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What Babies Understand About Adult Sadness

Fri, 06/12/2015 - 5:38pm

By the time they're 18 months old, kids know when you're sad, even if you're not bawling.

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Babies tend to wear their hearts on their tiny little sleeves. They cry because you took away that thing they picked up off the floor and then put in their mouths. They cry because they're tired. Sometimes, they cry just because.

But by the middle of their second year of life, it turns out, babies do understand that a stiff upper lip can be appropriate in certain situations. Children this age show more concern for adults who overtly express sadness, according to a study published this week, but they're also understanding of people who are more emotionally reserved.

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To figure this out, Sabrina Chiarella, who researches human development at Concordia University, rounded up 71 tots — all were around 18 months old — and acted out one of two scenarios for them. Half the babies saw Chiarella get sad and dejected after someone unjustly snatched away her toys. The other half saw her react a bit differently: When the toys were taken away, Chiarella remained outwardly collected.

A camera captured the childrens' facial expressions as they watched the skit. Those who saw Chiarella express sadness looked and acted a bit more concerned than those who witnessed her stoic reserve.

But later, when Chiarella played with each baby, they all seemed to be equally trusting of her emotional responses. They tried to help her when she seemed like she needed it, and they all showed her empathy.

"For example, if I acted sad while I was playing with them, they would give me a teddy bear," she says. "And all of the babies were just as willing to help me reach objects."

The study appears in the journal Infant Behavior and Development. It suggests that by 18 months of age, babies have a fairly sophisticated understanding of human emotion, Chiarella tells Shots. They seem willing, she says, to give stoic people the benefit of the doubt; they understand that overt sadness is appropriate after a negative experience, but also understand that a neutral response doesn't necessarily mean a person is untrustworthy.

"We see here that infants are making an association between events that happen and emotions," she says. "They can sort of deduce what the appropriate emotions should be, based on the events."

The study builds on Chiarella's previous research, which found that, unlike 15-month-old babies, by 18 months, children are able to pick up when someone's emotional reaction doesn't make sense. (You can watch a video about that research here). The 18-month-olds act confused when someone gets upset after good things happen, for example. And they are less likely to trust that person in the future.

Scientists have known for a while that babies can distinguish among various facial expressions. From very early in life, young humans understand that happy looks different from sad. "What we're just starting to see is how much they understand about what those emotions mean," Chiarella says.

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Indeed, recent research — including this study — shows that babies have a more nuanced understanding of emotion than scientists had previously thought, says Melissa Koenig, an associate professor of child development at the University of Minnesota, who wasn't involved in the recent study.

"It used to be that we thought that infants only looked to other people for emotional support and reassurance," she says. "And that's not wrong. But now we're beginning to see that there's more to it."

Infants learn a lot about their own emotions from those around them, Koenig says. It's looking like they're also able to learn a lot about other people based on how they emote.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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The Uninsured Rate Is Low, But Proving It's The Lowest Ever Is Tricky

Fri, 06/12/2015 - 10:00am

"Nearly 1 in 3 uninsured Americans have already been covered — more than 16 million people -– driving our uninsured rate to its lowest level ever," President Obama told a cheering crowd at the Catholic Health Association's annual conference Tuesday.

Jonathan Ernst/Reuters/Landov

Almost no one disputes that the implementation of the federal health law has helped Americans who were previously uninsured gain coverage. But exactly how much has the uninsured rate dropped?

A whole lot, says President Obama.

"Nearly 1 in 3 uninsured Americans have already been covered — more than 16 million people -– driving our uninsured rate to its lowest level ever," he told a cheering crowd at the Catholic Health Association's annual conference Tuesday. "Ever," he added for emphasis.

But is the uninsured rate really the lowest ever? Maybe, say experts. But you can't really tell.

Many pundits and others have been citing periodic polling by the Gallup organization. The 11.9 percent uninsured rate (among adults) it reported in April for this year's first quarter is the lowest measured since it's been keeping track. But Gallup has been measuring only since 2008.

A survey with a longer history – the one conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention – also found an uninsured rate of 11.9 percent for the first three-quarters of 2014. That was down from 16 percent in 2010, the year the Affordable Care Act became law.

But even that survey changed its methodology back in 1997, which was well after employers had begun shedding coverage for workers and families.

"I would say that we have definitive evidence that the uninsured rate for the nonelderly is the lowest it has been since 1997," said Genevieve Kenney, a policy researcher at the Urban Institute and co-director of its Health Policy Center. (Most surveys only measure the nonelderly because nearly everyone over age 65 has Medicare.) "Before that we are on less solid ground because of data limitations."

"Some of the surveys being used now to determine the rate weren't even around or weren't asking health insurance questions a decade ago," agreed Paul Fronstin, who's been studying the uninsured at the Employee Benefit Research Institute since 1993. "The surveys that have been around have changed."

Indeed, the administration's own numbers suggest that in the 1970s and 1980s, the uninsured rate might have been almost the same as it is now or even lower. A December report by the President's Council of Economic Advisers noted that that the uninsured rate at the end of 2014 was "at or near historic lows."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Health Insurance Premiums Will Go Up In 2016, But By How Much?

Fri, 06/12/2015 - 3:27am
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Some health insurance companies are asking for big price increases next year, and that has again riled critics of the federal health care law. But early analysis shows those steep hikes may not affect the majority of consumers.

The numbers released last week came out of a June 1 deadline, under the Affordable Care Act, that requires insurance companies to tell government regulators when they're requesting price hikes of more than 10 percent. Some officials opposed to the law, like Sen. Steve Daines, a Republican from Montana, decried the increases.

"Blue Cross Blue Shield, which is Montana's largest insurer, is asking for an average increase of 23 percent for Montanans enrolled in individual plans," he told colleagues from the U.S. Senate floor last week.

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While that sounds scary, it turns out that Blue Cross Blue Shield in Montana is actually asking for large price hikes on just two plans it wants to offers in the state. While it's not yet public how many they'll offer in 2016, they currently offer 50 plans.

Caroline Pearson, vice president for health reform at the consulting firm Avalere Health, has been digging into available numbers on insurance pricing across several states. She says such price hikes are not the norm. She's not seeing anything like a 20 percent average increase in the price of monthly premiums.

"Those are not necessarily the plans that hold the bulk of enrollment," she says. "So, while some of those plans may be going up a lot in price, that doesn't mean a lot of enrollees are necessarily affected."

In the handful of states where data is available (Connecticut, Maryland, Michigan, Oregon, Virginia, Vermont, Washington state and Washington, D.C.), Pearson says the majority of people buying health coverage on exchanges won't face serious sticker shock.

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"We have seen that about 6 percent average rate increases are expected for 2016," Pearson says.

As Avalere looks at the less expensive plans, she says, "We're seeing anywhere from a 5 percent increase for the lowest-cost plan available, to a 1 percent increase for the second-lowest-cost plan available. So we're really looking at very modest increases — very consistent with what we saw from 2014 to 2015."

Pearson also points out that the price increases — big or small — are by no means final. They're requests from insurance companies. And, in a lot of states, insurance commissioners have the ability to reject price increases they judge unjustifiable. The actual prices of health plans being sold on the exchanges will be final this fall.

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

Copyright 2015 Montana Public Radio. To see more, visit http://www.mtpr.org.
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Should Tanning Bed Warnings Take A Cue From Graphic Cigarette Labels?

Thu, 06/11/2015 - 4:12pm

The FDA requires tanning machines to bear a label explaining the risks, but the messages are not particularly attention-grabbing.

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Young white women like indoor tanning a lot.

Nearly a quarter of them hit a tanning bed in the past year. (The beds are even found on many college campuses.)

That habit is particularly concerning to public health officials because melanoma rates in young women are on the rise owing to UV exposure from the sun and from tanning beds. The Food and Drug Administration requires indoor tanning machines to bear a label saying that these aren't intended for people under 18, and it requires that consumers get other cautionary messages, too. But they're not particularly attention-grabbing.

Some researchers at Georgetown Lombardi Comprehensive Cancer Center wanted to know if a different type of warning featuring images would speak louder than words. And a study of young tanners found they might.

The researchers surveyed 682 non-Hispanic white women ages 18-30 who had tanned indoors at least once during the past year. Five different warning messages were tested.

One was based on the standard text warning that the FDA currently uses. Two of the warnings emphasized the potential downside of tanning — showing either a photo a young woman with scars on her face after skin cancer surgery or an image of melanoma lesions, accompanied by text about tanning risks. These are what the researchers call "loss-framed messages."

Healthy skin (left) shown in some safety messages was less effective than images of skin cancer in influencing young women's tanning intentions.

Courtesy of American Journal of Public Health

And the remaining two warning labels presented images of healthy skin alongside text about the rewards of avoiding tanning — these are called "gain-framed" messages.

Participants were shown all the messages in random order. And after seeing each type of message, they were asked to rate their intention to quit tanning on a scale of 1-7. The text-only message averaged a score of 4, the positive messages averaged a score of 4.2, and the graphic negative images averaged 4.9 and 5.2. The negative messages, but not the positive ones, also decreased participants' intention to tan in the future.

Even though the negative messages had the strongest impact, some people might respond better to the positive messages than to the negative strategy, which is why using both types of messages may maximize the public health impact, says Darren Mays, a behavioral scientist at Georgetown and the lead investigator of the study, which appears in the American Journal of Public Health. They could appear on warning labels or as part of a broader media campaign.

The gross-out tactic, of course, is featured in the graphic ads and package labels already used to discourage cigarette smoking. Those warnings focusing on the health risks of tobacco "have a significant impact on consumer perceptions, and also help to substantially denormalize the behavior so it's not considered socially acceptable," says Cliff Douglas, director of the American Cancer Society's Tobacco Control Center. (The graphic labels proposed for U.S. cigarette packages were withdrawn after tobacco companies successfully challenged them in court.)

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Douglas says it's important to tailor the public health message to the audience. Young people, who often consider themselves invincible, aren't as likely to respond to messages linking a habit to some likely far-off health outcome like lung cancer or early death. But he says they do care about shorter-term consequences, like how they are perceived by their peers and how the habit affects their appearance — like the risk of nasty-looking lesions and potentially disfiguring surgery emphasized in the tanning study, he says.

The study can't show that the messages will spark a long-term attitude change about tanning, or that intentions will translate to actual behavior change. That's what Mays would like to look at next.

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Got Water? Most Kids, Teens Don't Drink Enough

Thu, 06/11/2015 - 4:01pm
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Kids and teens should get two to three quarts of water per day, via food or drink, research suggests.

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Most American children and teenagers aren't drinking enough fluids, and that's leaving them mildly dehydrated, according to a new study. In fact, one-quarter of a broad cross-section of children ages 6 to 19 apparently don't drink any water as part of their fluid intake.

The Harvard scientists who turned up the finding were initially looking into the consumption of sugary drinks in schools and looking for ways to steer children toward water instead — a much healthier beverage.

Along the way, they noticed that "kids weren't really drinking that much fluid," says postdoctoral researcher Erica Kenney at Harvard's T.H. Chan School of Public Health. She wondered if that was posing any problems for them.

So she and her colleagues dug into data from the National Health and Nutrition Examination Survey, which gathers an amazing amount of information from study participants, including chemical tests of their urine. Those urine tests reveal whether people are adequately hydrated — people who don't take in enough water have darker, saltier urine.

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The researchers report Thursday in the American Journal of Public Health that more than half of the several thousand students studied between 2009 and 2012 were at least a bit dehydrated.

"This doesn't mean we're saying kids are dropping like flies or that they're very seriously dehydrated and need to go to the hospital or anything like that," Kenney says. But even mild dehydration can affect children's fatigue levels, mood and possibly their ability to learn, she says.

"It was astounding to me," Kenney says, that so many children said they drink no water at all. "And even among the kids who were drinking water — they weren't drinking very much of it."

The Institute of Medicine says children and teenagers should consume about two to three quarts of water a day (1.7 to 3.3 liters, the IOM says), depending on age, size and sex. Adolescent boys generally need to drink more water than girls do, research suggests.

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"That's total water, so that can be from any beverages — any water that's in your food like soups, juicy fruits and vegetables, things like that," Kenney says.

And while kids fall short, dehydration is an easy problem to fix: Just get them to drink more water throughout the day. But Kenney says it's not quite as simple as it seems.

Especially in cities, "a lot of schools have struggled with providing tap water to kids because of concerns about older plumbing infrastructure and concerns about lead," she says.

Some schools offer jugs of bottled water, but that's expensive and time-consuming to maintain.

Kenney says some school programs aimed at reducing consumption of sugary drinks are now making water more accessible and appealing in the cafeteria — adding a soda-fountain style dispenser for water, for example. Those mealtime programs, she says, can help on the dehydration front, as well.

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How An Economist Helped Patients Find The Right Kidney Donors

Thu, 06/11/2015 - 12:35pm

An economist has ideas for making the market for organ donations more efficient.

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Read an excerpt of Who Gets What - and Why

If you're one of the more than 100,000 people in the United States waiting for a kidney transplant, you might not realize that an economist is trying to get that kidney to you faster. And he wants to make sure it's the best possible kidney for you, so you'll have many healthy years ahead.

The economist in question, Alvin Roth, won a Nobel Prize in 2012 for his work in matching markets. Those are markets where price isn't a key factor. You can't buy a good job or a spot in college. And you can't buy a kidney, because that's illegal.

In his new book, Who Gets What — and Why?, Roth explains how he has applied his understanding of matching markets to make practical improvements in New York City's high school lottery, assignment of medical residencies and finding kidney donors. This conversation has been edited for length and clarity.

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Why kidney transplants? It's not a typical topic for an economist.

Often people expect I have some touching personal story about kidney disease, but it's actually the mathematics that led me to it.

When I would teach students about game theory in markets, I started using kidneys as an example. You can't use money because it's illegal to pay someone for a kidney. I moved to Harvard in 1998, and in 2000 the first kidney exchange in the United States was done at a hospital nearby.

I started to think, gee, there might be a way where I could help organize it, make it easier for people to find kidneys.

You really seem to like finding practical applications for your theories. For instance, you helped come up with a better lottery system for New York City high schools. Why is that?

Practically, I was trained as an engineer. My degrees are all in operations research, not in economics. I gravitated to economics because I'm interested in how people coordinate and collaborate with each other. Economics studies all the ways people get along with each other.

There aren't many kidney donors, which makes it hard for people to get a good match, or any match at all. And transplant centers tend to run their own databases. How did you overcome that?

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There are a couple of challenges as you make a marketplace. You have to make a marketplace thick. So the first thing we had to do was build a database of people who were willing to participate in a kidney exchange. We had to get re-consent forms from everyone in New England; there were 14 transplant centers working with us. Assembling the database and getting the permissions took about a year. Then the hospitals had to get organized so they could do surgeries on the same day. That took about a year to complete.

Once marketplaces get thick, they suffer from congestion. It has to do with all the things you have to do to complete the transaction. When you're shopping on Amazon, it involves searching. There's all this stuff, and you have to find what you want. When you're doing kidney transplants, you have to find out who can exchange kidneys with whom, doing blood tests to make sure it's true. You can't just work on the preliminary data. Then you have to organize the logistics. Initially we were doing simple exchanges, with two pairs of people or three pairs. An exchange with two pairs, where the patients got a kidney from the other patient's incompatible donor, needed four operating rooms because the surgery was done simultaneously. That way if a donor changed her or his mind at the last moment, someone wouldn't be left without a kidney. And a three-way exchange required six. That's about as much as we could manage in New England.

How did you break that logjam?

We figured out that if you had a nondirected donor, someone who wasn't paired with a patient but who was willing to donate a kidney to anyone, you didn't have to do simultaneous exchanges. If the chain of transplants was broken along the way, no one would be tragically harmed. So nowadays we do quite long chains of exchanges.

Market design is a very outward-facing form of economics. I'm talking with doctors. I'm talking with school administrators. I'm doing a lot these days on school choice. I'm constantly talking with people who aren't economists. A big deal in market design is finding the inside champions who the economists can help. I kind of think of economists as being helpers here. We have some ideas, but we don't do any of the surgeries.

What next?

There's a terrible shortage of organs around the world. Right now in the United States, there are 100,000 people waiting for a kidney. I've become interested in the fact that it's against the law to pay for a kidney anywhere in the world. But it's not against the law to remove financial disincentives. You might have to fly to California and be in a hotel room and miss a few days of work. Right now we don't make it easy to recoup those expenses, but the current law doesn't forbid it.

I would like to see steps taken making it easy for hospitals to reimburse donors' costs and then get reimbursed by Medicare or private insurance. This would pay for itself, because every transplant saves a quarter of a million dollar in the first five years. It costs $90,000 a year to do dialysis, $100,000 for the transplant and $20,000 a year for anti-rejection drugs. Plus you go back to work, you start feeling good again, you're not tied to a dialysis machine.

Medicine is a big part of the economy. Kidney disease is a big part of the medical economy. If we could do some of these better, it would be good. At some point in the future we won't have to do transplants anymore, but all of the people who need kidneys now will be dead by then. So we need better ways to organize our resources.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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If Obamacare Subsidies Disappear, States And Congress Will Bear Burden For Fix

Thu, 06/11/2015 - 11:07am

Secretary of Health and Human Services Sylvia Burwell talks before a Capitol Hill hearing Wednesday with Rep. Paul Ryan, R-Wis., as Rep. Pat Meehan, R-Pa., looks on.

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It will be up to state officials and Congress to help consumers who can't afford health insurance if the Supreme Court strikes down health law subsidies for millions of Americans, Health and Human Services Secretary Sylvia Burwell.

"The critical decisions will sit with the Congress and states and governors to determine if those subsidies are available," Burwell told the House Ways and Means Committee on Wednesday.

The secretary told Congress earlier this year that the administration has no authority to undo "massive damage" that would come if the court invalidates the subsidies in the online marketplaces, or exchanges, which the federal government operates in about three dozen states.

By the end of this month, the court is expected to issue a ruling in the case, King v. Burwell. More than 6 million people could lose those payments and many more residents could see their premiums increase because of the havoc the loss of subsidies would cause in the market.

The challengers argue that one clause in the law says those federal payments would be available to consumers only in states that run their own exchanges. But the administration has argued the legislative intent was to make subsidies available to customers in every state, regardless of how its exchange was established.

During Wednesday's hearing, Republicans pressed Burwell to indicate what type of legislation President Barack Obama might sign to restore subsidies if the court rules for the challengers. Many Republican lawmakers have acknowledged that they would like to find a way to offer a temporary option to help consumers, but they have failed to coalesce around a specific proposal.

Burwell said while the administration would be open to considering alternatives that make health care more affordable and accessible, the president would not sign legislation from Sen. Ron Johnson, R-Wis. That bill would maintain the subsidies for current beneficiaries through August 2017 but repeal the health law's requirements that most individuals get coverage, that larger businesses offer insurance to their workers or pay a penalty and that plans provide specific types of benefits.

"Something that repeals the Affordable Care Act is not something the president will sign," Burwell said.

A recent report from the American Academy of Actuaries said some changes favored by Johnson and other Republicans, such as eliminating the individual mandate, "could threaten the viability" of the health insurance market for individual plans.

Echoing comments she made last week, Burwell said the administration will work with states to help mitigate the consequences for consumers if the Supreme Court ruled against federal subsidies.

The session was billed as a hearing on the HHS budget fiscal 2016 request, but it quickly veered to Republican attacks on the sweeping 2010 health law while Democrats rushed to defend it.

"Whatever the Supreme Court decides this month, I think the lesson is clear: Obamacare is busted. It just doesn't work. And no quick fix can change this fact," said Ways and Means Chairman Paul Ryan, R-Wis. "Its very linchpin — its central principle — is government control. That means higher prices, fewer choices, and lower quality."

Rep. Sander Levin of Michigan, the panel's ranking Democrat, replied in kind. "What's busted," he said, "is not the ACA but [Republican] attacks on it. Endless attacks. Never coming up with a single comprehensive alternative all these years. So you sit as armchair critics while millions of people have insurance who never had it before. You're livid because it's getting better."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Data Dive Suggests Link Between Heartburn Drugs And Heart Attacks

Thu, 06/11/2015 - 3:45am
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A Stanford University study explored the medical records of millions of people looking for patterns. People taking proton-pump inhibitors for chronic heartburn seemed to be at somewhat higher risk of having a heart attack than people not taking the pills.

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Electronic medical records may seem like a distraction when your doctor is busy typing on a screen instead of looking you in the eye. But, as a new study shows, these systems have the potential to help identify some drug side-effects.

Researchers at Stanford University gathered about 3 million electronic medical records — with patients' names and other identifying material stripped away — to look for a link between a popular heartburn drug and heart attacks.

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The drugs in question are called proton-pump inhibitors, and include Prilosec, Nexium and Prevacid. These PPIs are among the most popular medicines in the world, with sales of $14 billion a year. Roughly 20 million Americans now take the drugs for heartburn, and several versions are sold over the counter.

The researchers had conducted some laboratory work suggesting that PPIs could affect heart tissue. So Nigam Shah, an assistant professor of medicine and biomedical informatics, and his colleagues dived into the electronic medical records compiled by Stanford and a private company to see whether people who took these drugs were also at higher risk of having a heart attack.

The problem is, it's very easy to do studies of this sort that lead to conclusions that can be misleading. I know because I've done that myself.

They report in the journal PLOS One that they did indeed find a modest correlation.

"The increase in risk is about 16 to 20 percent, depending on the particular drug involved," Shah says.

Assuming that link holds up, and the risk is spread evenly throughout the population, someone with a low risk of heart attack doesn't have much to worry about. "If your risk of a cardiovascular event or a heart attack is one in a million, now it is 1.2 in a million," Shah says.

But he's more concerned about people who have a higher risk of a heart attack. Since millions of people take these medications, even a low added risk for an individual can translate to quite a few people across the population.

"I wouldn't want the public to panic and to say we should stop taking these drugs," Shah says. But he does recommend that people taking these drugs talk to their doctors to see if they are at greater than average risk for having a heart attack. "And if your baseline risk is high, then maybe you want to take something else."

The study did not find a link between heart attacks and another popular family of heartburn drugs, called H2 blockers (such as Tagamet, Pepcid and Zantac).

But other scientists aren't ready to recommend the switch to those drugs, which are considered to be somewhat less effective for many people with serious heartburn. The correlation Shah has turned up in his data might stem from other factors.

"The problem is, it's very easy to do studies of this sort that lead to conclusions that can be misleading," says Dr. David Juurlink, a drug-safety researcher at the University of Toronto. "I know because I've done that myself."

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Juurlink has studied these PPI drugs and also found that people who take them are somewhat more likely to have a heart attack. But a correlation doesn't say anything directly about cause and effect. He has looked at all the factors that make someone more likely to be taking these drugs in the first place.

"Having a bad diet, drinking too much alcohol, smoking and all sorts of other things ... might lead people to be on a PPI," Juurlink says. One would expect those people to be at higher risk of heart attack, which leads Juurlink to think the medicine is likely not to blame.

Juurlink says these heartburn drugs have been studied directly in people with a high risk of heart attack, and they did not appear to increase that risk. (He adds that he takes no funding from drug companies.)

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And he notes that PPIs are not risk free — they can occasionally cause kidney problems, and they've been linked to osteoporosis, Vitamin B12 deficiency and low magnesium levels.

Though Juurlink is not persuaded by the Stanford study, he says that kind of research fills an important gap in our knowledge about medications.

"Drugs are brought to market because of randomized trials, typically with a few thousand patients. And then they get used in patients who are very, very different from the patients in randomized trials," Juurlink says. "They get used in sicker patients; they get used for longer durations of time and at different doses. So it's really important that studies like this get done."

The challenge is that results that turn up from mining big data aren't easy to interpret.

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Some Insured Patients Still Skipping Care Because Of High Costs

Wed, 06/10/2015 - 2:55pm
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Renee Mitchell says even though she has health insurance she'll have trouble paying for the eye surgery she needs to save her vision.

Jim Burress/WABE

A key goal of the Affordable Care Act is to help people get health insurance who may have not been able to pay for it before. But the most popular plans – those with low monthly premiums – also have high deductibles and copays. And that can leave medical care still out of reach for some.

Renee Mitchell of Stone Mountain, Georgia is one of those people. She previously put off a medical procedure because of the expense. But as the threat of losing part of her vision became a real possibility, she sought an eye specialist at Emory University, who told her she'd need surgery to correct a cataract procedure gone wrong.

That's not the scariest part, she says. Cost is: "further copays [and] more out-of-pocket expenses."

Mitchell is generally pleased with her insurance — a silver-level Obamacare plan. It's the most popular level plan with consumers because of the benefits it provides for the money. But she still struggles to keep up with her part of the bills.

"One in four adults who were fully insured for the whole year still reported they went without some needed medical care because they couldn't afford it."

"If not for having availability on my credit card, we'd probably be in the poorhouse," Mitchell says.

She still owes more than $20,000 for several years of medical expenses, with more debt accruing in interest each month. If she undergoes that eye surgery, she says, she'll owe another $4,000 – the deductible for the operation.

"It's a very big burden," Mitchell says.

A recent study released by the nonprofit Families USA shows that a lot of folks with coverage like Mitchell's feel a similar burden, and a poll from the Kaiser Family Foundation finds the same thing. The majority of people who buy insurance on state or federal exchanges pick silver-level plans, which often carry a lower monthly premium, but have a high annual deductible – $1,500 or more.

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"Consumers are still struggling with unaffordable, out-of-pocket costs," says Lydia Mitts, a senior policy analyst with Families USA. "One in four adults who were fully insured for the whole year still reported they went without some needed medical care because they couldn't afford it," Mitts says.

Many people in that situation skip follow-up care and don't fill prescriptions. Mitts says that only adds to long-term complications and costs.

But it doesn't have to be that way, she says. Plans in some states, including Pennsylvania, Texas, Florida and Arizona, have recently done away with deductibles on some silver-level insurance plans. And for certain basic services, including doctors' visits and generic prescriptions, other states are requiring only a small copay.

Still, while copays, deductibles and co-insurance weigh heavy on Renee Mitchell's mind, they're not her only insurance concern. Her monthly premium is also getting more expensive. This year, she says, it jumped by about $100 a month.

Mitchell wants to be clear, though: She's not looking for a handout.

"People seem to think that we just want something for nothing," she says. "I worked a lot of years. I took an early retirement to take care of my family. It's not my fault, so to speak, that I'm here."

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

Copyright 2015 WABE-FM. To see more, visit http://www.wabe.org/.
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More Evidence That Parents' Ages Could Influence Autism Risk

Wed, 06/10/2015 - 2:13pm

Children born to older moms and dads tend to have higher rates of autism, but researchers aren't sure why.

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Lots of factors may affect a child's odds of ending up with autism. Researchers around the world have been striving to fully understand how biology, genetics and environment play roles.

A huge study that includes data from more than 5.7 million children in five countries might shed some light on how autism develops — but it also raises new questions.

Researchers looked at autism rates among children born between 1985 and 2004 in Denmark, Israel, Norway, Sweden and Australia.

Shots - Health News Autism Risk 'High' For Kids With Older Sibling With The Disorder

The numbers confirmed what previous studies have shown: Kids born to older moms and dads had higher rates of autism. Rates were also higher among the children of teen moms, and among children whose parents have a relatively large gap between their ages.

"What we're still trying to figure out at this point is why," says Avraham Reichenberg, a professor of psychiatry at the Mount Sinai School of Medicine in New York and the senior author of the study.

Overall, chances that a child will end up with an autism spectrum disorder is around 1 in 100. But the relative risk for autism is two-thirds higher for children born to dads older than 50, compared with kids born to dads in their 20s, the study found.

Shots - Health News More Hints That Dad's Age At Conception Helps Shape A Child's Brain

Other research has suggested that this may be because as men get older, their sperm are more likely to contain random mutations that may, theoretically, contribute to disorders such as autism in their kids.

Researchers know less about why the children of older mothers more often have the disorder. The study found that the autism rate was 15 percent higher in children born to mothers in their 40s, compared with those born to moms in their 20s. Autism rates rose higher still when both parents were older.

"Of course, age is just one factor that may contribute to autism risk," Reichenberg tells Shots. "I think the first thing to remember is that most children who are born to older parents won't have autism."

When doctors work with prospective mothers who are over 35, it's standard to discuss the risks of pregnancy for older women. "This study shows it may be worth also asking how old the woman's the partner is, as that could potentially affect risks."

The figures concerning very young mothers and parents of discrepant ages are more puzzling, Reichenberg says.

Autism rates were 18 percent higher among children born to teen moms than among kids born to moms in their 20s. And when the gap between a mother and father's age widened, the chance that their child would develop autism went up.

Previous studies haven't been big enough to look at autism trends in such detail, he says. "Still, we didn't really get into this study expecting to see these figures."

Explaining the numbers is complicated, he notes, since so many different factors may be in play.

"All we can do is perhaps speculate," Reichenberg says. It could be that a teenage woman's reproductive systems are not fully mature, and that affects the development of her child. Or it could be that younger moms tend to have a lower socioeconomic status in many countries. So a younger mom may lack access to good health care, which, in turn, could affect the developing fetus.

"I think this is very powerful epidemiological work," says Simon Gregory, a genomics researcher at Duke University who wasn't involved in the recent study. "But there are a lot of caveats here as well."

For one, the study didn't take into account complications that mothers may have experienced during their pregnancy, which could affect the baby's odds of developing autism, Gregory says.

Plus, the way that autism is diagnosed in each country is slightly different. Although the researchers tried to account for any discrepancies, even small differences could skew the results, Gregory notes.

"In the research community, we're still trying to figure out how to properly diagnose and classify autism spectrum disorders. And we're a ways away from understanding the underlying mechanisms responsible" Gregory says. "It's a very complex story to tell."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Consumers In 'Grandfathered' Health Plans Can Face Higher Costs

Wed, 06/10/2015 - 8:37am

Health plans begun under the Affordable Care Act are required to cover FDA-approved contraceptive methods without cost to members. Older plans are exempt from that rule.

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Judy Naillon called her insurer several months ago to find out why she was being charged $35 every month for birth control pills. Her friends said they were getting their pills free under the federal health law.

Why wasn't she getting the same deal?

The insurance representative explained that was because the plan Naillon and her husband had through his job was "grandfathered" under the health law. In other words, unlike other health plans, Naillon's insurance policy, which existed before the health law was enacted, doesn't have to cover many preventive services, including contraception.

Naillon would have to continue to pay a share of the cost of her pills, the insurer told her. The plan also wouldn't pay if she wanted to switch to an intrauterine device, and there's no coverage for an annual physical.

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"I'm just really frustrated," says the Wichita, Kan., music teacher. When her husband took a new marketing job last fall, she says, "I thought that surely all these insurers must now be covering these benefits."

About a quarter of insured workers today are enrolled in grandfathered plans, according to the Kaiser Family Foundation, and these plans haven't significantly changed their benefits or costs to consumers since 2010.

Old Plans Not Subject To New Rules

These older plans differ in other ways, too. They don't have to guarantee a member's right to appeal a decision by the insurer, for example, and may charge consumers higher copays or higher co-insurance for out-of-network emergency services. The plans also aren't required to comply with the law's limits on a policy-holder's annual out-of-pocket spending (currently $6,600 for someone in an individual plan and $13,200 for families). So, consumers who have these health plans may be on the hook financially for more of their medical care than people with Obamacare policies.

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When the health law passed, President Barack Obama sought to reassure anxious consumers by promising that "if you like your health care plan, you can keep it." Since then, the number of grandfathered plans has steadily declined.

In 2011, about 72 percent of companies that offered health insurance included at least one grandfathered plan; by 2014 that number had declined to 37 percent, according to the Kaiser Family Foundation's annual survey of employer health benefits.

Smaller employers are more likely than large ones to offer the older policies, says Steve Wojcik, vice president of public policy at the National Business Group on Health, which represents the interests of large employers. Small firms typically buy a plan from an insurer that pays their claims. Larger companies, in contrast, often design their own plans and are self-insured — they pay their employees' claims directly.

Individual plans can also be grandfathered.

Some people who study the insurance market have two words for the demise of grandfathered plans: Good riddance. These policies lack many consumer protections and are generally subject to weaker regulation, so aren't necessarily good options for people who have health problems.

"Grandfathered plans are more likely to hang onto people who are low risk," says Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Some Upsides

On the other hand, the grandfathered policies may come with lower monthly premiums, and in some ways can be a good deal for people who are young and generally healthy.

In order to retain their grandfathered status, the older plans are limited in how much they can increase a policyholder's copayments and deductibles. So, if someone covered by such a plan had a $20 copayment in 2010, for example, the copayment today could be no more than $26 next year, says Joe Kra, a partner and actuary at Mercer, a human resources consulting firm. Likewise, a $500 annual deductible for such a health policy could rise to no more than $652.

"If an employee is in a grandfathered plan, they're one of the fortunate minorities," Kra says.

But Naillon probably wouldn't agree with that statement.

"Even though my doctor would like to do a physical and run labs," she says, "I can't afford to have those services."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Court Decision On Texas Abortion Law Could Hasten Clinic Closures

Wed, 06/10/2015 - 5:03am
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Abortion-rights supporters (foreground) try to disrupt an anti-abortion march to the Texas Capitol during a Texas Rally for Life on Jan. 24 in Austin, Texas.

Eric Gay/AP

A federal appeals court on Tuesday upheld a controversial state law requiring nearly all Texas facilities that perform abortions to operate like hospital-style surgical centers.

If the ruling stands, abortion providers say another dozen could close in the next few weeks. They say that would leave nearly a million women at least 150 miles from the nearest abortion provider.

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Since the law first passed in 2013, about half the state's 40 clinics have shut down.

Providers and women's rights groups have vowed to appeal to the Supreme Court, arguing that the restrictions pose an undue burden on women's constitutional right to abortions.

The 5th U.S. Circuit Court of Appeals decision reverses a lower court ruling, and allows most of a law passed in 2013 to finally take effect. In addition to the requirement calling for clinics to uphold surgical standards, the court upheld a provision that requires doctors who perform abortions to have admitting privileges at a local hospital.

"It is a resounding win, and it applies to virtually the entire state of Texas, except one small carve-out," says Joe Pojman, who heads the Texas Alliance for Life.

The court ruled that in most cases, the provision didn't put an unconstitutional burden on women seeking abortions — making only one exception for a remote clinic in McAllen, near the border with Mexico. But that clinic's owner says the exception is so narrow, she's not sure it will be able to stay open.

In another part of the state, the court ruled that it's fine if a clinic in El Paso closes, since women there can get the procedure just across the state line in New Mexico.

"We would hope that New Mexico would increase its safety standards, and do what Texas has done. But it's pretty silly to say that women in Texas don't have access to abortion, even in El Paso, when they're so readily available in the state of New Mexico," Pojman says.

Critics of the ruling disagree.

"The ruling is absurd because the court is essentially saying if you want to have an abortion you have to travel to other states that don't have these laws," says Stephanie Toti, a lawyer with the Center for Reproductive Rights, which challenged the Texas law. "The court is essentially recognizing that these laws don't provide any health or safety benefit. The point is to try to make Texas an abortion free state."

The impact of the law, even before this ruling, has been devastating, says Amy Hagstrom Miller who heads Whole Woman's Health, which owns several clinics in Texas and is a plaintiff in the case.

"So many women and families don't know where to go, don't know what the law is, think abortion is illegal, are confused about the status of their rights throughout the state," Miller says.

There could also be some confusion in the legal world. The very same 5th Circuit appeals court ruled differently on a similar law in Mississippi, saying that women there had a constitutional right to an abortion in the state where they live.

That could make it more likely that the Supreme Court will step in to decide this case, providing the biggest test of abortion rights in decades.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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In Texas, Federal Court Backs Abortion Restriction Law

Wed, 06/10/2015 - 5:03am
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A federal appeals court has upheld sweeping abortion restrictions in Texas — saying they aim to protect women's health. Providers say the decision could leave just seven or eight centers open.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Costs Of Slipshod Research Methods May Be In The Billions

Tue, 06/09/2015 - 5:43pm
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Laboratory research seeking new medical treatments and cures is fraught with pitfalls: Researchers can inadvertently use bad ingredients, design the experiment poorly, or conduct inadequate data analysis. Scientists working on ways to reduce these sorts of problems have put a staggering price tag on research that isn't easy to reproduce: $28 billion a year.

Better training for students, postdoctoral fellows, even principal investigators is in order here.

That figure, published Tuesday in the journal PLOS Biology, represents about half of all the preclinical medical research that's conducted in labs (in contrast to research on human volunteers). And the finding comes with some important caveats.

The $28 billion doesn't just represent out-and-out waste, the team that did the research cautions. It also includes some studies that produced valid results — but that couldn't be repeated by others because of the confusing way the methods were described, or because of other shortcomings.

Leonard Freedman, who heads a nonprofit called the Global Biological Standards Institute, decided to undertake the study with two Boston University economists, Iain Cockburn and Timothy Simcoe. Their goal was to identify ways to make research more efficient.

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"We initially were asking a very simple question," Freeman says. "We simply wanted to know how much money is being spent each year on basic preclinical research that is not reproducible."

That turned out to be a very difficult question; only a few studies have addressed the issue head-on, and they aren't directly comparable. The economists eventually homed in on a best estimate: $28 billion per year.

But that's a contentious conclusion.

There's no question there are some fields of research where reproducibility is a glaring problem. For example, many scientists who use human cells grown in the lab are actually using cells that aren't what they appear to be. A widely used cell labeled as breast cancer is actually a melanoma cell, it was recently discovered, and there are hundreds of similar examples.

Freedman notes that the National Institutes of Health annually funds about
$3.7 billion worth of research that uses cell lines. "So," he reasons, "if a quarter of these projects apparently use contaminated or misidentified cells, that's a large [share] of the $3.7 billion."

He figures that $1 billion could be saved if scientists first ran DNA fingerprint tests on their cells, to verify that they're studying the right tissue.

Other causes of trouble the scientists identified include poorly designed experiments, poorly documented lab protocols and inappropriate data analysis.

"Better training for students, postdoctoral fellows, even principal investigators is in order here," Freedman says.

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Stefano Bertuzzi, executive director of the American Society for Cell Biology, acknowledges these are all real problems in his field but says that's not the whole story.

"The problem I have with the study is it wants to be a little bit sensational," Bertuzzi says.

The analysis lumps together fatal flaws — like using contaminated cells — with much less serious weaknesses, he says. Some studies are labeled as irreproducible because they give poor descriptions of their methods, making it difficult for other scientists to repeat the experiment.

"While this could be a nuisance, it doesn't mean the study is flawed or is wrong," Bertuzzi says. "The problem is folding all of this into a monetary value that gives the impression that this is wasted money. That's not correct."

Bertuzzi has written a rebuttal to the study, published on his society's Web page.

Freedman agrees that the $28 billion isn't all wasted effort, though it may be easy to jump to that conclusion. "I hope this work is not misconstrued," he says. As science explores the frontiers of knowledge, some missteps are inevitable. And as researchers working in other labs attempt the same experiments, errors get weeded out — and good results get validated. Reproducibility is a cornerstone of scientific research.

Freedman says he hopes that the dollar values he calculated will help focus attention on areas where improvements will yield a big bang for the buck. And in fact, his organization has launched a campaign that's trying to get scientists to make sure they know the true identity of the cells they're studying in their labs.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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The Hard Work Of Waiting For A Hand Transplant

Tue, 06/09/2015 - 3:57pm
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Kevin Lopez makes breakfast with his sister Jenny. He is waiting for a donor hand to remedy a genetic defect.

Meredith Rizzo/NPR

Kevin Lopez remembers exactly when he knew he wasn't like his friends and family.

"It just hit me one day," he says. It was the morning he was picking out a shirt to wear for his first day of sixth grade. "I just looked at myself and I realized I was different."

Kevin was born missing the fingers on his right hand. His arm and wrist are fully developed, and he has most of a regular palm. But he just has nubs where his fingers should start.

When he looked in the mirror that day, Kevin says he suddenly felt overwhelmingly self-conscious. So he took off the short-sleeved shirt he was wearing and put on a long-sleeved shirt instead. Even all these years later, he gets choked up re telling the story.

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"It was at that point that it became more of a problem," says Lopez, who is now 20. He's waiting to become the first person to get a hand transplant because of a birth defect.

NPR is following Lopez through the process. This story explores how he ended up on the waiting list, and what it's like for Lopez and his family as he waits.

Lopez grew up in a big, close family in Chicago. Seeing Kevin so sad was hard for his sisters. So one of his them, Jenny, thought it might help if he talked about his hand more. She suggested he write about it for a school assignment. Kevin burst into tears.

"I remember him just crying and said, 'I just don't want to be like this. I don't want to be like this. I want you to help me,' " Jenny says. "He was telling me: 'Help me, help me' in some way. And I was like, 'Well, I don't know what to do. Right now there really isn't anything we could do.' "

Kevin moved from Chicago to Greenbelt, Md., so he could be closer to Johns Hopkins Hospital in Baltimore.

Meredith Rizzo/NPR

But Jenny says she told him, "OK, well, I'll help you. We'll figure it out. We'll figure something out."

Ever since then, Jenny's been trying to find a way. But back then, Jenny had no idea what she could.

So Kevin had to learn how to live that way. And, he did pretty well, even playing baseball all through high school by catching and throwing with his good left hand. He also worked as a lifeguard at Lake Michigan during summers.

Then one day Jenny spotted an article in a magazine about a doctor who was doing hand transplants. "I was like, 'Oh my God, that's the guy. That's the guy who's going to help us. I just have to find him,' " she says.

Jenny tracked down the surgeon, W.P. Andrew Lee, at Johns Hopkins Hospital in Baltimore. After a lot of testing and counseling, Lee and his colleagues agreed to put Kevin on the waiting list when he turned 18.

"We thought, 'Oh, they're going to call us at any time,' " Jenny says. So Kevin put off starting college and his family decided Kevin should move closer to his surgeon with one of his sisters. Jenny, who is 10 years older than Kevin, volunteered.

A photograph of Kevin Lopez at his high school graduation hangs on the wall at home. At 18, he was put on a waiting list to receive a hand transplant.

Meredith Rizzo/NPR

"I'll do it. I want to do this," she remembers sayings. She took her son out of elementary school and broke off her engagement.

Jenny remembers the rainy day her family loaded her big red sofa and the rest of her worldly belongings into the U-Haul.

"All of our stuff got wet, moving it into the truck," she says. "So it was a very gloomy day, just how we were feeling."

Jenny and Kevin drove all night and got to Maryland the next day. And then, the waiting began.

"My life changed obviously dramatically," she says, adding neither of them realized how long it would take.

Waiting for a hand is a lot more complicated than for organs like livers or kidneys. Those just have to match well enough so that the body won't reject them.

A hand has to look right, too. It has to be the right size, age and skin tone. The first person who got a hand transplant ended up asking his surgeon to remove it.

Doctors are being very careful about finding a hand that will match Kevin well. Kevin's case has been complicated by the fact that he's Latino. Latinos don't agree to donate organs as often as Caucasians, though rates of consent for donation among Latinos exceed those for blacks and Asian-Americans.

One morning in June, Kevin woke up, looked at his phone and found a bunch of missed calls and texts from Baltimore. He called his doctors.

"They told me that there was a possibility that we could have a donor," Kevin says.

Jenny was in Savannah, Ga., for a bachelorette party for one of their sisters. "I went to go talk to my sister and I told her, 'I have to leave. I have to drive back to Baltimore.' And she said, 'Why?' And I said: 'Kevin got called and it may be it.' "

The excitement didn't last long. The donor's family felt uncomfortable donating their loved one's hand. Kevin was relieved in a way, but he was also disappointed. "'Oh, wow, it didn't happen,' " he remembers thinking.

But another time, everything seemed like it was going well. This time, the donor's family consented, and the doctors texted a picture of the hand to Kevin. He took one look at it and thought to himself: "This is not the best possible match for me. So I'm not going to go through with it."

The skin tone wasn't quite right.

So Jenny and Kevin continue to wait.

They've been waiting now almost three years, which is longer than any of the other patients Kevin's doctor is caring for.

Kevin even decided he would accept a woman's hand once doctors explained that his hormones would eventually make it look more masculine.

As they wait, Kevin and Jenny are trying to get on with their lives. Kevin started taking classes at a community college. Jenny found a new job, and even recently got a big promotion. But living in limbo is hard for both of them. And sometimes Jenny lets her fears run wild.

Jenny, who is 10 years older than Kevin, broke off an engagement and left her job so she could move with him to Maryland.

Meredith Rizzo/NPR

"Sometimes I'll even play it out in my head: 'Well, what if the surgery goes so bad and you know — God forbid — he passes away? Then it's my fault,' " she says. "It's just horrible things I start thinking. I don't want to lose my brother. ... If anything bad happened I would never forgive myself for it."

Hand transplants are really complicated. Beyond the surgery itself, Kevin could end up worse off if he never learns how to use his new fingers or his body rejects the hand. And the anti-rejection drug he'll have to take for the rest of his life comes with side effects.

But Kevin says he understands the risks.

"It's worth anything — it's worth everything. That's how bad I want it," he says. "It will give me that sense of happiness that I don't have without it — that I could only get from having the hand. And that's ultimately why it's totally worth it."

So every time a Baltimore number pops up on their phones they freeze. "My stomach sinks," Kevin says.

But so far the closest they've ever come has been in Jenny's dreams. "I dreamt that Kevin had the surgery, but I couldn't see it," she says. "For some reason they were not letting me see Kevin. I remember the feeling — I was so worried."

In her dream, she remembers thinking: "'Why can't I go? Why can't I see it?' " And, she remembers crying. "It was just more waiting," she says. "We were just waiting to see."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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To Beat Insomnia, Try Therapy For The Underlying Cause Instead Of Pills

Tue, 06/09/2015 - 12:19pm

Lots of people say they have trouble sleeping. And 1 in 10 Americans has chronic insomnia.

Most often, sleep disorders are treated with medication. Between 6 and 10 percent of adults in the U.S. use sleeping pills.

But a review of the medical evidence has found that therapy might help people with chronic sleep troubles just as much — or even more — than pills.

Evidence that cognitive behavioral therapy — a form of talk therapy that focuses on changing how a person reacts to specific situations — can help people with chronically bad sleep has been growing over the past decade, says Dr. David Cunnington, director of the Melbourne Sleep Disorders Centre in Australia and the senior author of the recent study.

"We wanted to pull together all the smaller studies that have been done on cognitive behavioral therapy for insomnia," Cunnington says, "to really get a bigger pool of data and a better idea of how effective this is."

The results were published Monday in the Annals of Internal Medicine.

A typical treatment plan for insomnia includes four to six sessions with a sleep psychologist. Therapists help train patients to wake up at the same time every day and develop good sleep habits , such as avoiding alcohol or caffeine near bedtime and reserving their bed for sleep (rather than watching TV, for example). They also teach relaxation techniques and challenge people's negative attitudes toward sleep.

After completing therapy, on average, patients fell asleep almost 20 minutes faster and were awake in the middle of the night almost half an hour less, the study found. And the time they spent sleeping soundly increased by nearly 10 percent.

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"Based on other studies, we know that these results from therapy are very similar to what you'd see with patients who take medication," Cunnington says.

In many cases, therapy is a better treatment option, since it treats the underlying anxieties that cause insomnia. "A medication just puts a blanket over that anxiety and helps people get rest," Cunnington says. "But cognitive behavioral therapy addresses the core problems, challenging people's thinking around sleep. It can actually break the cycle of chronic insomnia."

Plus, medications can come with side effects — like feeling sedated all day. And most sleeping pills lose their effectiveness over time, Cunnington notes.

So why don't more doctors recommend therapy for sleep problems?

"I think it's an issue of awareness," says Kelly Baron, a clinical psychologist at the Northwestern University Feinberg School of Medicine who specializes in sleep disorders.

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"This review definitely gives us some hard and fast numbers on the efficacy of therapy," says Baron, who wasn't involved in the recent study.

But primary care doctors often don't know where to refer patients with chronic sleep issues, Baron says. And there's a shortage of therapists who are trained to treat insomnia, especially outside of big cities.

Proponents of therapy for insomnia are working to develop a better certification program for sleep psychologists, Baron says. "What we really need to focus on at this point is increasing accessibility, so more people with sleep disorders have the option to choose therapy if they want it."

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Highest-Charging U.S. Hospitals Are For-Profit And Concentrated In Florida

Tue, 06/09/2015 - 8:40am

Talk about sticker shock: Some U.S. hospitals charge patients more than 10 times the rates paid by Medicare.

Of the 50 U.S. hospitals with the highest charges, 49 are for-profit institutions, 20 operate in Florida, and half are owned by a single chain, according to a study published in the journal Health Affairs Monday.

That doesn't mean all or even most patients end up paying those charges. Private insurers are able to negotiate the sticker price down significantly. Patients paying out of pocket can often negotiate discounts or get charity care if they are low-income.

The average U.S. hospital charges a somewhat less staggering sum: 3.4 times the rates paid by Medicare, the federal health care plan for the elderly and disabled which pays fixed rates for procedures.

But for uninsured patients asked to pay full charges, insured patients who end up at an out-of-network hospital and patients whose treatment is covered by casualty or workers compensation insurance, these charges can matter a lot.

"Hopefully this is a wake-up call for people to recognize there's a problem," said Gerard Anderson, a professor of health policy at Johns Hopkins Bloomberg School of Public Health, and one of the authors of the study.

"There is no justification for these outrageous rates but no one tells hospitals they can't charge them," Anderson said. "For the most part, there is no regulation of hospital rates and there are no market forces that force hospitals to lower their rates. They charge these prices simply because they can."

Even after full expansion of coverage under the Affordable Care Act, 30 million Americans will remain uninsured and may face particularly high charges, the study said. The law requires nonprofit hospitals to offer reduced-cost or charity care to eligible patients, but the provision does not apply to for-profit hospitals.

"Hospitals' high markups, therefore, subject many vulnerable patients to exceptionally high medical bills, which often leads to personal bankruptcy or the avoidance of needed medical services," according to the authors of the study, which analyzed 2012 Medicare cost reports.

Of the 50 highest chargers, half are owned by Community Health Systems, a for-profit chain with 199 hospitals. The company made $18 billion in profits in 2014 — 45 percent more than in 2013. The researchers looked at charges at nearly 4,500 Medicare-certified hospitals nationwide.

Florida most likely had the most high-charging hospitals because it has an exceptionally high proportion of for-profit hospitals, consumer advocates said. North Okaloosa Medical Center, a CHA hospital in the Florida panhandle, had the highest charges of all: 12.6 times Medicare's rate.

In a written statement, CHA spokesperson Tomi Galin said CHA provided more than $3.3 billion in charity care, discounts and other uncompensated care for patients in 2014, as well as "millions of dollars in taxes that help fund critically important services in every community where we operate."

The charges examined by the study, Galin said, "are not relevant measures of what consumers, insurers or the government pay for services."

Chip Kahn, president and CEO of the Federation of American Hospitals, a trade group representing for-profit hospitals, also argued that the charges examined by the study were not a fair assessment of hospital prices. If the study had instead examined the actual payments by patients, they would have found that hospitals on the list charge just 1.3 times what Medicare pays, compared to a national average of 1.2, he said.

A hospital's charges can matter even for patients with private insurance, said Ge Bai, a co-author on the study and a professor at Washington and Lee University. Hospitals use those charges as leverage during negotiations with insurers, and starting from a higher price point can drive up even discounted prices.

"Except for patients with government insurance, few consumers are immune from negative financial impacts caused by hospitals' high markups," Bai said.

"We as consumers are paying for this when hospitals charge 10 times what they should," added Anderson. "What other industry can you think of that marks up the price of their product by 1,000 percent and remains in business?"

The highest charging hospitals were in 13 states, most in the South. Besides Florida, the others were Alabama, Arizona, Arkansas, California, Kentucky, New Jersey, Oklahoma, Pennsylvania, South Carolina, Texas, Tennessee and Virginia. Only California and New Jersey have state laws requiring for-profit hospitals to offer price discounts to eligible uninsured patients, the researchers said.

The markups charged by the 50 hospitals on the list varied dramatically by procedure. Anesthesiology had the highest charges: an average of 112 times more than Medicare rates. The markup for nursery services, on the other hand, was three times the Medicare rate.

The authors recommended that state and federal lawmakers enact policies to limit these charges. In Maryland and West Virginia, for example, state agencies set the rates that hospitals are allowed to charge for services. Requiring hospitals to disclose their charges for individual procedures could also help patients shop for the lowest-cost option, they said.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Some States Make Obamacare Backup Plans, As Supreme Court Decision Looms

Tue, 06/09/2015 - 3:47am
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Michael Carvin (right), lead attorney for the petitioners speaking before the Supreme Court in Washington, D.C., on March 4. The justices heard arguments in King v. Burwell.

Dana Verkouteren/AP

Online health insurance marketplaces are central parts of the Affordable Care Act. And HealthCare.gov, the federally run exchange, is where 27-year-old Kathryn Ryan, a restaurant server in Philadelphia, turned for health coverage, as soon as the law took effect.

"I was excited because if it weren't for Obamacare, I wouldn't be insured at all," she says. "I wouldn't have the ability to go to the doctor."

She can afford health insurance thanks to a $200 a month subsidy that brings her premium down to $60 a month.

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Ryan, who's also studying social work, is one of nearly 400,000 Pennsylvanians who have qualified for income-based financial assistance. But like a lot of people, she had no idea that a case before the Supreme Court puts at risk the subsidies in states like Pennsylvania that rely on the federally run exchange.

"You telling me this is, like my heart has sank a bit to the bottom of my stomach, because I was planning on keeping this insurance until I am gainfully employed with an agency that offers benefits," she says.

The reasons Ryan's subsidy and those going to millions of other people nationwide are in jeopardy has to do with a lawsuit before the Supreme Court.

The plaintiffs in the case argue that only those with coverage in state-based marketplaces are eligible for subsidies. If the Supreme Court agrees, Trish Riley with the National Academy for State Health Policy, says it could result in something insurance analysts refer to as a death spiral. "The whole individual market in states could collapse," she says.

Without subsidies, millions of people in the HealthCare.gov states would likely drop coverage. Those most likely to stay would be the really sick people who need expensive care. That change in customers would make insurance "premiums go through the roof," Riley says.

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So how are are the roughly three dozen states with federal marketplaces bracing for this? Not many states are officially declaring they have alternatives.

But Pennsylvania, for one, has a backup plan. "My biggest concern is, do we have a fallback if we need it?" asks Gov. Tom Wolf, a Democrat who took office in January after defeating an incumbent Republican. The state sent a blueprint of the contingency plan to the feds this month.

He stresses the plan is nonbinding and would only be set in motion if the court rules rules the subsidies for federally run marketplaces are illegal.

Teresa Miller, the state's insurance commissioner, says the potential legal setback is "forcing us to put together a plan that frankly most states spent years developing, and essentially we're having to do that in months," she says.

Under the plan Pennsylvania is considering, the state would transition to a model where HealthCare.gov would runs the technology but the state would oversee the funding, regulations and consumer assistance.

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The steps Pennsylvania has taken aren't the norm. "Pennsylvania stands out," said Joel Ario, a consultant with Manatt Health Solutions.

He says many states may be exploring options behind the scenes. But supporting an actual plan at this point "is a political nonstarter" for at least a third of states with federal marketplaces, where the governors and state legislatures opposed the health overhaul.

That's because a backup plan means "standing up and saying, 'I want to work with this law in a public way in a state-based exchange,' " he says.

Arizona even enacted legislation prohibiting a state-based marketplace, with similar bills pending in several other states.

In New Jersey, a Department of Insurance spokesperson says it's too soon to talk about alternative plans.

But neighboring Delaware, like Pennsylvania, has submitted a contingency plan for a state-supported marketplace to the feds, says Rita Landgraf, Delaware's health and social services director.

"Eighty-four percent of those who purchased plans on the marketplace received a financial subsidy, so that is critically important to our constituency that those subsidies are available to them," Landgraf says.

She says the federal marketplace won out over a state design due to the size of the state and the cost of running its own platform. Delaware officials considered a regional marketplace with other states, but it was too complicated.

A decision by the Supreme Court is expected by the end of this month.

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

Copyright 2015 WHYY, Inc.. To see more, visit http://www.whyy.org.
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Insurer Uses Personal Data To Predict Who Will Get Sick

Mon, 06/08/2015 - 3:08pm
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Carol and John Iovine say the health coach their insurer assigned John after he had a torrent of grave health problems in 2014 has helped them get the medical care he still needs. And it's helped keep him out of the hospital.

Todd Bookman/WHYY

The first thing out of John Iovine's mouth is an apology.

"You got to forgive me if I don't remember too much," he says. "I had a stroke."

Signs of that stroke are everywhere — the bed in the dining room, a shower installed in the pantry. John is thin, and sits in blue pajama pants in the wheelchair he uses to get around.

He may, however, have overstated his memory problems.

"We went to Harding ... that's the school right up here," he says. It was 1952, and that's where he saw the woman who would become his wife — "this girl, in this long red sweater, and her red hair. And I said, 'That's the girl for me,' " he says of Carol Iovine.

"I came out on top," he says, laughing.

Carol, who is sitting next to her husband, explains that John's stroke came in the middle of a bad run of health. First, he developed an ulcer, she says. Then he needed a bowel resection. After that came the stroke — and more.

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"He had pneumonia, jaundice, sepsis; clot in the right lung," she adds. All of that hit between October 2013 and January 2014.

John, a former house painter, spent 79 days in the hospital — some of that unconscious, and nearly all of it stuck in a bed.

"Aw, man — it was hell," he says.

Sink Or Swim

John Iovine finally went home in April of last year, after several months in a rehab facility.

And this point in patients' recovery — when they've been discharged and have to sink or swim on their own — is the stage that everyone in the health system is paying special attention to right now. For too long, too many people like John Iovine would take a dive at this stage, and end up back in the hospital again.

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The industry calls these returns to the hospital preventable readmissions, and they are a huge drain on finances, costing Medicare alone $15 billion annually. That's why Medicare launched an initiative a few years ago that penalizes hospitals that see too many patients readmitted too soon. And in turn, that spurred many hospitals to pay more attention to the problem.

Now insurance companies are also taking a stab at a solution.

"We are trying to identify which patients are likely to be hospitalized in the next three months — so that's our target," says Somesh Nigam. He's the chief informatics officer for Independence Blue Cross, a Philadelphia-based insurance firm.

Independence Blue Cross, he says, is working to identify all those among its customers who are sick or frail enough to be on the edge of hospitalization.

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To do so, the company runs algorithms on the huge amounts of health data at its disposal: billing claims, lab readings, medications, height, weight and family history. It also throws in information about the client's neighborhood, including poverty rates.

"The health care data we provided to build these algorithms is equivalent, I think, to five Wikipedias," says Nigam.

The computer algorithm sifts through all that information and pops out a score for each individual patient, identifying those it deems at highest risk.

Independence Blue Cross then assigns each high scorer a staff member — what it calls a "health coach," who will work at no charge to the client to see what extra services may be helpful.

"This coordinated effort then works for the patient," Nigam says. The coach may assemble health information tailored to the patient's needs; make medical appointments; resolve medication issues, or maybe help arrange transportation to the doctor's office. Sometimes the coach helps arrange for a home care nurse.

"And all of that," Nigam says, "is beginning to show a pretty significant drop in hospitalization rates in our region."

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Independence Blue Cross has identified 18,000 clients for this sort of extra attention and, as just one sign of success, has already seen a 40 to 50 percent reduction in expected hospital admission rates for people with congestive heart failure.

Early successes include the Iovines.

Carol Iovine's life changed, too, after her husband's stroke: She's having to manage his new medications, and help John shower and get to the toilet. They need to hire a wheelchair-accessible van for each appointment and therapy session, of which there are many.

She says having the support of John's health coach has made a big difference in helping her manage her husband's needs.

"He was supposed to get blood work, and they wanted me to take him to the ER to get blood work," Carol remembers. " 'Uh-uh,' I said. 'No way.' "

She called their health coach, Donna Crockett, and told her the problem. "And the next thing," Carol Iovine says, "a nurse was here taking blood."

Big picture: The money the health insurance plan spends on having Crockett arrange a visiting nurse, or streamline appointments is nothing compared to the cost of a hospital admission.

Writing The Rules

That promise of savings has a lot of health care specialists taking a harder look at the useful potential — and possible drawbacks — of these predictive computer formulas.

"There is a lot of interest in the area right now," says Glenn Cohen, a professor at Harvard's law school, who has written about the legal and ethical concerns raised by the collision of health care and big data. "It is a great coming together of the health care world and the computer science world, as well as the patient experience world."

Still, he has some qualms.

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"There are questions of whether people whose data is going to be used to build the engine have the right to opt out," Cohen says. "Do they have to affirmatively opt in? Do they have to even be notified it's being used?" These are still grey areas, he says.

The field is so new it doesn't yet have established standards for how this information should be handled, Cohen says.

Independence Blue Cross says it follows federal health privacy guidelines regarding anonymity, and is only using the information to better serve its members. But it doesn't ask the clients who subscribe to its health plans if they want to opt in.

"The data is only used to improve or coordinate care," Nigam says. "And that is something that you would agree is our role."

Health-wise, coordinated care seems to have made all the difference for John Iovine. He hasn't been hospitalized in the year since Independence Blue Cross assigned him a health coach.

The insurer says the early results are so promising that the company is expanding its efforts. The firm is partnering with New York University's Langone Medical Center on a next target — Type 2 diabetes. The goal is to spot people who are most at risk of getting diabetes before they start showing symptoms — and then intervene, in hopes of preventing the illness.

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

Copyright 2015 WHYY, Inc.. To see more, visit http://www.whyy.org.
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Do Creativity And Schizophrenia Share A Small Genetic Link? Maybe

Mon, 06/08/2015 - 11:17am

The genetic underpinnings of psychosis are elusive and diffuse. There are hundreds of common genetic mutations scattered throughout the human genome that each bump up by just a tiny bit the risk of developing a mental illness like schizophrenia. Many people carry some set of those genes, but most don't end up with a psychotic disorder. Instead, a study suggests, they might be getting a small creative boost.

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Those genetic changes may persist in human DNA because they confer benefits, according Dr. Kári Stefánsson, a neurologist and CEO of a biological research company called deCODE Genetics, which conducted the study published in Nature Neuroscience Monday.

"They are found in most of us, and they're common because they either confer or in the past conferred some reproductive advantage," he says. The advantage of having a more creative mind, he suggests, might help explain why these genes persist, even as they increase the risk of developing debilitating disorders, such as schizophrenia.

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It's an idea from the ancients. The philosopher Aristotle famously opined that genius and madness go hand in hand. Psychiatric studies have to some degree supported the adage. Studies of more than 1 million Swedish people in 2011 and 2013 found that people who had close relatives with schizophrenia or bipolar disorder were much more likely to become creative professionals. (The patients with mental illness were not themselves more creative, with the exception of some who had bipolar disorder.)

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What's more, studies that looked at healthy people who carry genetic markers associated with a psychotic disorder found their brains work slightly differently than others who lack those genetic markers.

"They were small [differences] but you could kind of see, gee, if you add a bunch of these up it could add up to something important," says Dr. Ray DePaulo, Jr., a psychiatrist at Johns Hopkins University School of Medicine. "Something" like schizophrenia or bipolar disorder or, as Stefánsson thinks, a creative disposition.

Stefánsson and his colleagues studied the genes of more than 80,000 Icelanders to see if writers, dancers, artists, actors or musicians had genetic markers that were associated with an added risk for certain psychiatric disorders.

"And, indeed, the risk for schizophrenia is substantially higher in creative professions than in the average population in Iceland," he says. If people are getting at least some of their creative impulse from these genes, Stefánsson says, then "the variance in the genome that leads to creativity also leads to schizophrenia."

Not So Fast, Other Scientists Say

Other researchers are cautious about making that claim. "Any particular set of genes is only going to explain a very small part of variation in any psychological trait," says Scott Barry Kaufman, a psychologist at the University of Pennsylvania. He says there are so many more things that determine whether or not someone is going to have schizophrenia or be creative — "things like what you have going on in your life, your environment, etc."

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And the apparent genetic effect in Stefánsson's study, while statistically significant, is minute. In essence, these genes have less than a 1 percent effect on creativity. That's not quite enough to say for sure if there's a strong connection between genetics and creativity, or if it means that creativity came at the price of schizophrenia.

"It's a hint ... it may be worthy of note," DePaulo says, with an ambiguous groan. "But eh, it's no cigar. In horseshoes, it's not a horseshoe."

Genes Can't Be The Only Answer

Stefánsson stand by his hypothesis, though. He thinks genes must be influencing creative minds in a substantial way. But, he admits, they can't be the sole source of creativity in a human being. "I'm convinced [these genes] are not a major contributor to the creativity in all of us," he says. "But they exist ... with fairly high frequency."

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Kay Redfield Jamison, a clinical psychologist at Johns Hopkins University School of Medicine and author of Touched with Fire: Manic Depressive Illness and the Artistic Temperament, agrees with Stefánsson.

"[The paper] shows ... not just a vague psychological connection between mental illness and creative thinking, but also something very fundamental," she says, and the implications for that run deep. "If you can figure out what these genes are, can you make people not be creative?"

But there are so many components to creativity that this can't be the only answer.

"It's not going to be anything terribly simple," Redfield Jamison says. "And why would it be?" After all, she adds, if there were a singular source of inspiration, then there probably wouldn't be a lot of original work.

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