Kristin Espeland Gourlay, RINPR, Author at ��ϳԹ�� News

How Millennials Win And Lose Under The GOP Health Bill

Kristin Espeland Gourlay, RINPR — Wed, 22 Mar 2017 21:00:40 +0000

Designing skateboards is just one of Luke Franco’s gigs. On a recent afternoon, he had just enough time before his next shift to chat at a café in downtown Providence, R.I.

“I work at the YMCA Monday through Friday with kindergartners through fifth-graders. It’s split shift; 7 to 9, 2 to 6 daily,” he said. “With the rest of my day, I also work at a local pizza place. And in addition to that, I also own and operate a small skateboard company.”

But none of his jobs comes with an offer of health insurance. Does that worry him?

“Yes, especially being an avid skateboarder,” the 26-year-old said. “That’s constantly something in the back of my head now — before I try this trick, what happens if I get hurt?”

So he’s looking for a full-time job with benefits. Beyond that, Franco hasn’t fully explored his insurance options. He’s a member of the . They represent more than a quarter of the nation’s population. These are people loosely defined as 18 to 34 years old, and they figure prominently in the health care debate. How they fare under the GOP health care bill going through Congress is complicated.

Franco doesn’t know whether he qualifies for Medicaid or a subsidy to buy coverage on the exchange set up under the , also called Obamacare.

“I’m assuming that paying full price for it [health care] would be completely unaffordable for me,” he said.

The GOP plan would offer Franco a tax credit of $2,000 a year — that’s the flat amount available to 26- to 29-year-olds to help them buy insurance. The amount goes up to $2,500 for those ages 30 to 39. But even if Franco could buy a plan for a few hundred dollars a month, he doesn’t want to. He would rather hold on to what little pocket money he has for dinner or drinks with friends.

Jen Mishory heads an organization called , a tongue-in-cheek name for millennials who think they’re too healthy to need health insurance. But the organization is serious about advocating for young people. Mishory said the ACA helped this generation.

“You’re starting pre-ACA with an uninsurance rate of about 29 percent for young people. We see that uninsurance rate drop, over the course of the last five, six years to about 16 percent,” she said. That’s due to many factors, the expansion of Medicaid, for one, and children being able to stay on their parents’ insurance until age 26. That’s how Franco was insured until his last birthday.

But coverage on the exchange is still expensive for some millennials. Even with subsidies, they didn’t sign up for the ACA exchanges in the numbers insurers were hoping for.

Mishory points out the GOP proposal to roll back Medicaid expansion could hurt some young, single adults. The proposed tax credit might help others.

“For some young people, [the tax credit] may be more than what they received under the ACA,” she said. “But for a lot of the low-income young people, they could see reductions in that subsidy.”

What concerns Mishory most is the Republican provision that insurance companies could charge customers 30 percent more for a plan if their coverage lapses.

“Young people are the most likely to see gaps in coverage,” she said. That’s because young adults move and . They also tend to have lower incomes [than their elders], so the penalty might discourage millennials, especially healthy ones, from enrolling in coverage again.

Molly Tracy, 25, is in a different category than Franco: She’ll buy insurance, penalty or not. But she worries the Republican model won’t be affordable.

“I’m not rich! I work in public education,” said Tracy, who works in a charter school. “So even if I do have coverage, having a $3,000 medical bill … that’s going to pose a significant challenge for me.”

Right now, Tracy is covered by her father’s health insurance. But her 26th birthday is coming soon, “so I’m trying to get a tonsillectomy before my insurance lapses. That’s one of the issues. The other issue is scheduling, having enough time to recover.”

When Tracy does get her own health insurance through work this fall, she wants to know what she will be getting. Will birth control remain affordable? Will mental health care be covered? A Congressional Budget Office finds that people like Tracy might end up paying much more out-of-pocket for those benefits than they do now.

This story is part of a partnership that includes , and Kaiser Health News.

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Hospitals Worry Repeal Of Obamacare Would Jeopardize Innovations In Care

Kristin Espeland Gourlay, RINPR — Wed, 01 Feb 2017 10:00:08 +0000

Much has been written about the who gained health insurance under the Affordable Care Act, and to these patients if the ACA is repealed without a replacement. But some people don’t realize that hospitals nationwide could take a big financial hit on several fronts, too.

First, it’s likely that fewer patients would be able to pay their hospital bills, health policy analysts say, so the institutions would be stuck with that bad debt, as they were before Obamacare.

“If the Medicaid expansion goes away wholesale, and things go back to the way they were before this expansion was in place, a lot of those hospitals would see an increase in their uncompensated care costs,” said , an analyst with the Kaiser Family Foundation. The American Hospital Association estimates that hospitals across the U.S. could more than $160 billion from the reduction in Medicaid revenue and the increase in unpaid medical bills. (KHN is an editorially independent program of the foundation.)

Then there’s this: The ACA has used financial incentives to encourage hospitals to experiment with ways to improve their care of patients, while reducing health care’s cost. That sort of experimentation has included a sizable upfront investment by many hospitals.

Massachusetts General Hospital in Boston, for example, signed with physicians and insurers to create , in hopes of saving money in the long run. With an ACO, insurers pay doctors for making sure the patient is getting the best and most appropriate care, instead of paying for every test and procedure a doctor does.

“We have now more than 20 different programs,” said , an internist and medical director of the Mass General Physicians Organization. “Video visits, electronic consultation with specialists, home hospitalization, [and] programs for patients with diabetes and heart disease. I would be worried that a repeal of the ACA would undermine our ability to invest in services for our patients.”

Ferris acknowledged that most of those experiments saved money. But they need more time to work out the kinks safely, he said.

“One of the things that it’s difficult for people outside of health care to appreciate — particularly politicians — is how long it takes to make significant improvements in the delivery of care,” Ferris said. “You have to be very careful when you make changes.”

Ferris said the threatened repeal of the ACA makes him worry “that the progress we’ve made over the past five years would be threatened.”

Many other have invested in accountable care organizations — often overhauling their medical records systems, hiring staff and creating new services. , head of a large hospital chain called in Rhode Island, said he, too, worries about the future of his ACO, .

“I think, if there’s a real change in direction away from these alternative payment models, we will be assuming risk to care for a population,” Keefe said. “We have invested enormously to be successful in this area.”

But these seismic changes in the way hospitals do business were predicated, he adds, on long-term support from the federal government — support that might disappear if the ACA is repealed.

This story is part of a partnership that includes , and Kaiser Health News.

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Laughing Gas For Labor Pain? It’s Poised For A Comeback

Kristin Espeland Gourlay, RINPR — Tue, 08 Nov 2016 10:00:04 +0000

Since the mid-1800s, laughing gas has been used for pain relief, but it’s usually associated with a visit to the

target=”_blank” rel=”noopener”>dentist

In the early 20th century, women used it to ease the pain of labor, but its use declined in favor of more potent analgesia. Now, a small band of midwives is helping to revive its use in the U.S.

One hospital in Rhode Island, South County Hospital in North Kingstown, has just added nitrous oxide, the formal name for laughing gas, to its menu of pain relief options for labor.

Amy Marks jumped at the chance to use it because she wanted to avoid an epidural — an injection in the fluid around the spinal cord that blocks feeling below the waist. The day after she gave birth, she sat with her son, Ethan Thomas, snug in the crook of her arm.

“When the contractions started getting pretty intense, I was like, ‘wow, this is pretty bad,'” she said. “So they brought it in and it really took the edge off.”

But is taking “the edge off” really enough relief for labor pain? It was for Marks, once she got the hang of breathing in the gas through a face mask, timing it to anticipate the peak pain of a contraction by 15 to 30 seconds.

“You’re going through the contraction, you’re breathing in and out, maybe do five, six breaths, get to the peak of the contraction, and I kind of didn’t really need any more, I could bear the rest of the contraction,” she said. “I was giggly. But only for like 15 to 30 seconds.”

Marks’ midwife Cynthia Voytas said Marks was breathing a mixture of 50 percent nitrous oxide and 50 percent oxygen.

“It gives you this euphoria that helps you sort of forget about the pain for a little bit,” Voytas said.

“Absolutely. That’s exactly what happened,” said Marks.

The laughing gas set up is on a little cart stocked with two gas tanks. It’s mobile, so nurses can just roll it up to the woman’s bedside. There’s a hose with a breathing mask. When she wants a little gas, a woman can just pick up the mask and breathe. Voytas said it gives a mom more control over her pain relief.

Until 2011, only a couple of hospitals in the United States offered nitrous oxide to women in labor. Today, it’s in the hundreds, according to the two main manufacturers of nitrous oxide systems. One of those manufacturers, Porter Instrument, maker of , says nearly 300 hospitals and birth centers use the option for pain management.

Dr. , professor and director of nurse midwifery at the Vanderbilt University School of Nursing, is helping lead the charge to bring back nitrous oxide as one of several options women should be offered for pain relief during childbirth. She sees the effort as being in line with what midwives have always done: advocating for women to have more control of the experience of giving birth.

Baby Ethan Thomas is less than 24 hours old.

Prior to the 1950s, Collins said, nitrous oxide was commonly used in labor. But then in the 1950s and 1960s, doctors started using drugs that could make a person drowsy. Women would go to the hospital, be completely knocked out, and wake up with a baby in their arms. The epidural, which came on the scene in the 1970s, gave women the possibility of a pain-free labor while awake. But it came with trade-offs: epidurals can make it difficult to move around and can prolong the second stage of labor.

Collins said women want more options to be more involved in the birth of their babies.

“Now, women are more informed, and they’re demanding that their voices be heard, which is a really great thing in my book,” she said.

Nitrous oxide has continued to be used regularly in Europe, so there’s that shows it’s , especially in smaller doses. It doesn’t reduce pain, like an epidural. Rather, it induces a sense of euphoria or relaxation.

“For some women, the epidural is going to be their number one choice. For other women, they want to be unmedicated and have nothing and that’s their choice. For other women, nitrous oxide is a viable choice,” she said. “It’s seen somewhat like a menu and for everything that’s safe, it should be on that menu and available to the woman.”

Another of this mini-revolution, retired nurse midwife and epidemiologist Judith Rooks, said the gas leaves the body in seconds.

“It does pass the placenta and go into the fetal circulation, but as soon as the baby takes a breath or two, it’s gone,” Rooks said.

The American College of Nurse-Midwives came out with a in 2011, saying it’s important for midwives be aware of nitrous oxide as a good option for women in labor and get trained in how to administer it. Dr. Laura Goetzl, a professor of obstetrics and gynecology at Temple University’s medical school, researches pain relief in childbirth. She considers nitrous oxide a “safe and reasonable” option and she is encouraging Temple to offer it at its hospital.

The American Society of Anesthesiologists and in May 2011, said in a paper that they would like to see more and more rigorous studies on its safety and effectiveness — much of the research is decades old. They also warn that facilities should have a good system for capturing any gas that escapes into the air, so those nearby don’t breathe it in. They note its use in Europe showed, “good safety outcomes for both mother and child.”

Nitrous oxide is less expensive than an epidural by hundreds, sometimes thousands, of dollars. Collins said the disposable breathing apparatus may cost about $25 and the cost of the gas alone, she said, is about 50 cents an hour. An anesthesiologist does not need to administer it — it can be done by a nurse midwife or other trained medical staff. Hospitals are having a hard time figuring out the billing, however, because it’s so new, said Collins.

“The interesting thing is that there’s not a charge code for this particular use of nitrous oxide in labor,” she said. “So places around the country are being very creative in how they’re approaching the charge portion of it.”

One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient’s credit card, or don’t charge at all.

This story is part of a reporting partnership with NPR, local member stations and .

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In Prince’s Age Group, Risk Of Opioid Overdose Climbs

Kristin Espeland Gourlay, RINPR — Fri, 06 May 2016 12:17:12 +0000

Evidence is mounting that opioid pain medication may have played a role in the death of pop legend Prince. While the medical examiner hasn’t yet released the results of the autopsy and toxicology tests in this case, opioid overdose in middle age is all .

In 2013 and 2014, according to the The Centers for Disease Control and Prevention, people ages 45 to 64 accounted for of all deaths from drug overdose. Prince died on April 21 at his home and music studio Paisley Park in Minneapolis. He was 57.

Experts say there are a number of scenarios that increase risk of overdose, which is often accidental, for people over 55. Imagine you are in that age group and you injured your shoulder a while back. It just hasn’t gotten better, so you take prescription painkillers — an opioid like OxyContin — to help with the pain. Let’s say you’ve been taking it for a couple of years. Your body has built up a tolerance to the drug, and now, you need to change it up to get the same amount of relief. When it comes to the potential for overdose, said Boston Medical Center epidemiologist , this is one of the most dangerous crossroads.

“We oftentimes see that the dose will increase with an individual over time or they might rotate or switch to another medication to experience pain relief. And so, at each rotation or change, there’s a risk [of accidental overdose] because you’re moving from one drug to another,” she said.

Your body might not be used to that high dose, she said, or that different medication. She continued: Let’s say you also suffer from anxiety. Benzodiazepines can help with that. But taking opioids and benzodiazepines, or “benzos,” together is a .

“There are wonderful medications used for treating anxiety,” she said, but there’s a different calculus when they are taken with opioids.

“One opioid plus one benzo doesn’t equal the effect of two in the individual,” Green said. “It’s like one plus one equals four, or six.”

Opioids can depress the body’s drive to breathe and so can benzodiazepines. Combine them and that effect mounts. You could stop breathing and never wake up. And lots of people are taking these drugs in combination. In fact, people in their mid-40s to mid-60s are more likely than any other group to be prescribed opioids with benzodiazepines, according to the National Center for Health Statistics.

“It is indeed a demographic to keep an eye on,” Green said, partly because of another risk factor. People in this older age range may be likely to live alone or be otherwise isolated — maybe from divorce or because their kids have moved out.

So, Green said, “If something happens, if no one’s there to revive you, then you’re more likely to die of that experience.”

University of Rhode Island pharmacy professor said the way people in this age group tend to take drugs is also putting them at higher risk.

“They’re taking longer-acting opioids,” he said. “They’re taking doses that, at certain thresholds, are associated with increased overdose death.”

Also, Bratberg said, they’re more likely to have chronic health conditions that put them at higher risk of respiratory depression.

Medical conditions like chronic obstructive pulmonary disease or even the flu can amplify opioids’ ability to depress breathing. And some percentage of these drug users, he said, will develop a .

So why are doctors prescribing so much, in such combinations? Bratberg said it’s how the physicians were trained.

“If you’re a primary care prescriber and your patients are doing OK, maybe you’re just not thinking about that,” he said. “Plus there’s difficulty in telling the person whose pain may be controlled by opioids, and their anxiety may be controlled by benzodiazepines, to say, ‘Now we’re going to taper you off because this is harmful.’ “

So millions of people are on opioids — most of them over 45 — and that means some are at risk of overdose. Bratberg said we should be educating patients and doctors.

“We’re really making a push nationally and regionally to educate prescribers about those risks, and to use tools available to warn folks about that.”

Tools that help lower the risk include , the overdose rescue drug. There’s also medication, such as or , to assist people who have become addicted to painkillers to stop their use safely. In essence, those drugs keep a low level of opioids in the system to keep someone from going into withdrawal without getting them high.

This story is part of NPR’s reporting partnership with local member stations and .

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Tiny Opioid Patients Need Help Easing Into Life

Kristin Espeland Gourlay, RINPR — Mon, 28 Mar 2016 09:00:25 +0000

Swaddled in soft hospital blankets, Lexi is 2 weeks old and weighs 6 pounds. She’s been at in Providence, Rhode Island since she was born, and is experiencing symptoms of opioid withdrawal. Her mother took methadone to wean herself from heroin when she got pregnant, just as doctors advised. But now the hospital team has to wean newborn Lexi from the methadone.

As rates of opioid addiction have climbed in the U.S., the number of babies born with has increased, too — from 2000 to 2012, according to the National Institute of Drug Abuse.

It can be a painful way to enter the world, abruptly cut off from the drug in the mother’s system. The baby is usually born with some level of circulating opioids. As drug levels decline in the first 72 hours, various withdrawal symptoms may appear — such as trembling, vomiting, diarrhea or seizures.

At some point, if symptoms mount in number or severity, doctors will begin giving medication to help ease them. The idea is to give the the baby just enough opioid to reduce their symptoms, and then then slowly, over days or weeks, decrease that dose to zero.

A doctor comes to check on Lexi and her mother, Carrie. To protect her family’s privacy, Carrie asked us not to use their last name.

“So, hi, Peanut!” the doctor says to the baby. “Any concerns?” she asks Carrie.

“Coming down has been catching up with her,” says Carrie.

“Do you feel like she’s jittery?” the doctor asks.

“She didn’t want to be put down last night — like [she had] the shakes,” Carrie says.

Lexi has neonatal abstinence syndrome, and has been getting methadone treatments for it. She is getting better — most babies do — but even with treatment, she’s had tremors, diarrhea, and she’s cried and cried. Her little arms and legs tighten up, her fingers and toes clenched. She’s been feverish, her mother says.

“I know what she’s feeling,” Carrie says. “And that is the worst part.”

Carrie was addicted to heroin herself and knows withdrawal is miserable. She’s been off heroin since she found out she was pregnant, she said, with help from methadone. It keeps a low level of opioid in her system so she doesn’t go into withdrawal, but it doesn’t get her high. For Carrie and thousands like her, methadone is a lifesaver — helping them quit a heroin or oxycodone or other opioid habit for good.

But getting pregnant posed a dilemma: If Carrie stopped taking opioids altogether, she risked relapse or miscarriage. Yet, if she continued to take any opioid — including methadone — there would be a 60 to 80 percent chance that her baby would be born with neonatal abstinence syndrome, the doctors told her.

“It’s hard to watch, as her mother,” Carrie said, “because you’re helpless and there’s really nothing you can do. You are a lot of the reason why she’s going through what she’s going through.”

Babies going through withdrawal spend weeks — even months — in hospital nurseries like this one.

Cindy Robin, a registered nurse at Women and Infants Hospital in Providence, R.I., helps newborns through symptoms of withdrawal.

“Their cry is very different,” said Cindy Robin, a registered nurse at the Providence hospital, who has been caring for mothers and newborns for more than 30 years. “It’s a more distressed cry,” she said, “and it really pulls at your heartstrings to have to listen to them.”

Robin said babies with mild symptoms of the withdrawal syndrome will sneeze and sniffle. They have trouble settling down. Babies who have a more severe case can have seizures and dangerously high fevers. Robin said nurses have to dim the lights, and swaddle the newborns tightly to help keep them calm.

“They just need to be held in a nice, quiet spot,” she said. “We have nice quiet music playing, and try to keep them as comfortable as possible.”

Nurses with special training check on the babies every couple of hours.

“So these are the things that we look for … and what we teach the parents,” she said: “Is the baby crying excessively? Is it a high pitched cry? Is it just a continuous cry? How do they sleep after they eat?”

Medication, which is gradually decreased, can help ease this constellation of symptoms.

“The American Academy of Pediatrics and others recommend an opioid for the babies, because you’re giving them back what they’re withdrawing from,” said , a neonatologist and chief of newborn medicine at Tufts’ Medical Center. “Morphine and methadone are the two most common.”

But Davis said no one’s really done the research to determine which drug works better for babies, and doctors are left to figure that out by trial and error, case by case. Though the Food and Drug Administration hasn’t officially approved morphine or methadone for use in newborns, doctors prescribe these drugs to the children anyway, in smaller doses than they give adults.

“As I spoke to people around the country, everyone would have their own approach and a very different way of treating these babies,” Davis said. “And we thought that quite odd.”

Their cry is very different. It’s a more distressed cry and it really pulls at your heartstrings.
Cindy Robin

So he and a colleague, Brown University developmental psychologist , have launched a major study to sort out what works best. The two are hoping to enroll 180 babies in their double-blind, randomized, controlled trial — no one will know which newborns are getting methadone, and which are getting morphine, for example, until the study’s end. And they’re taking the research further: No study yet has looked at the long-term effects of the drugs, so Davis and Lester will continue to follow-up with measures of cognitive and physical development until the children are 18 months old.

“It may be,” Davis says, “that one agent is safer short-term, but when we look longer-term it may actually be more dangerous.” Teasing out long-term effects of a drug isn’t easy, Lester says; many factors can influence a baby’s development.

“If you’re drug-exposed and you’re growing up in an inadequate environment — which may not be poverty, it may be inadequate parenting — that’s a double whammy,” he says. “Those are going to be your worst case scenarios.”

Despite many remaining unknowns, doctors have consistently found that treatment with morphine or methadone enables most babies to get through withdrawal in about six to eight weeks.

“It can be heartbreaking,” said Robin, who has helped shepherd many kids through dark days. “But at the end, it is also rewarding,” she said, “because you see them get better and you see them go home.”

This story is the first in our four-part series, “Treating the Tiniest Opioid Patients,” a collaboration produced by Kaiser Health News, NPR and local NPR member stations.

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