Care plan for 2015 even though the premiums rose 21 percent, he said.

No other major insurer has reported cancellation of small-business plans at the same rate as Anthem.

"We didn't see that," said Rick Allegretti, vice president of marketing at Health Care Service Corp., operator of Blue Cross plans in five states including Illinois and Texas. "We actually saw our [small-group] business grow slightly — mind you, it's probably a tenth of a percent."

Businesses shifting workers into the individual exchanges tend to be the very smallest, employing a handful of people, said Skip Woody, a partner at Hill, Chesson & Woody, a North Carolina benefits firm. "Anything above 15, we haven't had any dropping coverage," he said.

Instead, many small companies are taking advantage of rules letting them maintain insurance bought before the health law took effect. President Obama, who promised consumers they could keep coverage they liked, allowed carriers to extend noncompliant plans after facing fierce criticism over their imminent extinction.

Most, but not all, states approved the adjustment. Because older policies may lack features required by the health law, and because their rates are often set according to employee health history, not communitywide costs, they can be less expensive than compliant plans, say brokers and consultants.

"I haven't sold one of the new plans yet" to a small employer, said John Jaggi, an Illinois broker and consultant. Faced with price increases of as much as a third or more for new plans, all 40 or so of his small-business clients including Allen Engineering renewed older coverage for 2015, he said.

Heavy renewal of old plans plus workers shifting to individual coverage help explain why the health law's online portal for new small-business plans has attracted only modest interest, analysts say.

For some companies there is logic to ending coverage altogether.

For Italian Oven's Dunn, "it made sense to recommend that he drop coverage," said Elena Merino, CEO of the Meridian Group, a benefits firm in Alpharetta, Ga. "It hurts me. But that was the responsible thing to tell him."

Italian Oven employs the equivalent of about 30 people — less than the 50-worker threshold that would get it fined for not sponsoring insurance. The company does not offer coverage to servers and kitchen staff, but full-time managers have always had a plan.

All are eligible for tax credits to buy insurance on, said Dunn. Next year, the subsidies are available for individuals with income of up to $46,680 and families of four with income of up to $95,400.

With subsidies factored in along with unrelated pay increases, the managers "are going to be saving money out of the deal" while getting coverage comparable to what they had before, Dunn said. "My managers actually got excited about it because they're saving money on their health insurance."

Brokers expect more small businesses to make the same move, especially after the ability to extend older, noncompliant plans expires between now and the end of 2017, depending on state policy. Allen, the engineering firm executive, is concerned premiums could rise even higher next year than they did for the 2015 renewal.

"If it's up in the 25- to 30-percent increase [range] — I've heard as high as 40 — we'll just have to drop it," he said. "Turn everybody loose."

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To Stop Teen Drinking Parties, Fine The Parents

NPR Health Blog - Mon, 12/15/2014 - 3:24am
To Stop Teen Drinking Parties, Fine The Parents December 15, 2014 3:24 AM ET Listen to the Story 4 min 28 sec   Maria Fabrizio for NPR

When it comes to teenage drinking, the typical venue is a party — where some teens play drinking games and binge. It may surprise you to learn that the majority of parents are aware that alcohol is flowing at these events.

On any given weekend, some teenagers receive three to four text messages about parties, says Bettina Friese, a public health researcher at the Prevention Research Center in Oakland, Calif.

Friese recently conducted a study on teen drinking. She interviewed 1,100 teenagers living in Northern California. Most did not host parties with alcohol. But of the 39 percent who did, 70 percent said their parents knew kids at the party were drinking. Twenty-four percent said their parents "probably" knew, leaving just a handful of parents in the dark.

“ The bottom line is you can't provide alcohol to minors, period.

Now some communities across the United States are trying to hold these parents accountable and fine them for allowing underage drinking in their homes.

When Friese interviewed parents about why they allowed alcohol, there were many excuses, she says — everything from concern about alienating their children to worries that imposing strict rules might encourage more dangerous rebellion.

Many parents felt drinking was inevitable, she says. One mother told Friese, "I'd rather they make their mistakes when they're at home than when they're away."

Many parents said they believed it was safer for their child (and even their child's friends) to drink at their house rather than someplace else, Friese says. The biggest concern among the parents was drunken driving; many said they had their child's friends stay the night to avoid driving. Many parents said they knew it was "wrong" to allow alcohol at teen parties. But, Friese says, they felt they had no choice.

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That may be changing. Nationwide, cities and communities are starting to crack down. So far, 28 states have some sort of social host law on the books. These laws hold adults responsible for any underage drinking that happens on their property.

The details of the law vary, community to community and state to state. One of the most stringent laws is in Ventura County in California, says Bernadette Compean, an alcohol beverage control officer with the Ventura Police Department.

"The bottom line is you can't provide alcohol to minors, period," she says, adding that Ventura is the only county in California where all of the cities have similar laws.

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The county's laws are crystal clear: If you're 21 or older and you host a party where alcohol is available to teenagers, you can be fined $1,000 on the spot. If parents aren't home, the teen who's hosting the party gets the ticket. And to make sure tickets don't get ignored, police promptly follow up with a letter to parents informing them about the party, the ticket and the $1,000 fine.

If police are called a second time in one year, the fine doubles to $2,000 plus the cost of city services — which can run into thousands of dollars more if the fire department or other emergency services are involved. Compean says most teens and parents get the message the first time. She hasn't been called back much for second offenses.

Since the law was passed six years ago, underage drinking has declined throughout the county, and teenagers report that it's become more difficult to obtain alcohol.

And it's not just in Ventura that such laws are changing behavior. Public health researcher M.J. Paschall, also with the Prevention Research Center, recently did a study comparing cities in California that had social host laws with cities that did not.

"We found that cities with more stringent and enforceable social host laws had lower levels of drinking at parties among teenagers compared to cities with less stringent laws, or without any kind of social host law," Paschall says.

He plans future research to see if the laws also result in fewer alcohol-related accidents and injuries — especially from drunken driving.

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