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Maybe Early Humans Weren't The First To Get A Good Grip

NPR Health Blog - Thu, 01/22/2015 - 3:45pm
Maybe Early Humans Weren't The First To Get A Good Grip January 22, 2015 3:45 PM ET Listen to the Story 2 min 40 sec  

An example of a human precision grip — grasping a first metacarpal from the thumb of a specimen of Australopithecus africanus that's thought to be 2 to 3 million years old.

T.L. Kivell & M. Skinner

The special tool-wielding power of human hands may go back farther in evolutionary history than scientists have thought.

That's according to a new study of hand bones from an early relative of humans called Australopithecus africanus. Researchers used a powerful X-ray technique to scan the interior of the bones, and they detected a telltale structure that's associated with a forceful precision grip.

"It's clear evidence that these australopiths were using their hands and using grips that are very consistent with what modern humans did and what our recent relatives like Neanderthals did," says Matthew Skinner, a paleoanthropologist at the University of Kent, in the United Kingdom. He was part of the team that published the new work online Thursday in Science.

The human hand is capable of fine manipulation that is way beyond the capabilities of our closest living relatives, the great apes. A chimpanzee, for example, would find it impossible to hold a pencil in the way that people do. That's because the human hand has short fingers and a relatively long thumb, letting us easily press our thumb against the pads of our fingers.

The Human Edge A Handy Bunch: Tools, Thumbs Helped Us Thrive The Human Edge Building A Human Body

And while chimpanzees do use tools — they might use a twig to fish termites out of a mound, for example — the use of stone tools has long been seen as a uniquely human activity. The earliest known members of the human group were named Homo habilis, or "handy man." These early humans were thought to be the first stone toolmakers; their hand bones had external features similar to those seen in modern humans.

Scientists have clear evidence of stone tool use as early as 2.4 million years ago. Recently, though, researchers made the controversial claim that they'd found animal bones from about 3.4 million years ago that seemed to have cut marks made by stone tools. That find was associated with an ancient relative of humans called Australopithecus afarensis; the discovery suggested that the precursors to humans also might have been handy.

Now, this new study of hand bones adds another bit of evidence. Skinner and his colleagues knew that bone is a living tissue that responds to the forces and stresses exerted on it. And they found that humans, but not chimpanzees, have a distinctive structural pattern inside the hand bones; it seems to be created when you, for example, forcefully oppose your thumb with your fingers.

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What's more, the humanlike pattern was found inside the hand bones of Australopithecus africanus, suggesting that this type of grip may have been commonly used as early as 3 million years ago.

"We were very excited," says Skinner. "There are aspects of our anatomy which are very interesting and very unique and define us of a species. And what we have shown here is that some of the aspects of the hand which are so unique to modern humans have a much deeper evolutionary history than we thought previously."

(Top row) First metacarpals of the thumb in (from left to right) a chimpanzee, fossil hominins Australopithecus africanus, and two specimens belonging to either a robust australopith or early Homo, and a human. The bottom row shows 3D renderings from the microCT scans of the same specimens, showing a cross-section of the spongy trabecular bone inside.

T.L. Kivell

He says it's not clear whether this species was actually using stone tools, or doing something else with their hands. But he thinks the new finding will probably prompt researchers to start looking for more evidence of stone tool use by these more remote ancestors to humans. "Because there's been a general feeling that one didn't even need to look for them, because they just didn't use them," Skinner says.

Brian Richmond, a paleoanthropologist at the American Museum of Natural History in New York, agrees that the big question is what these folks were doing with their hands to create this internal bone pattern. "It's not direct evidence of tool use," he says. "It's direct evidence of handling objects in a fairly humanlike way."

He says Australopithecus walked upright and had more or less the same hand proportions as modern humans, so it makes sense that they would be capable of using their hands to manipulate lots of things.

"But this suggests that they were actually doing it, not just that they could. There's evidence of behavior," he says. "It gives us a really high-resolution glimpse into the kinds of joint stresses that were happening in the hands, some 2 to 3 million years ago."

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Disneyland Measles Outbreak Hits 59 Cases And Counting

NPR Health Blog - Thu, 01/22/2015 - 12:24pm
Disneyland Measles Outbreak Hits 59 Cases And Counting January 22, 201512:24 PM ET


Lisa Aliferis

People who visited Disneyland in December were at risk of getting an unwelcome souvenir: the measles.

George Frey/Landov

The measles outbreak that started at Disneyland and one other California theme park is expanding, with 59 confirmed cases in patients ranging in age from 7 months to 70 years. The California Department of Public Health has linked 42 of these cases to people who visited Disneyland or Disney's California Adventure Park.

Initially, cases were linked to people who visited the parks in mid-December, but health officials now say that other people with measles were at the parks in January while infectious and also have spread the disease.

The outbreak has spread beyond California with seven cases in Utah, Washington, Colorado and Oregon. Mexico has also confirmed a case.

Vaccination status is known for 34 of the California patients. State officials say that 28 were not vaccinated at all, one was partially vaccinated and five were fully vaccinated. Six of the unvaccinated were babies, too young to be vaccinated.

"Measles is not a trivial illness," state epidemiologist Dr. Gil Chavez said Wednesday. "It can be very serious with devastating consequences." Those consequences include pneumonia, encephalitis and even death. Before the measles vaccine was introduced in 1963, 500 people a year died of the disease nationwide. In the current outbreak, 25 percent of people with measles have been hospitalized.

"If you are not vaccinated, stay away from Disneyland."

In 1989-1991, a measles epidemic swept California and other places around the U.S. There were 17,000 cases in California, and 70 people died. In Philadelphia, nine children died in just three months. "The city was in a panic," Dr. Paul Offit of Children's Hospital of Philadelphia says. "I saw children die of measles dehydration ... measles encephalitis. Measles can kill you."

Chavez stressed that Disneyland was a safe place to go — as long as you are vaccinated. "If you are not vaccinated, stay away from Disneyland," he said. The problem is not with Disneyland itself, but any place where large numbers — including people from foreign countries — congregate. Chavez described Disneyland staff as being helpful and "quite concerned" about the outbreak. Five Disneyland staff members are among the 59 cases.

Measles was declared eliminated from the United States in 2000, but can still be reintroduced if someone from another country is infected and travels to the U.S., or an unvaccinated person in the U.S. travels abroad and brings the illness back.

Measles is a highly infectious, airborne illness. It starts off with fever as high as 105 degrees, followed by symptoms that resemble a cold — a cough and runny nose. The hallmark of measles is a red rash that appears first on the face and upper neck, and then spreads to the rest of the body. If someone with measles coughs or sneezes it can spread droplets of virus that can live on surfaces for up to two hours.

Shots - Health News Measles Makes An Unwelcome Visit To Disneyland

On the press call with reporters Wednesday afternoon, Kathleen Harriman with the California Department of Public Health described published case reports of a person with measles at a basketball game — and people across the court became infected, "because the virus can float and hang out in the air for a long, long time," she said.

Chavez urged everyone who was not vaccinated to get immunized. The first dose of vaccine, called MMR as it protects against measles, mumps and rubella, is given at 12 to 15 months of age. The second dose is given at age 4 to 6. Most people who get the vaccine do not experience side effects, but the most common ones are fever and a mild rash.

If you were born before 1957, you are presumed to be immune to measles, because the disease was so widespread before the introduction of the vaccine. For years, only one dose was recommended; it protects 95 percent of people. The second dose was recommended starting in 1991. If you don't know your vaccine status, Harriman said you can safely get the MMR vaccine — if it's an extra dose it won't hurt you, she said.

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Local health officers in counties affected are busy tracing those who infected patients have been in contact with. Dr. Erica Pan, deputy health officer of Alameda County, says the county has shifted resources from Ebola preparedness to contact tracing for measles. Last year there were four cases of measles in Alameda County, she said, "but we had 400 contacts to investigate."

The measles outbreak comes after years of increases in the number of parents who refuse to get their children vaccinated. In California, the rate of kindergarten parents choosing the "personal belief exemption" to refuse vaccines doubled from 2007 to 2013. While the statewide rate of personal belief exemptions reached 3.15 percent, geographic clusters had significantly higher opt-out rates.

But that steady increase in vaccine refusals was halted with the current school year — likely due to a new California state law. This school year is the first when parents who chose to opt out needed to meet first with a health care provider to discuss vaccines and vaccine preventable illnesses. The goal is to dispel misinformation and fear of vaccines. The opt-out rate dropped from 3.15 to 2.54 percent, nearly a 20 percent decrease.

That change in vaccine refusals may be too late to make a difference in this outbreak, but state officials are nonetheless pleased. "That may change the number of people opting not to vaccinate out of pure misinformation," Chavez said.

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit
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Hospitals' Medicare Quality Bonuses Get Wiped Out By Penalties

NPR Health Blog - Thu, 01/22/2015 - 7:30am
Hospitals' Medicare Quality Bonuses Get Wiped Out By Penalties January 22, 2015 7:30 AM ET

Partner content from

Jordan Rau

What Medicare gives with one hand, it's taking away with another. Most government quality bonuses to hospitals this year are being wiped out by penalties issued for other shortcomings.

The government is taking performance into account when paying hospitals, one of the biggest changes in Medicare's 50-year-history and one that's required by the Affordable Care Act.

This year 1,700 hospitals, 55 percent of those graded, earned higher payments for providing comparatively good care in the federal government's most comprehensive review of quality. The government measured criteria such as patient satisfaction, lower death rates and how much patients cost Medicare. This incentive program, known as value-based purchasing, also led to penalties for 1,360 hospitals. (You can see all the bonuses and penalties here.)

However, fewer than 800 of the 1,700 hospitals that earned bonuses from this one program will actually receive extra money, according to a Kaiser Health News analysis. That's because the rest are being penalized through two other Medicare quality programs. One punishes hospitals for having too many patients readmitted for follow-up care, and the other lowers payments to hospitals where too many patients developed infections during their stays or got hurt in other ways.

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When all these incentive programs are combined, the average bonus for large hospitals, those with more than 400 beds, will be nearly $213,000, while the average penalty will be about $1.2 million, according to estimates by Eric Fontana, an analyst at The Advisory Board Company, a consulting firm based in Washington.

For hospitals with 200 or fewer beds, the average bonus will be about $32,000 and the average penalty will be about $131,000, Fontana estimated.

Twenty-eight percent of hospitals will break even or get extra money.

On top of that, Medicare this year also began docking about 200 hospitals for not making enough progress in switching over to electronic medical records. Altogether more than 6 percent of Medicare payments are contingent on performance.

"You're starting to talk about real money," said Josh Seidman, a hospital adviser at Avalere Health, another consulting firm in Washington. "That becomes a really big driver; it really gets the attention of the chief financial officer as well as everybody else in the executive suite of the hospital."

Among these programs, the Hospital Value-Based Purchasing initiative, now in its third year, is the only one that offers bonuses as well as penalties. It is also the only one that recognizes hospital improvement even if a hospital's quality is still subpar. These bonuses and penalties are based on 26 different measures, including how consistently hospitals followed a dozen recommended medical guidelines, such as giving patients antibiotics within an hour of surgery, and how patients rated their experiences while in the hospital.

Medicare also examined death rates for congestive heart failure, heart attack and pneumonia patients, as well as bloodstream infections from catheters and serious complications from surgery such as blood clots. Medicare this year added a measure intended to encourage hospitals to deliver care in the most efficient manner possible. Hospitals were judged on how much their average patient costs Medicare, not only during the patient's stay but also in the three days before and a month after. Medicare is adding a hospital's bonus or penalty to every Medicare reimbursement for a patient stay from last October through the end of September.

Shots - Health News Hospitals To Pay Big Fines For Infections, Avoidable Injuries

Nearly 500 more hospitals earned bonuses in the value-based purchasing program compared to last year. The biggest is going to Black River Community Medical Center in Poplar Bluff, Mo., which is getting a 2.09 percent increase, the analysis found. The largest penalty this year is assigned to the Massachusetts Eye and Ear Infirmary, a teaching hospital of Harvard Medical School, in Boston. It is losing 1.24 percent of its Medicare payments.

The Massachusetts infirmary said in a statement that it was losing about $60,000 because most of its patients do not remain overnight in the hospital, and the penalties apply only to inpatient stays. The infirmary had so few of those cases that Medicare could not assess its performance on more than half the measures the government uses. Medicare's program "is a poor match for what" the infirmary does, it said.

More than 1,600 hospitals were exempted from the incentives, either because they specialize in particular types of patients, such as children or veterans, or because they are paid differently by Medicare, such as all hospitals in Maryland and "critical access hospitals" that are mostly in rural areas.

Medicare awarded bonuses to at least three-fourths of the hospitals it evaluated in Alaska, Hawaii, Maine, Minnesota, Montana, Oregon, South Dakota and Wisconsin, the KHN analysis found. Medicare penalized more than half the hospitals it evaluated in Arizona, Arkansas, California, Connecticut, Delaware, the District of Columbia, Florida, Nevada, New Jersey, New York, North Dakota, Pennsylvania, Washington and Wyoming. You can see the state tallies here:

Copyright 2015 Kaiser Health News. To see more, visit
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E-Cigarettes Can Churn Out High Levels Of Formaldehyde

NPR Health Blog - Wed, 01/21/2015 - 5:03pm
E-Cigarettes Can Churn Out High Levels Of Formaldehyde January 21, 2015 5:03 PM ET Listen to the Story 3 min 23 sec  

Vapor from an e-cigarette obscures the user's face in a London coffee bar.

Dan Kitwood/Getty Images

Vapor produced by electronic cigarettes can contain a surprisingly high concentration of formaldehyde — a known carcinogen — researchers reported Wednesday.

The findings, described in a letter published in the New England Journal of Medicine, intensify concern about the safety of electronic cigarettes, which have become increasingly popular.

The Two-Way 29 State Attorneys General Ask FDA To Strengthen E-Cig Regulations Shots - Health News Health Organizations Call For A Ban On E-Cigarettes Indoors

"I think this is just one more piece of evidence amid a number of pieces of evidence that e-cigarettes are not absolutely safe," says David Peyton, a chemistry professor at Portland State University who helped conduct the research.

The e-cigarette industry immediately dismissed the findings, saying the measurements were made under unrealistic conditions.

"They clearly did not talk to [people who use e-cigarettes] to understand this," says Gregory Conley of the American Vaping Association. "They think, 'Oh well. If we hit the button for so many seconds and that produces formaldehyde, then we have a new public health crisis to report.' " But that's not the right way to think about it, Conley suggests.

E-cigarettes work by heating a liquid that contains nicotine to create a vapor that users inhale. They're generally considered safer than regular cigarettes, because some research has suggested that the level of most toxicants in the vapor is much lower than the levels in smoke.

Some public health experts think vaping could prevent some people from starting to smoke traditional tobacco cigarettes and help some longtime smokers kick the habit.

But many health experts are also worried that so little is known about e-cigarettes, they may pose unknown risks. So Peyton and his colleagues decided to take a closer look at what's in that vapor.

"We simulated vaping by drawing the vapor — the aerosol — into a syringe, sort of simulating the lungs," Peyton says. That enabled the researchers to conduct a detailed chemical analysis of the vapor. They found something unexpected when the devices were dialed up to their highest settings.

"To our surprise, we found masked formaldehyde in the liquid droplet particles in the aerosol," Peyton says.

He calls it "masked" formaldehyde because it's in a slightly different form than regular formaldehyde — a form that could increase the likelihood it would get deposited in the lung. And the researchers didn't just find a little of the toxicant.

Shots - Health News FDA Moves To Regulate Increasingly Popular E-Cigarettes

"We found this form of formaldehyde at significantly higher concentrations than even regular cigarettes [contain] — between five[fold] and fifteenfold higher concentration of formaldehyde than in cigarettes," Peyton says.

And formaldehyde is a known carcinogen.

"Long-term exposure is recognized as contributing to lung cancer," says Peyton. "And so we would like to minimize contact (to the extent one can) especially to delicate tissues like the lungs."

Conley says the researchers found formaldehyde only when the e-cigarettes were cranked up to their highest voltage levels.

"If you hold the button on an e-cigarette for 100 seconds, you could potentially produce 100 times more formaldehyde than you would ever get from a cigarette," Conley says. "But no human vaper would ever vape at that condition, because within one second their lungs would be incredibly uncomfortable."

That's because the vapor would be so hot. Conley compares it to overcooking a steak.

"I can take a steak and I can cook it on the grill for the next 18 hours, and that steak will be absolutely chock-full of carcinogens," he says. "But the steak will also be charcoal, so no one will eat it."

Peyton acknowledges that he found no formaldehyde when the e-cigarettes were set at low levels. But he says he thinks plenty of people use the high settings.

"As I walk around town and look at people using these electronic cigarette devices it's not difficult to tell what sort of setting they're using," Peyton says. "You can see how much of the aerosol they're blowing out. It's not small amounts."

"It's pretty clear to me," he says, "that at least some of the users are using the high levels."

So Peyton hopes the government will tightly regulate the electronic devices. The Food and Drug Administration is in the process of deciding just how strict it should be.

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Scientists Give Genetically Modified Organisms A Safety Switch

NPR Health Blog - Wed, 01/21/2015 - 3:03pm
Scientists Give Genetically Modified Organisms A Safety Switch January 21, 2015 3:03 PM ET Listen to the Story 4 min 9 sec  

Scientists reprogrammed the common bacterium E. coli so it requires a synthetic amino acid to live.

BSIP/UIG via Getty Images

Researchers at Harvard and Yale have used some extreme gene-manipulation tools to engineer safety features into designer organisms.

This work goes far beyond traditional genetic engineering, which involves moving a gene from one organism to another. In this case, they're actually rewriting the language of genetics.

The goal is to make modified organisms safer to use, and also to protect them against viruses that can wreak havoc on pharmaceutical production.

The Salt Who Made That Flavor? Maybe A Genetically Altered Microbe

To understand what they've done, you may need to remember a bit of basic biology. The enzymes and other proteins in our bodies are all built from building blocks called amino acids. There are usually just 20 amino acids in nature. But George Church, a professor of genetics at Harvard Medical School, has created a bacterium that requires an additional amino acid, one made in the lab and not found in nature. His lab did that by rewriting the bacteria's genetic language to add a "word" that calls for this unnatural amino acid.

"So this really makes it a completely new branch of life," Church says.

These modified E. coli bacteria essentially speak a different genetic language from all other life on Earth. That means they can't easily swap genes, which bacteria often do to pick up or get rid of traits. And it also means that these modified E. coli must be fed the synthetic amino acid to survive.

"It will die as soon as you remove that essential nutrient," Church says.

The scientists say this radical re-engineering actually makes these synthetic life forms safer, because if they escape into the wild they'll die. One key question is whether these engineered bacteria can shed the traits that make them dependent on the synthetic amino acid. (Bacteria mutate all the time, picking up new traits and dropping others).

Genzyme had to halt production at its Allston, Mass., pharmaceutical plant in 2009, after bacteria used in manufacturing were contaminated with viruses.

Brian Snyder/Reuters Landov

Church says that if his lab had modified just one trait, the bacteria would have a one in a million chance of getting rid of this safety feature. But by modifying several traits, he says the odds are more like one in a trillion that the bacteria can survive without the synthetic amino acid.

These modified organisms have another plus: With their altered genetic code, they are resistant to viruses that frequently attack bacteria. Viruses need the conventional DNA language in order to infect bacteria. So this is a selling point for industries that use E. coli.

"If you get your factory contaminated, it can be hard to clean out for a year," Church says, pointing to an episode at Genzyme Corp., a Cambridge, Mass., pharmaceutical manufacturer, in 2009. Viruses there contaminated a plant where bacteria were used to make drugs for two rare genetic disorders, Gaucher disease and Fabry disease, cutting off supplies.

And industrial uses are potentially just the start for engineered organisms.

"This also sets the stage for opening up new types of applications going forward," said Farren Isaacs , an assistant professor of molecular, cell, and developmental biology at Yale University. Isaacs left Church's lab at Harvard to start his own at Yale. He has kept pace with his former boss. He, too, has built some safety features into E. coli. Their reports were published together Wednesday in the journal Nature.

Other uses might include engineering oil-eating bacteria to use on a spill. They could be killed off when they're done by withholding the essential nutrient. Isaacs says scientists could also engineer bacteria to produce probiotics for human consumption.

It's harder to think about how this technology could be used in agriculture. Countless acres of genetically engineered crops would need to be fed this manmade ingredient, from a crop duster or by some other means. Scientists would also need to show that the synthetic protein component is safe to eat.

"I think it's commendable they're starting to design safety into genetically modified organisms," says Jennifer Kuzma, co-director of the Genetic Engineering and Society Center at North Carolina State University. "However, I don't really think it's going to affect the public perception that much or the way we have to deal with the uncertainty anyway. You may reduce the chance of spread, but you cannot eliminate it completely."

Science doesn't offer absolutes. But this technology is evolving quickly, and Church says it's important to engineer in safety features as they go.

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War Over Obamacare Heats Up In States

NPR Health Blog - Wed, 01/21/2015 - 5:03am
War Over Obamacare Heats Up In States January 21, 2015 5:03 AM ET Fred Schulte

Oklahoma state Rep. Mike Ritze, a Republican and a physician, plans to revive the fight against the Affordable Care Act in the 2015 legislative session.

Sue Ogrocki/AP

Oklahoma state Rep. Mike Ritze is a foot soldier — one of hundreds — in a passionate war over the Affordable Care Act that is reigniting as state legislatures convene across the country.

The Republican lawmaker, a family doctor, has stood behind three anti-Obamacare bills supported by conservative groups in Oklahoma and other states. None has made it into law, but Ritze plans to pick up the fight in the 2015 legislative session that convenes in the Sooner State next month.

"We need to do everything we can to try and reverse this," said Ritze, who practices in Broken Arrow.

In Washington, D.C., there's been little consensus on modifying the health care law. But in state capitals around the country, from Albany and Columbia to Austin and Sacramento, lawmakers have been mulling over hundreds of proposals that reflect many starkly different views on Obamacare as settled law.

A Center for Public Integrity review found that more than 700 Obamacare-related bills were filed in the states during 2014 or carried over from 2013 in states where legislatures allow that. (You can read in-depth about the center's findings here.)

Some states saw 50 or more health bills each, according to data from the National Conference of State Legislatures, or NCSL. It's not yet clear how many will be reconsidered in 2015 — many states are just kicking off their legislative sessions — but few expect any substantial retreat from the battlefront.

A Bit Of Everything

Some bills seek to "nullify" the law or find creative ways to hinder its enforcement, while others are perennial filings inspired by Tea Party activists and other early foes of Obamacare, such as the John Birch Society.

Dozens of anti-Obamacare bills appear to take their cues from a handful of activist groups — some well-financed at least partly by big corporate donors, and others run on shoestring budgets.

On the flip side, scores of bills to bulk up Obamacare have also landed in state hoppers, especially last year. Most would either expand eligibility for Medicaid, the health care plan for low-income people funded by states and the federal government, or require insurers to cover more medical services.

NCSL data show that to date, pro-Obamacare forces have had the upper hand in bills actually signed into law. In all, more than 75 Obamacare-related bills were signed into law in 2014. About 50 moved the law forward, mostly by expanding Medicaid, while the rest appeared to impede its reach. But the tide may be shifting. Conservative groups that have tried to peck away at the law say they feel energized by Republican gains in state legislatures in 2014 midterm elections.

Style And Substance

Harvard University sociologist Theda Skocpol, a supporter of the law, said that some of the anti-Obamacare bills are "largely symbolic" and stand little chance of passage, but that others can put significant pressure on state governments.

Congress passed the Affordable Care Act in 2010 to help pay for health care coverage for millions of uninsured Americans. But the law leaves some key decisions on how to do so partly up to the states.

State lawmakers also are awaiting the Supreme Court's decision over the legality of subsidies paid in states that did not set up their own exchanges. A ruling in the case, King v. Burwell, is due this summer.

That would no doubt result in a new flood of proposals. But state lawmakers haven't been shy about weighing in to date.

Among the trends:

  • More than 200 bills, most sponsored by Republicans, have attacked Obamacare's foundation from different flanks. At least 25 bills seek to repeal or "nullify" it, while others would offset any fines collected from people who refuse to purchase health insurance, or otherwise limit the law's reach. A "model" bill considered in at least 11 states would forbid state employees from enforcing any part of the law. Most didn't pass.
  • At least 85 bills would tinker with insurance exchanges set up by the states or the federal government to sell policies. Just over half would choke off funding or inhibit exchanges by cutting off their spending on marketing or advertising. Four bills would stop insurers from taking any federal subsidies, though none passed. Most of these bills have failed.
  • More than 55 bills filed in about two dozen states tried to tighten oversight of "navigators," who assist people in choosing a health plan that best fits their needs. Obamacare supporters see these bills as little more than a ruse to disrupt the law, and most did not pass. Yet six states in 2014 passed laws to tighten training standards or bar felons from getting these jobs.
  • At least 26 states have taken up bills that would petition Congress to let states make health care financing decisions. Nine states have joined these health care compacts, data show. Nine compact bills were put forward in six states during 2013 and 2014, but only Kansas approved one, in 2014.
  • More than 100 bills, most sponsored by Democrats, would expand Obamacare by covering more lower-income people under Medicaid or requiring insurers to cover new medical services. Most did not pass.

Organized Opposition

One high-profile group fighting Obamacare in statehouses is the American Legislative Exchange Council, or ALEC. The "free-market" group says it works to "advance limited government."

Among other initiatives, ALEC favors a "Health Care Freedom Act" that would suspend the business licenses of insurers that accept "any remuneration, credit or subsidy" paid under the Affordable Care Act. The measure was introduced in Kansas, Missouri and Ohio, but didn't pass.

ALEC has a foil in the State Innovation Exchange, which says it helps advance "progressive legislation." The group has yet to write model bills, according to executive director Nick Rathod. He expects to be playing defense over the next few years to stop "rollbacks" of Obamacare and predicts an "all-out assault" on the law.

Medicaid Growth

The attacks from the right have not deterred proponents from pressing ahead with their own measures.

Most of these bills add benefits under Medicaid or insurance policies. The NCSL database logged 27 bills in nine states that would guarantee coverage for autism spectrum disorder, or study the idea of doing so. Bills to do that were signed into law in four states.

Other bills sought to guarantee insurance coverage for other medical and mental health care, such as chemotherapy and substance abuse.

Outcome Uncertain

Some observers predict that ideological opposition will crumble in the face of mounting pressure from the business community, including hospitals and insurers, which stand to profit from Medicaid expansions that will largely be paid for by the federal government.

Robin Rudowitz, who works with the Kaiser Family Foundation, puts the matter simply: "There's a lot of federal money on the table."

The Center for Public Integrity is a nonprofit, independent investigative news outlet. For more of its stories on this topic, go to

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Tax Preparers Get Ready To Be Bearers Of Bad News About Health Law

NPR Health Blog - Wed, 01/21/2015 - 2:59am
Tax Preparers Get Ready To Be Bearers Of Bad News About Health Law January 21, 2015 2:59 AM ET Jeff Cohen, WNPR April Dembosky, KQED Listen to the Story 4 min 41 sec  

Lou Graham prepares taxes in Connecticut and is ready to answer client questions about the Affordable Care Act.

Jeff Cohen/WNPR

Are you thinking about tax day yet? Your friendly neighborhood tax preparer is. IRS Commissioner John Koskinen declared this tax season one of the most complicated ever, partly because this is the first year that the Affordable Care Act will show up on your tax form.

Tax preparers from coast to coast are trying to get ready. Sue Ellen Smith manages an H&R Block office in San Francisco, and she is expecting things to get busy soon.

"This year taxes and health care intersect in a brand-new way," Smith says.

For most people who get insurance through work, the change will be simple: checking a box on the tax form that says, "Yes, I had health insurance all year."

Shots - Health News Tax Time Gets New Ritual: Proof Of Health Insurance

But it will be much more complex for an estimated 25 million to 30 million people who didn't have health insurance or who bought subsidized coverage through the exchanges.

To get ready, Smith and her team have been training for months, running through a range of hypothetical scenarios. She introduces "Ray" and "Vicky," a fictional couple from an H&R Block flyer. Together they earn $65,000 a year, and neither has health insurance.

An H&R Block flyer with fictional couples representing possible scenarios of what people might encounter reconciling their taxes under the Affordable Care Act.

H&R Block

"The biggest misconception I hear people say is, 'Oh, the penalty's only $95, that's easy,' " says Smith, but the Rays and Vickys of the world are in for a surprise. "In this situation, it's almost $450."

That's because the penalty for being uninsured in 2014 is $95 or 1 percent of income, whichever is greater. Next year, it's 2 percent. Smith says the smartest move for people to avoid those penalties is to sign up for insurance before Feb. 15, the end of the health law's open enrollment period.

But a lot of people may not think about this until they file their taxes in April. For them, it will be too late to sign up for health insurance and too late to do anything about next year's penalty, says Mark Steber, chief tax officer for Jackson Hewitt Tax Services.

"They're kind of stuck," says Steber. "Quite frankly that's a very difficult discussion."

Steber's team at Jackson Hewitt is also role playing with tax advisors to prepare them for delivering bad news, in case taxpayers want to blame the messenger.

Lou Graham works at an H&R Block office in Hartford, Conn., and he is facing the same concerns. He is bracing to tell some people who got a subsidy all year long that it was actually too generous — maybe they made more money than they originally estimated. And, soon, they'll have to pay the government back.

ACA Penalties Infographic

H&R Block

"I'm going to tell a client, 'I'm sorry, $300 of your return is not going to be yours.' Well, that will send them right through the roof," Graham says.

Like his colleague Smith in California, Graham is afraid some people may be completely unaware of the penalty for not having insurance.

That means Graham may have to deliver two pieces of bad news. First, he'll tell them they owe a penalty for 2014, and then he'll tell them it's too late to sign up for 2015. "So they're going to get stymied twice," he says.

Graham says he also hopes to guide people to some good news. A lot of people may not know that they're able to get an exemption from the law's mandate to get insurance, and it's his job to pull it out of them.

A client could say to him, for example, "'I didn't have insurance for six months, but you know what? I had got a notice that my electricity was going to be cut off.' Well, you fall into a hardship case," says Graham. "Those things need to be explored and not many people want to bring that forward."

Bringing it forward it important. Tax preparers like Graham can only help if tax filers seek them out, and most people don't - not this early, at least, he says. "People don't really start thinking about tax work until they get their W-2s in their hands."

That presents a real crunch. Most people won't get those W-2s until the end of January. That gives them just two weeks before the Obamacare clock runs out on them on February 15.

This story is part of a reporting partnership with NPR, WNPR, KQED and Kaiser Health News.

Copyright 2015 NPR. To see more, visit
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Parents Who Shun Vaccines Tend To Cluster, Boosting Children's Risk

NPR Health Blog - Tue, 01/20/2015 - 3:45pm
Parents Who Shun Vaccines Tend To Cluster, Boosting Children's Risk January 20, 2015 3:45 PM ET Liza Gross

Although vaccines are among the safest, most effective ways to protect children from major communicable diseases, some parents still doubt this. As a result, some choose immunization schedules that defy science or refuse to vaccinate altogether.

If these parents were distributed randomly, their decisions would be less likely to harm others, especially babies too young for vaccination. But parents who use personal belief exemptions to avoid school vaccination requirements often live in the same communities, studies have found.

And parents of children too young to go to school do, too, according to a study published Monday in the journal Pediatrics. These younger children face the highest risk of dying from whooping cough and other vaccine-preventable diseases.

The study has come out as California is grappling with a measles outbreak linked to people who visited Disneyland in mid-December. So far, the state has reported 41 cases, including in people who didn't visit the theme park, and seven cases have been reported in other states and Mexico.

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The researchers knew that places like Marin and Sonoma counties had higher rates of personal belief exemptions. But those parents probably refused vaccines some years ago, says Dr. Tracy Lieu, director of Kaiser Permanente's Division of Research, who led the study. Her team hoped to spot clusters of refusals earlier, when recommended vaccines are due, so they could take steps to ward off outbreaks.

Communities at higher risk

To look for at-risk communities, Lieu and her colleagues analyzed the medical records of 155,000 children in Kaiser's system who lived in 13 Northern California counties and were born between 2000 and 2011. They were looking both for children who had received no vaccines and for children who had been "under-immunized," meaning they had missed one or more shots by age three.

Researchers then matched these children's vaccination records to their addresses, to see if these children were clustered geographically.

Across the 13 counties analyzed, the proportion of children who'd missed one or more shots increased from an average of 8 percent at the beginning of the study period to 12.4 percent at the end.

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But that's a broad geographic range. When the researchers drilled down to the county level, they found pockets of even higher rates of under-immunization, ranging from 9.2 percent in Santa Clara County to 17.9 percent in Marin County between 2010 and 2012.

Five hot spots stood out, including a 1.8-mile area in Vallejo, where 22.7 percent of kids were under-vaccinated. More than 10,000 toddlers lived within the five clusters.

The team also identified five clusters where all vaccines were refused for the babies and toddlers in the study:

  • 10.2 percent of children in an area from El Cerrito to Alameda
  • 7.4 percent in northeastern San Francisco
  • 6.6 percent in Marin and southwest Sonoma counties
  • 5.5 percent in northeastern Sacramento County and Roseville
  • 13.5 percent of kids in a small area south of Sacramento

Altogether, nearly 9,000 young children lived in these clusters.

In nearly every case, vaccine-refusal clusters overlapped with large areas of under-immunization.

When Lieu's group analyzed vaccination against specific diseases, they found that under-vaccination rates for the MMR vaccine – which protects against measles, mumps and rubella – were 1.69 times higher for children living in Marin and Sonoma counties compared with other areas.

"These are early signals," says Lieu. "These kinds of clusters can be associated with later epidemics."

Measles cases on the rise

The Disneyland measles outbreak is a stark reminder that pathogens can gain a foothold where vulnerable people congregate. That's why states require children to be fully vaccinated before entering kindergarten.

"Not surprisingly, areas that are under-immunized directly correlate with those areas at greatest risk of infections when they occur," says Dr. Paul Offit, who directs the Vaccine Education Center at Children's Hospital of Philadelphia and was not associated with the study. When enough people stop vaccinating, he says, measles and whooping cough, among the most contagious diseases, rapidly exploit holes in community, or herd, immunity.

Last year, when a record number of California parents claimed personal belief exemptions, health officials reported the most measles cases seen here since 1995 and the most whooping cough cases since 1947.

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Marin, Napa and Sonoma counties — where Lieu and her team found under-immunization clusters ranging from 17.5 to 18.1 percent — had the highest rates of whooping cough in the state in 2014. During the same time, a review of state immunization records shows, vaccination rates for whooping cough at nearly two-thirds of Marin schools, a third of Napa schools and 37 percent of Sonoma schools fell below targets to halt disease spread.

In another study, Prof. Saad Omer at Emory University found that clusters of personal belief exemptions contributed to the 2010 California whooping cough epidemic that killed 10 babies. Omer says that by using electronic medical records, Lieu and her team have developed a tool that can estimate risk earlier, without having to wait until children enter school.

The main problem with this clustering behavior, says Omer, is that every child's risk for disease depends on what others do. That's because no vaccine is 100 percent effective, so even a vaccinated child could get sick if exposed. (In the Disneyland measles outbreak, at least four of the cases had been vaccinated.)

Children on chemo or who have other genuine medical reasons for exemption are particularly vulnerable when they interact with unvaccinated people, whether at school or places like Disneyland.

"I don't know how many Make-a-Wish Foundation kids were (at Disneyland)," Omer said in reference to the foundation that grants wishes to children with life-threatening illnesses. "But parents of kids with all sorts of illnesses like to give them an opportunity to have fun like other kids. ... And they depend on herd immunity."

How risky is it?

Some parents think measles isn't such a big risk, Offit says. And compared to the pre-vaccine days, he says, when every year millions of children got sick, 48,000 were hospitalized and 500 died, that's true. But as a veteran of the 1991 Philadelphia measles epidemic that infected 1,400 and killed nine children who weren't immunized, Offit cautions that playing the odds is a dangerous game.

But creating rules that make that game safer is challenging in a society that cherishes individual rights. "We're open-minded in the U.S.," Offit says, "even to the point where we let parents hurt their children."

But increasingly, pediatricians, including Offit's wife, Bonnie, refuse to help parents do that.

The alternative is to sit back and let parents make bad decisions.

Not long ago, a one-and-a-half-year-old boy was admitted to Offit's hospital. He'd been seen at the hospital's outpatient clinic at two, four, six and 12 months — all the times when kids get the pneumococcal vaccine. But his parents chose not to vaccinate and the staff didn't push it, Offit says. "He came in with pneumococcal meningitis," and then suffered a devastating brain herniation, Offit said. "He will never see, walk or speak again and probably won't live past five. It's not OK."

Liza Gross is an independent science journalist based in the San Francisco Bay area who writes frequently about science and society. A version of this story appeared in State of Health, KQED's health blog.

Copyright 2015 NPR. To see more, visit
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The City Might Not Be To Blame For High Asthma Rates

NPR Health Blog - Tue, 01/20/2015 - 1:11pm
The City Might Not Be To Blame For High Asthma Rates January 20, 2015 1:11 PM ET Listen to the Story 3 min 20 sec  

Dr. Stephen Teach helps Jeffery Ulmer listen to his daughter Alauna's asthmatic breathing at Children's National Medical Center in Washington, D.C. Alauna's mother, Farisa, holds her. The District has one of the highest rates of pediatric asthma in the country.

Jahi Chikwendiu/Washington Post

Asthma affects children regardless of where they live and whether they are rich or poor. But scientists have long thought that living in poor urban neighborhoods adds an extra risk for this troublesome lung inflammation. A new study suggests that's not necessarily the case.

Asthma is often triggered by something in the environment, so in the 1960s, scientists started looking for places where asthma was especially bad.

"Researchers started noting that people living in inner cities like New York, Chicago and Baltimore, had rates of asthma in general and they seemed to have very high rates of hospitalization and emergency room visits," says Dr. Corrine Keet, a pediatric allergist at the Johns Hopkins Children's Center.

Keet and her colleagues realized that nobody had ever taken a sweeping look to see if what was true in those cities applied nationwide. So they did that study to check those assumptions. Their surprising findings appear in the Journal of Allergy and Clinical Immunology.

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"We found that living in an inner-city area was actually not a big risk factor for having asthma," she says.

Absolutely, lots of children in these poor neighborhoods had asthma.

"But we also found that even more children had asthma in some poor suburban and medium sized towns in other regions of the country," she says. What's more, for children outside of the Northeastern states, "living in the inner city didn't seem to a risk factor at all for having asthma."

When they dived in to isolate the actual risks, they found that poverty itself was an overwhelming factor, along with African-American or Puerto Rican heritage. There's apparently a genetic component to asthma, though it's tough to tease out. Genetics may help explain why Hispanics from places other than Puerto Rico generally have lower rates of asthma, regardless of their income levels.

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"Where we used to conflate inner city with poverty, now we're see even more concentrated poverty in suburban areas and smaller towns," Keet says.

This means that the environment right outside your door doesn't matter nearly as much as what life is like in your home.

According to Dr. Rosalind Wright, a professor of pediatrics at Mt. Sinai Hospital in New York, there's plenty of evidence that bad housing, beset with cockroaches and mold, can increase the risk of asthma.

"This can also be true in non-urban areas, of course," Wright says. "If you live in lower-quality housing, you may have similar types of risks."

Second-hand smoke is also a risk for children, and poor people tend to smoke more. And people in poverty, no matter where they live, also experience day-to-day stress.

"Certainly people who live with lower incomes have many more challenges to deal with and psychological stress, and this can affect your immune system," Wright says.

Scientists really want to track down the root causes of asthma, so it's helpful to replace the vague observation about life in the inner city with more specific threats that can trigger asthma attacks.

Wright has been chipping away at this problem for years, but she doesn't think we'll end up zeroing in on just a few specific factors.

"The problem is it's not the same environmental factors that might be most relevant or important, if you're talking about the Upper East Side of New York City versus East Harlem versus rural Michigan or something like this," she says.

Wright says what we need now are studies that don't simply survey the landscape but that get down to the nitty-gritty, so scientists can understand how environmental factors and genes interact to trigger this common and occasionally deadly disease.

Copyright 2015 NPR. To see more, visit
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Malpractice Changes In Massachusetts Offer Injured Patients New Options

NPR Health Blog - Tue, 01/20/2015 - 12:17pm
Malpractice Changes In Massachusetts Offer Injured Patients New Options January 20, 201512:17 PM ET

Partner content from

Michelle Andrews

When a woman had gallbladder surgery at a Massachusetts hospital in 2013, doctors noticed something suspicious on a CT scan that they thought could be ovarian cancer. But the recommendation that she get a pelvic ultrasound fell through the cracks. Months later, she was diagnosed with stage 3 ovarian cancer.

Normally, this type of medical mistake could mark the start of a protracted malpractice lawsuit. But a recently enacted state law establishes a process and time frame for discussing mistakes designed to benefit patients, doctors and hospitals. The woman in this case used the process, according to her attorney who recounted the basic facts in an interview but declined to provide identifying details.

The law mandates that people give health care providers six months' notice if they intend to sue. The woman's lawyer notified the hospital of the mistake. Hospital officials, who had 150 days to respond, determined that their actions hadn't met the standard of care. The hospital arranged a meeting between the woman and one of their physicians to talk about why the error occurred and the measures being taken to make sure it won't happen again. The physician apologized, and soon after the woman accepted a financial settlement from the hospital.

The whole process took about a year, far less time than a drawn-out legal battle would have involved, says Jeffrey Catalano, the Boston attorney who represented the woman.

"The hospital did the right thing," he says. "My client felt really good about it. She felt like she was heard."

Traditionally, medical liability reform has often focused on laws that set caps on the dollar amount that plaintiffs can receive in damages. But interest in non-traditional types of medical liability reform has been growing.

In 2010, the Obama administration awarded $23 million in planning and demonstration grants around the country as part of a patient safety and medical liability reform initiative.

Boston's Beth Israel Deaconess Medical Center and the Massachusetts Medical Society received a planning grant for $274,000 to develop a road map for a statewide communication, apology and resolution system.

Communication and resolution programs are gaining in popularity. Advocates emphasize moving quickly when a medical error is made to discuss it with the patient and the patient's family, apologize and, if the standard of care hasn't been met, offer compensation.

In Massachusetts, six hospitals joined a pilot project to implement the model. Medical, legal and consumer groups that had participated in developing the road map formed a health care alliance to exchange information and develop best practices, and provide support for the hospital pilot projects.

In turn, that law bolsters the alliance's efforts to change how medical injuries are addressed. In addition to the six-month cooling off period before a suit can be filed, the law requires that patients be told when medical mistakes are made that result in unexpected complications and allows providers to apologize for unanticipated outcomes without fear their words will be used against them in court.

The broad-based Massachusetts' effort is modeled after the University of Michigan's communication and resolution program. Since the program began in 2001, medical malpractice costs have declined as have the rates of claims and lawsuits, according to a 2010 study published in the Annals of Internal Medicine.

Saving money shouldn't be the primary motivation for adopting a program, says Richard Boothman, the chief risk officer for University of Michigan Health System and the man who pioneered their program. Patient safety is the goal.

"The very best risk management is to not hurt anybody in avoidable ways, and the second best [strategy] if we do hurt someone is not to do it again," he says.

Copyright 2015 Kaiser Health News. To see more, visit
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When Bariatric Surgery's Benefits Wane, This Procedure Can Help

NPR Health Blog - Mon, 01/19/2015 - 3:33am
When Bariatric Surgery's Benefits Wane, This Procedure Can Help January 19, 2015 3:33 AM ET Listen to the Story 3 min 24 sec  

For most of her life Fran Friedman struggled with compulsive eating. At 59 years old she was 5 foot 2 and weighed 360 pounds. That's when she opted for bariatric surgery.

The surgery worked. Friedman, who is now 70 and lives in Los Angeles, lost 175 pounds. "It was a miracle," Friedman says, not to feel hungry. "It was the first time in my life that I've ever lost a lot of weight and was able to maintain it."

Friedman kept the weight off for almost 10 years. But then to her dismay she started to gain it back. "I thought I was cured," she says. "I thought I could eat like regular people."

She's not alone, says Dr. Rabindra Watson, Assistant Clinical Professor at the University of California, Los Angeles, Division of Digestive Diseases.

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About one in three patients regain significant amounts of weight a few years after surgery to reduce the size of the stomach pouch. Bariatric surgery shrinks the stomach to about the size of an egg, so people feel full from eating very little food. The problem is that over the years the stomach stretches, and when that happens, Watson says, "Patients are able to eat more at one sitting and they feel hungrier more often."

At the same time, hormonal changes that reduce the appetite and take effect immediately after the surgery begin to decline. Watson says we don't know for sure, but it's possible the body begins to adapt to those changes, which is why the weight loss is reversed over time.

For Fran Friedman, it meant a 20-pound weight gain and a bout of depression. "The reality hits," she says. "Do I want to go back to where I was or do I want to maintain this level of quality of life?"

So Friedman opted for a less invasive procedure to make her stomach smaller again. It's called Transoral Outlet Reduction – or TORe for short. It's one of several procedures designed to help people maintain the benefits of bariatric surgery. This procedure involves inserting an endoscope through the mouth into the stomach while the patient is under anesthesia. It costs $8,000 to $13,000 and insurance coverage varies.

If the stomach pouch has stretched, new sutures are put in place to once again reduce the size of the stomach. After the surgery, Watson says, patients report feeling fuller and less hungry and they ultimately gain greater control over what they are eating. And research conducted over the past decade suggests it works. There are no significant side effects to the surgery, and patients can return to work the day after they have the procedure.

For Friedman, it did the trick. She has lost 30 pounds since her second surgery. And now, she says, with the help of a support group she is recommitted to watching what she eats and how much she exercises. She wants to lose another 20 pounds. And more importantly, she wants to keep the weight off.

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Sure You Can Track Your Health Data, But Can Your Doctor Use It?

NPR Health Blog - Mon, 01/19/2015 - 3:32am
Sure You Can Track Your Health Data, But Can Your Doctor Use It? January 19, 2015 3:32 AM ET


Amy Standen Listen to the Story 3 min 48 sec   Katherine Streeter for NPR

Dr. Paul Abramson is no technophobe. He works at a hydraulic standing desk made in Denmark and his stethoscope boasts a data screen. "I'm an engineer and I'm in health care," he says. "I like gadgets." Still, the proliferation of gadgets that collect health data are giving him pause.

Abramson is a primary care doctor in San Francisco and lots of his patients work in the tech industry. So it's not surprising that more and more of them are coming in with information collected from consumer medical devices — you know, those wristbands and phone apps that measure how much exercise you're getting or how many calories you're eating.

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The "wearables" market is growing fast. Credit Suisse estimates it's already worth between $3 billion and $5 billion. Add to that nearly 50,000 health apps, and you have a booming new digital health industry aiming to transform health care in the same way Amazon took on publishing.

Abramson says all the information these devices collect can be overwhelming. One of his patients arrived with pages and pages of Excel spread sheets full of data — everything from heart rate to symptoms to medications. Abramson says he didn't know what to do with it all.

"Going through it and trying to analyze and extract meaning from it was not really feasible," he says.

To Abramson, the spreadsheets just didn't say all that much. "I get information from watching people's body language, tics and tone of voice," he says. "Subtleties you just can't get from a Fitbit or some kind of health app."

Despite this reluctance on the part of doctors, technology startups are actively trying to insert their products into the doctor's office.

“ "We can't make the leap that just because this data is coming in digitally that it's accurate."

Doctors get pitches from entrepreneurs almost daily, says Dr. Michael Blum, a cardiologist at the University of California, San Francisco. "Their perspective is, 'You old doctors have kept things the same as they are for 50 years. We've got new technology and it's going to disrupt health care,'" he says.

Don't get him wrong. Blum thinks health care needs an update, for sure.

The problem is, just because a device looks shiny and new doesn't mean it's useful. FitBits and Apple Watches aren't regulated by the Food and Drug Administration. In fact the FDA doesn't intend to regulate what it calls "low-risk devices" that are only intended to promote general wellness, like weight loss, physical fitness or stress management. Only medical devices that are intended for use in the diagnosis or treatment of disease need FDA approval.

All Tech Considered For Wearable Tech, One Size Does Not Fit All

Blum says, "We can't make the leap that just because the data from these low-risk devices is coming in digitally doesn't mean that it's accurate." He says validation studies are needed.

Often that task falls to doctors and hospitals. At UCSF, Blum now heads an entire new department created to sort out which technologies are game changing and which are dead ends.

Other health care groups are following suit, running pilot studies that give devices to people with certain illnesses to see whether they help.

Bret Parker is taking part in one such study for Parkinson's disease. He's 46 years old, lives in New York City and has blogged about his illness. "When I heard there was a trial that involved a wearable that would help me better manage my symptoms and my condition, I said to myself, 'Well, that's a pretty cool thing. I've got to try that.' "

Bret Parker went skydiving in 2013 to raise money for the Michael J. Fox Foundation. Parker participated in a study earlier this year about whether a wearable tracker could effectively measure the severity of tremors caused by Parkinson's.

Courtesy of Bret Parker

Parker enrolled in a pilot study to see whether an activity tracker made by Intel would be useful to track the severity of his tremors. It creates a digital diary showing how tremors respond to minor changes in diet, sleep patterns or what time of day Parker takes his medication.

Parker says in the early stages of his disease, he didn't pay close attention to those kinds of details. But as the Parkinson's progresses, he believes he'll have to change his approach.

"This is going to be a battle between me and Parkinson's in the years to come," he says. "As it advances, it means I've got to be better and smarter at my role in it."

He hopes the wearable will help him do that.

Copyright 2015 KQED Public Media. To see more, visit
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Calif. Strike Highlights Larger Issues With Mental Health System

NPR Health Blog - Sun, 01/18/2015 - 4:57pm
Calif. Strike Highlights Larger Issues With Mental Health System January 18, 2015 4:57 PM ET NPR Staff Listen to the Story 4 min 51 sec  

A Kaiser mental health worker with the National Union of Healthcare Workers looks through a pile of signs Monday during day one of a week-long demonstration outside of a Kaiser Permanente hospital in San Francisco.

Justin Sullivan/Getty Images

This past week, more than 2,000 mental health workers for the HMO health care giant Kaiser Permanente in California went on strike.

The strike was organized by the National Union of Healthcare Workers. The union says Kaiser Permanente patients have been the victims of "chronic failure to provide its members with timely, quality mental health care."

On Thursday, about 150 Kaiser Permanente employees picketed the Woodland Hills Medical Center in the San Fernando Valley. One of them was therapist Deborah Silverman. In her eyes, the biggest problem at Kaiser right now is understaffing.

Silverman says there are so many patients waiting to see therapists, that Kaiser sends new patients to see her, even if she's already overbooked. She says for three days over a two-week period she had four people she didn't know.

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"I have to put them some place, and I didn't have any appointments for at least three weeks. So that's a huge emotional cost to me," Silverman says. "I either have to try to find someone else who has an open slot, which means the person has to switch, or people have to wait, and they've come to see you. It makes you feel — it really bumps up against our ethical standards."

Silverman says switching therapists often makes it difficult to establish a bond and make progress.

John Nelson, Kaiser Permanent's vice president of government relations, says the company delivers some of the highest-quality mental health care in California and in the country. But, he says, they absolutely want to get better.

"Really the only way we can do that is by working together," Nelson says. "So we need our therapists and psychologists and others to be working with us, and constructively on how to get better, and not walking away from patients and being gone for seven days."

But it's not just the union saying there's a problem at Kaiser.

In 2013, the state of California fined Kaiser $4 million, finding that some of these problems — like the long wait times, and the company discouraging people from seeking costly individual therapy — violated federal and state laws about mental health care.

Technology New Apps Give Teens Easier, Persistent Access To Mental Help

April Dembosky has been following the story for NPR member station KQED. She says even though Kaiser paid the fine last September, the union is still unhappy.

"They're arguing that Kaiser has simply shifted resources," Dembosky tells NPR's Arun Rath. "So that fine was directed mainly at initial visits ... [those] arguing they had to wait an unreasonably long time" to be seen for their first visit.

Dembosky says the union is alleging that now patients might get that initial appointment faster, but "good luck with a follow-up appointment."

"They're saying people are still being made to wait two, four, six weeks," she says.

Dembosky says she thinks what might be happening now, as far as patient wait times, is a result of campaigns that have sought to reduce stigma around mental health services. Some of that seems to have worked and more people with mental health problems are coming forward, she says.

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"In my reporting I'm seeing this come up in several other venues, not just at Kaiser," she says, including the state's university system. "This is something that ... is an issue that's coming up in other health care systems."

Dembosky says there is also a shortage of mental health care professionals to meet the demand of new patients — not enough people are completing the lengthy licensing process necessary to provide care.

Meanwhile, there's no sign that an agreement between Kaiser Permanente and the union is imminent — but Kaiser's mental health workers will be back on the job Monday.

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One Scientist's Race To Help Microbes Help You

NPR Health Blog - Sun, 01/18/2015 - 5:46am
One Scientist's Race To Help Microbes Help You January 18, 2015 5:46 AM ET Katherine Harmon Courage

Biologist Rob Knight, co-founder of the American Gut Project, recently moved the project to the University of California, San Diego's School of Medicine.

Casey A. Cass/University of Colorado

The rate of recent discoveries about the human microbiome has been dizzying. And Rob Knight wants to crank up the pace.

One of the top scientists in a field that's discovering possible bacterial influences on everything from diabetes to depression, Knight was also co-founder of a massive citizen science experiment called the American Gut Project. He recently moved from the University of Colorado, Boulder and took the gut project with him — to the medical school at the University of California, San Diego.

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The project lets anybody, for a $99 fee, have the microbes of the gut, mouth, skin or other orifices inventoried. And it's not just for people, but pets, too. Last year I roped my husband, mom and dog into having their gut microbes analyzed along with mine in hopes of discovering what microscopic stories we share. (You can read more about the results here.)

I caught up with Knight by phone on Friday to talk about what's next. Below is an edited version of our chat.

What is the current state of microbiome research?

Right now a lot of microbiome research is about pattern discovery. We're finding connections between microbes and all kinds of conditions we never knew they were involved with — ranging from obesity to colon cancer to rheumatoid arthritis and (in mouse models) even things like autism, depression and multiple sclerosis.

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In the future it's going to move beyond the correlations to actually finding out which of those conditions microbes cause — and which of those conditions we can either predict or modify with improved knowledge about the microbial world.

What are some of the current challenges in microbiome research?

In microbiome studies, some of the effects are so obvious that you can see them with just a handful of people. But other effects you might need to get a population of fives of thousands or tens of thousands to be able to understand what's going on.

That becomes especially true if you start to look at combinations of variables. So, maybe exercise has a particular effect on your microbiome if you're on a special diet, or if you're taking a particular drug. Once you start to look at those combinations of factors (talking about, say, racial or ethnic background, or medication or lifestyle effects, such as diet and exercise) in combination and trying to make predictions, you could see how you would need relatively large numbers of people to even begin to get anywhere.

Another challenge is in computation. The ability to generate the data has greatly outstripped a lot of people's ability to analyze the data.

Then there's the user interface. Especially if we want to get this into the hands of clinicians, which we do, and to people who want to interpret their own microbiome results, you really don't want a huge table of numbers. So we are trying to make this easy for users to understand — the same way that GPS went from being just inscrutable numbers to being a map where you can see, turn by turn, where you're supposed to go. That's what we mean to do for the microbiome — to make it easy to use.

With your move from CU Boulder to UCSD, where do you hope to take microbiome research next?

There are several things that are exciting about this move. One is that San Diego is one of the world's premier biotechnology hubs. So being able to collaborate with companies on technology and being able to help companies discover, for example, if a particular probiotic, prebiotic or diet will affect your microbiome. Being able to work with these companies directly to figure out whether their product has an effect — and whether that effect is beneficial or harmful — is really exciting.

Another factor is getting the resources at the [UCSD] medical school — and at the Rady Children's Hospital. The bio bank here is collecting 300,000 biological specimens a month, so we will be able to add a microbiome dimension to the study of diseases — including diseases where there is no hint yet that the microbiome is involved. When you consider the number of diseases where, just over the last five years, it went from being crazy to think the microbes were involved to now being crazy to think the microbes aren't involved, it's amazing how rapidly the evidence has been accumulating. There's a lot of potential there.

What's happening with the American Gut Project?

We have our equipment up and running in San Diego, so we're able to do DNA extractions, PCRs, sequencing and so forth. And samples that have been sent to Boulder are being redirected to San Diego, so no one needs to worry about their sample being lost!

What's next?

We're hoping to scale it up and decrease costs.

We want to reach out to people who share the same factors — whether it's people who live in the same area, do the same sport, have the same diet, are taking the same medication or have the same medical condition. Finding out what matters and what doesn't matter in your microbiome — and which of these factors in which you resemble another person also cause your microbiome to be similar — is going to be really fascinating.

I can't say anything too explicit yet, but we're also looking to partner with companies where we might be able to do things like integrated human genome and microbiome sampling.

We already launched the British Gut Project and the Australian Gut Project, and expanding those kinds of spinoffs to more countries is going to be exciting.

It's going to take a while, but the potential is just tremendous, especially given the disparities between countries — even those that share a border — in a lot of conditions that we now know are linked to the microbiome. So understanding what factors affect those health issues across different geographic regions is going to be very exciting.

We are also hoping to create an open platform where any scientist, physician, educator, student or anyone at a company can very rapidly look at the dataset to get an idea about what the effect on the microbiome a treatment or product might have — and then use that as a basis for designing more carefully controlled studies.

And we think there's a tremendous amount of potential for medical education about probiotics, prebiotics, antibiotics and the microbiome.

I think the possibility of not just discovering patterns but turning those patterns into things that actually affect and benefit people's lives is tremendous.

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

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Teens Who Skimp On Sleep Now Have More Drinking Problems Later

NPR Health Blog - Fri, 01/16/2015 - 4:12pm
Teens Who Skimp On Sleep Now Have More Drinking Problems Later January 16, 2015 4:12 PM ET

Sleep-deprived teenagers find it difficult to focus in class, and they're more likely get sick. They are also more likely to develop problems with alcohol later on, according to a study published Friday in the journal Alcoholism: Clinical & Experimental Research.

The study included teens who suffered from conditions like insomnia as well as those who simply weren't getting enough sleep. Teenagers ages 14 through 16 who had trouble falling or staying asleep were 47 percent more likely to binge drink than their well-rested peers.

Sleep problems were linked to even more issues with alcohol later on.

Teens who had trouble sleeping when the researchers first checked in with them were 14 percent more likely to drive drunk and 11 percent more likely to have interpersonal issues related to alcohol a year later. And five years after that — when everyone was college-aged or older — those who had sleep issues in high school were 10 percent more likely to drive drunk.

Shots - Health News Less Sleep, More Time Online Raise Risk For Teen Depression

About 45 percent of adolescents don't get the recommended eight to 10 hours a night, polls show.

The findings are based on data collected from 6,500 adolescents who were part of the larger National Longitudinal Study of Adolescent Health, which began tracking a group of adolescents in the mid-90s.

Researchers have known for a while that lack of sleep and alcohol use are related, says Maria Wong, a psychologist at Idaho State University who led the study. "This study shows that sleep issues can actually precede and even predict alcohol use later on."

And the influence of sleep on drinking behaviors can be dramatic, Wong tells Shots. In the study, each extra hour of sleep the teens got corresponded with a 10 percent decrease in binge drinking.

"We're not saying that sleep is the only risk factor for alcohol use," Wong says. In fact, another study published in the same journal issue found that a combination of genetics and peer influence affect teens' decisions to drink.

Shots - Health News Pediatricians Say School Should Start Later For Teens' Health

But a child's genetic makeup isn't something anyone can change, Wong says, "and beyond a certain extent, we cannot control whom kids spend time with outside the home."

Sleep, however, may be something that teenagers and their parents can control. "If we can make sure they have enough sleep, we can help them make good choices," Wong says.

Of course, that's much easier said than done. Teens don't usually take well to having bedtimes imposed on them. And even if they did, forcing kids to get in bed early won't necessarily help, says Dr. Maida Chen, the director of the Pediatric Sleep Disorders Center at Seattle Children's Hospital. "Because of their biology, simply saying to teens, 'Go to sleep earlier' is not a plausible solution," says Chen, who wasn't involved in the recent research.

The body's natural circadian rhythms tend to shift during adolescence, Chen explains, so teens may find it difficult fall asleep until 11 p.m. or midnight.

That's why many parents and pediatricians have been pushing to delay school start times for middle and high school students. "Teens have to get up at 5 or 6 in the morning in order to get to school by 7 or 8," Chen says, which means that most of them aren't getting nearly enough rest.

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Last year the American Academy of Pediatrics issued a policy statement calling on middle and high school to start at 8:30 a.m. or later.

"This new research shows what we have long suspected — there seems to be a link between lack of sleep and risky behaviors in teenagers," Chen says.

The people involved in the recent study were teenagers in the 1990s, Chen points out. "I wouldn't be surprised if the situation was in some ways worse these days," she says, "because nowadays, everyone has some electronic distraction that they carry into bed with them."

Many of the patients Chen sees at Seattle's Children come in because their grades have started to fall or because they're having behavior issues at school, she says.

"This is not just about teens not sleeping enough and then feeling a bit grumpy the next day," Chen says. "Sleep really affects their ability to function and make good decisions."

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A Weight-Loss Device Aims To Curb Hunger By Zapping A Nerve

NPR Health Blog - Fri, 01/16/2015 - 11:56am
A Weight-Loss Device Aims To Curb Hunger By Zapping A Nerve January 16, 201511:56 AM ET Alison Bruzek

Electrical impulses generated by a pacemaker-like device are transmitted to the vagus nerve by electrodes.


What if you could zap your hunger away? A device approved by the U.S. Food and Drug Administration on Wednesday promises to do just that.

The VBLOC vagal blocking device, developed by EnteroMedics of St. Paul, Minn., generates an electrical pulse in the vagus nerve, perhaps blocking communication between the brain and stomach. Normally, the nerve helps tell the brain whether the stomach is empty or full, among many other tasks.

"I suspect it blinds the brain of what's going on in the gastrointestinal tract," says Dr. Scott Shikora, director of the Center for Metabolic and Bariatric Surgery at Brigham and Women's Hospital and consulting chief medical officer to EnteroMedics. However, researchers don't really know why stimulating the vagus nerve might make people feel less hungry.

"A lot of the interest in the vagus nerve as an avenue to promote weight loss stems from animal studies that found that stimulating the vagus nerve close to the stomach resulted in weight loss and decreased eating," psychologist Jamie Bodenlos at Hobart and William Smith Colleges, who is unaffiliated with the device, told Shots via email.

Zapping the vagus nerve is not a new therapy. Vagus nerve stimulation has been approved by the FDA to treat chronic or recurrent depression that doesn't respond to treatment, as well as epilepsy. It also can be used for patients with gasteroparesis, a condition when the stomach doesn't empty completely.

The device is intended to interrupt signals sent from the stomach to the brain.


But VNS is not considered a first-line solution for those disorders, and it won't be for obesity, either.

This device won't be for most people who need to lose weight. It's only approved for patients over 18 who have unsuccessfully tried a weight loss program, have a body mass index of 35 to 45 and have an additional obesity-related illness like Type 2 diabetes.

The system includes three implanted devices. There's a pulse generator that sends electrical impulses, placed in the upper left chest, and two lead wires that are placed on the vagus nerve in the abdomen. Outside the body, the signals can be modified by a controller that attaches to a battery charger and a transmitter coil.

In a clinical trial, published in the September 2014 issue of JAMA, the journal of the American Medical Association, 233 patients in Australia and the United States with a BMI of 35 or greater used the device for 18 months. Some had it turned on, while others had the device implanted but inactive.

The participants had an average BMI of 41, which means a person who is 5 foot 8 would weigh 270 pounds. They were considered about 97 pounds overweight on average.

After 12 months, the group using an active device had lost about 24 percent of that excess weight, or 9 percent of their total body weight. That's compared to the people with the sham devices, who lost 16 percent of excess weight, or about 6 percent of body weight. The people who had the sham devices probably lost weight because of the placebo effect, the researchers speculate, and also because all of the people in the study were participating in a diet and exercise program.

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The people using the active devices did say they were less hungry. About 4 percent of people reported serious adverse events, including surgical complications, pain at the electrode sites, heartburn, and abdominal pain.

Although the device didn't help people lose 10 percent more excess weight, than the control group, which was the study's target, the FDA Advisory Committee on Gastroenterology-Urology Devices found that the benefits were still significant enough to approve the device for patients meeting certain criteria.

Researchers not involved with the device caution that the results show only moderate weight loss and shouldn't be overstated.

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"It is possible that this will be a component of treatment of obesity, but it's too early to tell," says Dr. Dario Englot, a neurosurgeon at the University of California San Francisco who has studied vagus nerve stimulation for epilepsy. "It's also possible that the effects that have been seen are the result of coincidence and this is going to be a fad that falls by the wayside."

However, Englot says, "Because obesity is such a problem, I think it's a positive step to try new treatments as long as we know that they're safe, and we know now that this is relatively safe."

The FDA hadn't approved an obesity device since September 2007, when the Realize gastric band was approved for bariatric surgery.

The FDA has ordered EnteroMedics to follow at least 100 additional patients over the next five years to collect safety and effectiveness data on weight loss and side effects with the device.

According to the company, they're working on getting insurance coverage for the device. They say pricing will be comparable to other bariatric procedures, in the $10,000 to $30,000 range.

But, says Englot, the best tool against obesity "continues to be a diet and exercise regime – and no surgical procedure or device is going to replace that."

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By Making A Game Out Of Rejection, A Man Conquers Fear

NPR Health Blog - Fri, 01/16/2015 - 3:23am
By Making A Game Out Of Rejection, A Man Conquers Fear January 16, 2015 3:23 AM ET Listen to the Story 6 min 56 sec   Daniel Horowitz for NPR

Fear is one of the strongest and most basic of human emotions, and it's the focus of Fearless, the second episode of Invisibilia, NPR's new show on the invisible forces that shape human behavior.

This segment of the show explores how a man decided to conquer his fear of rejection by getting rejected every day — on purpose.

The evolution of Jason Comely, a freelance IT guy from Cambridge, Ontario, began one sad night several years ago.

"That Friday evening that I was in my one-bedroom apartment trying to be busy," Comely says. "But really, I knew that I was avoiding things."

See, nine months earlier, Jason's wife had left him.

"She ... found someone that was taller than I was — had more money than I had. ... So, yeah."

And since then, Jason had really withdrawn from life. He didn't go out, and he avoided talking to people, especially women.

But that Friday, he realized that this approach was taking a toll.

“ "I asked myself, afraid of what? I thought, I'm afraid of rejection."

"I had nowhere to go, and no one to hang out with," Comely says. "And so I just broke down and started crying." He realized that he was afraid. "I asked myself, afraid of what?

"I thought, I'm afraid of rejection."

Which got him thinking about the Spetsnaz, an elite Russian military unit with a really intense training regime.

"You know, I heard of one situation where they were, like, locked in a room, a windowless room, with a very angry dog, and they'd only be armed with a spade, and only one person is going to get out — the dog or the Spetsnaz."

And that gave him an idea. Maybe he could somehow use the rigorous approach of the Spetsnaz against his fear.

So if you're a freelance IT guy, living in a one-bedroom apartment in Cambridge, Ontario, what is the modern equivalent of being trapped in a windowless room with a rabid dog and nothing to protect you but a single handheld spade?

"I had to get rejected at least once every single day by someone."

He started in the parking lot of his local grocery store. Went up to a total stranger and asked for a ride across town.

"And he looked at me, like, and just said, 'I'm not going that way, buddy.' And I was like, 'Thank you!'

"It was like, 'Got it! I got my rejection.' "

Jason had totally inverted the rules of life. He took rejection and made it something he wanted — so he would feel good when he got it.

Cards from the Rejection Therapy game.

Courtesy of Jason Comely

"And it was sort of like walking on my hands or living on my hands or living underwater or something. It was just a different reality. The rules of life had changed."

Without knowing it, Jason had used a standard tool of psychotherapy called exposure therapy. You force yourself to be exposed to exactly the thing you fear, and eventually you recognize that the thing you fear isn't hurting you. You become desensitized. It's used in treating phobias like fear of flying.

Jason kept on seeking out rejection. And as he did, he found that people were actually more receptive to him, and he was more receptive to people, too. "I was able to approach people, because what are you gonna do, reject me? Great!"

That was when Jason got another idea.

He wrote down all of his real-life rejection attempts, things like, "Ask for a ride from stranger, even if you don't need one." "Before purchasing something, ask for a discount." "Ask a stranger for a breath mint."

He had them printed on a deck of cards and started selling them online.

Slowly, the Rejection Therapy game became kind of a small cult phenomenon, with people playing all over the world.

Cards from the Rejection Therapy game.

Courtesy of Jason Comely

Jason has heard from a teacher in Colorado, a massage therapist in Budapest, a computer programmer in Japan, even a widowed Russian grandmother. She's using rejection therapy to pick up men.

"That's really cool — so, there's an 80-year-old babushka playing Rejection Therapy," he says.

So what has Jason learned from all this?

That most fears aren't real in the way you think they are. They're just a story you tell yourself, and you can choose to stop repeating it. Choose to stop listening.

“ "Just get out there and get rejected, and sometimes it's going to get dirty. But that's OK, 'cause you're going to feel great after, you're going to feel like, 'Wow. I disobeyed fear.' "

"Don't even bother trying to be cool," Jason says. "Just get out there and get rejected, and sometimes it's going to get dirty. But that's OK, 'cause you're going to feel great after, you're going to feel like, 'Wow. I disobeyed fear.' "

To hear more about fear and what would happen if we made it disappear, listen to Fearless, the second episode of Invisibilia, NPR's newest program. It explores how invisible things shape our behavior and our lives. The program runs on many public radio stations, and the podcast is available for download at and on iTunes.

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Limited Insurance Choices Frustrate Patients In California

NPR Health Blog - Thu, 01/15/2015 - 5:20pm
Limited Insurance Choices Frustrate Patients In California January 15, 2015 5:20 PM ET


Pauline Bartolone Listen to the Story 3 min 30 sec  

Dennie and Kathy Wright sift through a stack of medical bills at their home in Indian Valley, Calif.

Pauline Bartolone for NPR

Dennie Wright lives in Indian Valley, a tiny alpine community at the northern end of the Sierra, close to the border with Nevada.

Wright works as a meat cutter in a grocery store and lives in a modest home overlooking a green pasture. He also lives in one of the 250 ZIP codes where Blue Shield of California stopped selling individual policies in 2014. As his insurance agent explained it, Wright had only one choice of companies if he wanted to buy insurance on Covered California, the state's health insurance exchange. That lone option was Anthem Blue Cross, so Wright bought one of the Anthem policies.

"That was new to us, you know, Covered California," Wright says. "Anthem Blue Cross was the insurance carrier. Then of course, three months later, I have a heart attack."

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More than once, he was flown across the state line to Reno for care. Wright and his wife, Kathy, now have piles of medical bills and insurance paperwork. Though Anthem Blue Cross covers emergency care out of state, it doesn't cover routine doctor care outside a patient's home state. But Wright says traveling from his home to doctors on the California side of the mountains is not as safe or as convenient as going to Reno.

He continues to see the Nevada doctors who put a defibrillator in his chest and saved his life. Anthem Blue Cross will pay some of the bills, but the Wrights still don't know if everything will be covered.

There are other insurance options for Wright, but not through Covered California. Although he didn't need a subsidy, he was left in the same position as people in his area who do need financial help to buy insurance. People with lower incomes can't readily take their business to a competitor, because the state exchange is the only place customers can use federal subsidies to help them buy health insurance. So for these people who are pinched financially, Anthem is the only option.

"I mean, you should have some choices, especially if you're going to have one that's not going to cover you in the places you choose to go," Wright says.

Last July, Covered California Executive Director Peter Lee offered a different impression of choices the marketplace would offer.

"In every corner of the state, consumers will have at least two plans to choose from, and in most areas, where most of the Californians live, they can choose between five or six plans," said Lee during an event to announce the marketplace's 2015 plans and premium rates.

Northern California Pricing Region

Almost half of the Covered California members who have one choice of insurer live in Northern California.

Source: Covered California

Credit: Alyson Hurt/NPR

Shots - Health News A Single Insurer Holds Obamacare's Fate In 2 States

But in 22 counties in Northern California, there are ZIP codes where there is only one choice of insurer, even if that company offers a few different plans. There are areas around Monterey and Santa Cruz on California's central coast that also have only one carrier.

Blue Shield of California said it had to stop selling individual plans in areas that didn't have a hospital contracted with Blue Shield. The insurance firm said it had offered doctors in those areas rates of payment that would keep premiums low, but not all doctors accepted the payment terms.

Covered California estimates that statewide, there are 28,896 Covered California customers who have only one choice of insurance carrier — slightly over 2 percent of the total exchange membership as of November 2014.

Lee says the exchange is now working to increase the range of choices in places where there are none. But he says the problem predated the exchange.

"The challenges of northern, rural counties have been there for a long time," Lee says, "and are still a challenge that we're trying to address head-on."

He says the exchange is now discussing with others how to bring more insurer competition to these areas in 2016.

"We aren't the solution to all the problems that have always been there in terms of challenges in rural communities, and that's something we're certainly looking at — how to improve access and choice," Lee says. "And we'll continue doing that."

Shots - Health News Two Doctors Weigh Whether To Accept Obamacare Plans

Covered California should help increase the number of insurers, says consumer advocate Anthony Wright from Health Access. And policymakers, he says, should lean on insurers and providers to participate in that market.

"Some of this is a combination of putting pressure on the insurers," he says, "and some of this is trying to do work to actually increase the number of providers on the ground in these areas — whether through more training, [or] incentives to be in some of these more rural areas."

Having more insurers in the marketplace, says Anthony Wright, would make it more likely that people can get the care they need.

"At one level, we're trying to make a functioning market," he says, "but it still means that consumers are at the mercy of the market."

This year, people who want more choice than Covered California offers, must venture into the broader health insurance market — if they can afford it.

This story is part of an NPR reporting partnership with Capital Public Radio and Kaiser Health News.

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This Year's Flu Vaccine Is Pretty Wimpy, But Can Still Help

NPR Health Blog - Thu, 01/15/2015 - 1:42pm
This Year's Flu Vaccine Is Pretty Wimpy, But Can Still Help January 15, 2015 1:42 PM ET Listen to the Story 3 min 13 sec  

Bruno Mbango Enyaka gets his flu shot at a community health center in Portland, Maine, on Jan. 7.

Gabe Souza/Press Herald via Getty Images

As expected, this year's flu vaccine looks like it's pretty much of a dud.

The vaccine only appears to cut the chances that someone will end up sick with the flu by 23 percent, according to the first estimate of the vaccine's effectiveness by the federal Centers for Disease Control and Prevention.

The CDC had predicted this year's vaccine wouldn't work very well because the main strain of the flu virus that's circulating this year, known as an H3N2 virus, mutated slightly after the vaccine was created. That enables the virus to evade the immune system response created by getting vaccinated.

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The effectiveness of the flu vaccine varies dramatically from year to year, but can be as high as 50 percent to 60 percent, the CDC says. So if the early estimate of this year's vaccine's effectiveness, reported in this week's Morbidity and Mortality Weekly Report, holds up, it would put the protection at the low end.

Nevertheless, the CDC and others are still urging people to get their flu shots because the vaccine does appear to work well against other, less common strains of the virus that are circulating, and they could become more common as the flu season progresses. We're about halfway through.

"The flu season is not yet over," said William Schaffner, an infectious disease expert at Vanderbilt University. "There are other less impressive strains that are out there making people sick, and against those strains the vaccine is actually on target. So it's providing partial protection."

The CDC has been predicting that this year could be a bad year for the flu because of the expectation that the vaccine wouldn't work very well and because H3N2 viruses tend to be pretty nasty. So the CDC has been urging doctors to be more aggressive about using antiviral drugs like Tamiflu and Relenza when their patients get the flu, especially those at high risk for complications.

"Physicians should be aware that all hospitalized patients and all outpatients at high risk for serious complications should be treated as soon as possible with one of three available influenza antiviral medications if influenza is suspected, regardless of a patient's vaccination status and without waiting for confirmatory testing," the CDC's Joe Bresee said in a statement.

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Why I Left The ER To Run Baltimore's Health Department

NPR Health Blog - Thu, 01/15/2015 - 1:22pm
Why I Left The ER To Run Baltimore's Health Department January 15, 2015 1:22 PM ET Leana Wen

Dr. Leana Wen became Baltimore's health commissioner on Thursday.

Mark Dennis/City of Baltimore

When I was just beginning my third year as a medical student, I learned an important lesson about what matters most in health.

It was a typical summer afternoon in St. Louis, with the temperature and humidity both approaching 100. My patient was a woman in her 40s who was being admitted to the hospital because her lungs were filling with fluid, a complication of kidney failure. She had missed all three dialysis appointments that week.

She told me that her son had been arrested, and he was the one who drove her back and forth from the dialysis clinic. She couldn't pay her bills, and her electricity had been shut off.

When I relayed her story to my supervisor, the attending physician, he cut me off. "It's not your job to open Pandora's box," he said. "Don't ask questions you don't want to know the answers to."

I was dismayed. I grew up in poor neighborhoods around Los Angeles where families routinely had to choose between transportation and food, between medicines and shelter. My patient could have been my mother or my aunt.

I felt compelled to ask my patient about her life so that I could understand the social factors that play such a key role in health. But after that reprimand and many more experiences like it, I learned that this wasn't what most doctors do.

Shots - Health News Heart Of The Matter: Treating The Disease Instead Of The Person

So I began to inhabit two worlds. In one world, I became an ER doctor who diagnoses diseases and treats health problems fast. I help children having asthma attacks breathe. I treat the victims of gun violence by putting tubes in their chests and stabilizing them for surgery. And I resuscitate patients having heart attacks. My job puts me at the front line of public health crises, but it is the dedicated nurses, social workers, and case managers who devise ways to connect our patients with the resources they need in the community.

In my other world, I became an activist and public health professor. I worked on national and international policies that would encourage more equitable access to health care and life-saving pharmaceuticals. While taking my case to officials in Washington, D.C., and Geneva, I learned how important people's immediate environment is to their health. Removing lead from homes and eliminating indoor pollutants help children stay healthy and able to learn. Designing streets for walking and ensuring affordable, nutritious food help prevent obesity and reduce the future costs of diabetes and heart disease.

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Policy decisions that affect everyday life are the ones that can do the most for people's health. For all the billions of dollars invested in new technologies, it's still our environment — indeed, our zip codes — that predicts more about our health than our genetic codes. Where people live, work and play is where we can do the most to prevent disease and ensure wellness.

Now, I have the opportunity to bridge the worlds of frontline medical care and public policy. On Thursday, I began serving as the Health Commissioner of Baltimore City and will lead the oldest, continuously-operating health department in the U.S.

Like many other cities, Baltimore has problems rooted in poverty that have persisted for generations. But the city also has scores of amazing, committed leaders, starting with Mayor Stephanie Rawlings-Blake, who has demonstrated her willingness to tackle big problems with bold solutions. When she talked with me about joining her administration, I saw how well she understands the critical importance of health to other social policies. We also share a common vision that includes helping our children achieve their highest potential, curbing the epidemic of substance abuse and achieving health care access and equity.

The move from academia and daily medical practice to city government presents a daunting challenge, but it's one that I have spent my entire life preparing to face. Given where I come from and what I've seen, I just can't accept geography or circumstance as destiny.

I love clinical practice, and I will miss it. I'll also miss teaching the terrific students and residents I've had the privilege of learning from as well.

But I feel ready to tear Pandora's box wide open and take on the hard problems. I want to ask what I couldn't in medical training. I want to go beyond figuring out how to get one patient to dialysis and instead tackle the factors that led her and many people like her to develop kidney failure in the first place.

I am eager to bring together hospitals, civic leaders, government, frontline providers and people in the community to work on what matters most to improve health for all.

Dr. Wen is an emergency physician and the Health Commissioner of Baltimore City. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine.

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