Thames, a small-town Mississippi native, said the East Central Mississippi HealthNet RuralÌýFamily Medicine ResidencyÌýProgram has been “exactly what I was looking for.”

Unlike the vast majority of doctors, Thames sought a residency in a rural clinic instead of in a teaching hospital because his ambition is to practice in the sort of place where he grew up, where doctors are scarce. He wants to be able to handle anything that comes through the door, from infections to gunshot wounds to a woman who might deliver a baby any second.

But budget decisions in faraway Washington, D.C., may make it more difficult for Thames and other doctors who want to practice in small towns or underserved cities.

Under the Teaching Health Center Graduate Medical Education program, which is part of the Affordable Care Act, the federal government dispenses grants to community health centers to train medical residents. The goal of the program is to address the shortage of primary care physicians in rural and poor urban areas.

But under current law, the federal government will stop funding the program, which serves nearly 750 primary care residents in 27 states and Washington, D.C., at the end of September. Without congressional action, it might be shut down.

“The program is absolutely doing what it is designed to do, which is to put doctors in underserved areas like ours,” said Darrick Nelson, the director of Hidalgo Medical Services’ teaching health center program, which is training six residents in Lordsburg, New Mexico.

The teaching health centers have received bipartisan support in the past. But supporters worry that because the program is new, relatively small, and not as well-known as other federally funded doctor training programs, it might fall through the federal budgetary cracks.

“The greatest threat to the teaching health centers is the dysfunction in Washington,” said Dan Hawkins, a vice president at the National Association of Community Health Centers, a research and advocacy group.

Earlier Cuts

Bipartisan support didn’t protect the program from earlier cuts. In 2010, Congress allocated $230 million over five years, or about $46 million a year. But when it approved a two-year extension in 2015, it reduced funding to about $43 million a year. That reduction was enough to cause some of the teaching health centers to train fewer residents. Some have closed.

Studies have found that most to where they did their residencies. But most teaching hospitals are located in urban centers, far from rural regions with acute doctor shortages. Poor urban neighborhoods also have difficulty attracting physicians.

The American Association of Teaching Health Centers, a nonprofit advocacy group, said the ACA residency program is having the intended result. According to the organization, 55 percent of teaching health center graduates , compared to 26 percent of those who graduate from hospital-based residencies.

“The program is doing exactly what we wanted it to do,” said John Sealey, director of medical education for Authority Health in Detroit. More than 60 percent of residents who graduated from teaching health centers in Detroit go on to practice in medically underserved areas, many of them in Michigan, he said.

Progress in Montana

RiverStone Health, a health care provider in Billings, Montana, was a teaching health center even before the federal program began. RiverStone started training residents in 1998, after partnering with two local hospitals.

“The state was completely reliant on recruiting from other areas, which was clearly not working as well as it should,” said Roxanne Fahrenwald, a RiverStone vice president. Fifty-one out of 56 of primary care doctors, according to the federal government.

With the federal money awarded to it under the ACA, RiverStone has been able to add one medical resident a year to its program, bringing its number of residents to 24. About 70 percent of RiverStone graduates have remained in the state.

Supporters also argue that teaching health centers expose residents to the types of ailments and health disparities, such as higher rates of obesity, diabetes and heart disease, that they are likely to encounter if they practice primary care in underserved areas.

“In a community health center, most of the patients are going to present with conditions or ailments more common to a primary care practice, whereas those in the hospital will be sicker, with more acute needs,” said Shawn Martin, a vice president at the American Academy of Family Physicians.

The residents in teaching health centers do spend some of their time training in hospitals. They must complete hospital rotations in surgery, inpatient care, obstetrics and gynecology.

But health center residents also see what many hospital residents never do. In Washington, D.C., for example, medical residents at Unity Health Care Inc. often work in jails, homeless shelters and HIV/AIDS clinics.

Those receiving care at such sites would bear the brunt of the impact if federal money for the health center residency program disappears.

“I’m very nervous,” said Eleni O’Donovan, director of the teaching health center program at Unity. “The program is not sustainable without that funding.”

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The key element in that effort is to encourage all states to go beyond the information provided on a typical death certificate by having mortality review panels investigate the causes behind every maternal death that occurs during pregnancy or in the year after delivery.

The hope is the investigations will reveal systemic causes for at least some of the deaths and lead to preventive measures to save the lives of more would-be or new mothers.

A number of suggest that one in three maternal deaths is preventable.

“It’s hard to do anything about a problem if you don’t have the problem fully defined,” said Cynthia Shellhaas, an associate professor in the division of maternal-fetal medicine at the Ohio State University Wexner Medical Center.

The campaign is led by the Association of Maternal & Child Health Programs (AMCHP), a public health advocacy group, and the U.S. Centers for Disease Control and Prevention.

AMCHP and the CDC want every state that doesn’t have one already to create a maternal mortality panel of medical and forensic experts. They want the panels to collect as much information as possible related to every maternal death, including matters related to prenatal care, other health conditions, use of medications, drug and alcohol abuse, violence and medical procedures performed.

They also are encouraging states to standardize the data they collect. And they will provide a digital application to help them collect it, to make it easier to analyze the data for possible trends and remedies.

About half the states — including , New York and Texas — already have panels, although each currently devises its own ways of classifying information and determining which cases to investigate.

For example, some consider as maternal any death up to 42 days after a pregnancy. Others examine any death up to a year after delivery.

High U.S. Rate

In the U.S., there are 18.5 maternal deaths for every 100,000 live births, according to the at the University of Washington, which tracks mortality trends worldwide. (For African-American women, the rate is three times higher, according to the CDC.) The CDC says that about 700 maternal deaths occur in the U.S. every year.

The rate is down from a recent peak — in 2009, when it was 22 deaths per 100,000 — after rising steadily for more than a decade.

But preliminary numbers suggest that maternal deaths are again on the rise after 2013, the institute said. The death rate is significantly higher in the U.S. than in other developed countries. For example, the rate is 8.2 in Canada and 6.1 in the United Kingdom and Japan.

There are several possible reasons for the higher U.S. rate, including better reporting, mothers giving birth at older ages (increasing the odds of pregnancy-related complications) and the growing percentage of expectant mothers with untreated chronic conditions such as obesity, hypertension and diabetes. The upsurge in also may be a factor.

Maternal deaths often signal broader health problems among expectant and new mothers.

The Joint Commission, a nonprofit that accredits health care organizations and programs, maternal deaths “sentinel” events. “For every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy, labor and delivery,” Dr. William Callaghan, a senior CDC scientist who maternal morbidity, said in the Joint Commission’s 2010 alert.

Renewed Effort

The notion of investigating the deaths of mothers to prevent them isn’t new.

Medical societies in some large cities and states began establishing in the 1930s, when the maternal mortality rate was more than 600 deaths for every 100,000 live births.

Even then, there was a strong sense that many of the deaths could be prevented through improved medical and hygienic practices.

The work of those panels, combined with the Social Security Act of 1935, the advent of antibiotics, advances in obstetrics and medicine in general, and the trend toward more hospital births, led to a precipitous drop in the mortality rate through the early 1960s.

Many of the review panels disappeared. But as rates started rising again the late 1990s, panels began to resurface. David Goodman, the senior scientist for the CDC’s Maternal and Child Health Epidemiology Program, estimates that at least 20 states have panels and another dozen are creating them. Some states, including Illinois, have additional maternal mortality panels that focus on violent deaths.

Most of the mortality panels are appendages to state health departments, although Goodman said most operate with little state revenue. They rely instead on the financial contributions and participation of its volunteer members, which usually includes doctors, coroners, lawyers and even police officers.

Some states also have mortality review panels for fetal, infant and child deaths.

Beyond Death CertificatesÌý

Although death certificates usually provide a cause of death, the quality of the information from state to state.

The certificates lack the level of detail that would help hospitals and other providers make adjustments that could prevent recurrences, Goodman said.

For example, he said, a death certificate may indicate that a new mother might have died as a result of an infection. But a deeper examination of her case and similar ones could reveal deficiencies in the sterilization of surgical equipment in hospital obstetrics units.

Something like that happened in California. Evidence revealed by the California mortality review panel led to protocols in the handling of post-delivery hemorrhages in all California hospitals beginning in 2008.

Barbara O’Brien, program director of the Office of Perinatal Quality Improvement at the University of Oklahoma Health Sciences Center, said that evidence collected by her state’s mortality review panel has led to the use of compression devices for all pregnant women undergoing cesarean sections to reduce the risk of developing a deep vein thrombosis — a blood clot, usually in the leg, that can be fatal.

The panels turn to many sources of information, including autopsies, hospital and provider medical records, and, in some cases, records from police and social service agencies.

Some states have laws that give the panels access to those records, but not always. “If you want to go to the provider’s office who provided prenatal care [in Oklahoma] they aren’t required to give you the records,” O’Brien said.

Dr. Shellhaas of Ohio, who oversees her state’s maternal mortality panel, said it usually waits two years before delving into a case to allow any civil lawsuits to be resolved, which removes an impediment to getting the necessary documents.

AMCHP and the CDC are testing the new data collection system in . Eventually it will be made available to all states, thanks in part to funding from the pharmaceutical giant Merck & Co. Inc., which is engaged in a $500 million, worldwideÌý to improve maternal health and reduce maternal deaths.

AMCHP also plans to create an Internet portal to help states communicate with each other on issues related to maternal health and mortality, said Lori Tremmel Freeman, AMCHP’s CEO.

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The drugs boast cure rates of 95 percent or better, compared to 40 percent for previous treatments. But they cost between $83,000 and $95,000 for a single course of treatment.

The class actions, all filed in the last eight months in federal courts in Indiana, Massachusetts, Minnesota and Pennsylvania, present a series of extremes: a deadly epidemic, a treatment that can stop the disease in its tracks and an enormous price tag.

At least Americans have hepatitis C, a virus spread through blood-to-blood contact that is usually contracted through the sharing of needles or other equipment to inject drugs. Left untreated, hepatitis C slowly destroys the liver. Medicaid beneficiaries, a low-income population, have a slightly higher rate of hepatitis C infection than the privately insured, and the rate among prisoners is higher than in the general population.

The U.S. Food and Drug Administration approved the first of the new drugs, Sovaldi, in 2013. Since then, the FDA has also approved two other drugs, ViekiraÌýPak and Harvoni.

But because the drugs are so expensive, state Medicaid programs and prisons have been restricting them to people in the advanced stages of the disease.

While they are waiting to meet that standard, patients with less advanced hepatitis C may develop cirrhosis, liver cancer or liver failure, which may necessitate a liver transplant. According to the U.S. Centers for Disease Control and Prevention, 60 to 70 percent of those with hepatitis C will develop chronic liver disease; 5 to 20 percent will develop cirrhosis; and 1 to 5 percent will die of liver failure or liver cancer.

The plaintiffs in the lawsuits argue that by denying the drugs to hepatitis C patients, states are violating the law. Under federal law, states can exclude a drug from Medicaid coverage only if its prescribed use “is not for a medically accepted indication” as determined by the FDA.

Federal court cases have established a lower standard for prison health care. Prisons must provide health care to inmates, but can deliver it as they see fit, as long as they don’t demonstrate “a deliberate indifference to serious medical need.”

“A medically necessary treatment is a medically necessary treatment, no matter what the cost,” said Gavin Rose, an attorney for the American Civil Liberties Union, which brought theÌý in Indiana in December on behalf of Medicaid beneficiaries in that state who have hepatitis C.

Some infectious disease doctors and legal analysts agree.

“The restrictions states are using are not based on medical evidence,” said Lynn Taylor, an infectious disease doctor in Rhode Island who finding that a large majority of state Medicaid agencies are restricting access to the new drugs. “They make these rules up out of thin air, and they are discriminatory.”

But Matt Salo, executive director of the National Association of State Medicaid Directors, said making the drugs available to all those infected with hepatitis C “would blow up state budgets.”

“We would be spending more on this one drug than all other drugs combined,” Salo said. “There isn’t the capacity to do that.”

Corrections officials agree. Dr. Steven Shelton, medical director of Oregon’s state prison system, estimated it would cost more than $200 million to treat Oregon prisoners with the disease, an amount four times greater than the system’s entire annual health care budget.

“There would be no care for any other disease, there would be no day-to-day care, there would be no hospital care, there would be no emergency care, there would be no staff,” Shelton said.

A Leading Killer

At a recent meeting on infectious diseases, Scott Holmberg, chief of the Epidemiology and Surveillance Branch at CDC’s Division of Viral Hepatitis, that in 2013, more Americans died of hepatitis C than from 59 other infectious diseases combined, including HIV and tuberculosis.

But in December, the U.S. Senate Finance Committee, which investigated the impact of the high price of Sovaldi, found that in 2014, only about 2.4 percent of Medicaid beneficiaries with hepatitis C had received the drug.

Vincent Lo Re, an epidemiologist and infectious disease doctor at the University of Pennsylvania, reported in November that in Medicaid agencies in four states — Delaware, Maryland, New Jersey and Pennsylvania — nearly half of all claims for the new hepatitis C drugs had been rejected. Lo Re found a 5 percent denial rate for Medicare beneficiaries and 10 percent for policyholders with private insurance in those same states.

Lo Re said he undertook the study because so many of his patients were being turned down for the new drugs despite his insistence that they needed it. Many of those patients, he said, are advancing to more serious stages of liver disease.

Discriminatory Restrictions?

Taylor’s study, published last summer, examined how state Medicaid agencies decide who will get Sovaldi, which is manufactured by the pharmaceutical company Gilead.

At least 34 states restricted treatment to patients who had reached an advanced stage of liver disease, as determined by the level of scarring on the liver. Thirty-seven states permitted their Medicaid agencies to determine whether the potential recipient was abusing alcohol or drugs, and some required some period of abstinence. And 29 states would only consider approval if the prescriber was a specialist in gastroenterology, hepatology, infectious diseases or liver transplantation.

Some state Medicaid agencies, such as Pennsylvania’s, have recently lifted the restrictions. A spokesperson for the state Medicaid office acknowledged that the policy change would result in a “significant fiscal challenge” and the state was pressing hard for any discounts that might be available.

Separate from the lawsuits, Massachusetts Attorney General Maura Healey, a Democrat, late last month threatened Gilead with an investigation of its possible “unfair trade practice in violation of Massachusetts law” if it doesn’t lower its prices for Sovaldi and Harvoni, which it also manufactures.

The drugmaker, which has consistently said that its hepatitis C drugs are worth the price because of their effectiveness, has asked to meet with Healey.

“Gilead responsibly and thoughtfully priced Sovaldi and Harvoni,” the company said.

Taylor said states’ restrictive practices are discriminatory because they aren’t applying the same standards to treatments for any other diseases. “We don’t withhold cancer treatment to only those with the most advanced stages of the disease,” she said. “We don’t deny smokers treatment for lung cancer.”

Many doctors point out that while the new hepatitis C drugs can arrest the disease, they cannot undo liver damage.

Stopping the Spread

Advocates for universal treatment also argue that treating patients sooner rather than later spares the health system the greater costs of treating liver cancer or undertaking transplants. It also prevents the spread of the infection to others.

Several medical societies, including the Infectious Diseases Society of America and the American Association for the Study of Liver Disease, recommend early treatment for hepatitis C. The American College of Correctional Physicians says that prison doctors should decide which inmates to treat based on medical evidence, not cost. It , however, that to eradicate the virus in prisons, “We must be allocated adequate resources to implement the goal in a medically responsible way, including funding for disease surveillance, screening, medically appropriate evaluation and complete disease treatment.”

But paying for treatment for everyone now is unimaginable for states, which are required to balance their budgets every year, said Salo of the Medicaid directors group.

He said the penny wise and pound foolish argument isn’t relevant to the real world of state budget-making.

“It’s true if you take a time horizon of 30 years, but that’s not reasonable or rational or realistic in Medicaid,” he said. “We budget on a one-year or a two-year cycle.”

Several legal analysts said the plaintiffs in the Indiana lawsuit, which concerns Medicaid beneficiaries, might have a better chance than the prison plaintiffs in suits in ,Ìý and .

“At first glance, I’d say the plaintiffs [in Indiana] have a strong case,” said Nicholas Bagley, a health law professor at the University of Michigan Law School. “I’ll be very curious to see what justification Indiana presents for their denials.”

The state said it could not comment on pending litigation.

John V. Jacobi, a professor at Seton Hall Law School who specializes in health policy, said the medical necessity standard does not apply to prisoners. The question in the prison cases, Jacobi said, will be whether the denial of the drugs qualifies as “deliberate indifference.”

Joel Thompson, an attorney with Prisoners’ Legal Services, who is representing prisoners in the Massachusetts case, said he thinks it does.

“People knew for years these new drugs were coming,” he said. “Prisoners were counseled for years away from the treatments that were then available because better stuff was coming with no side effects and a guaranteed cure. A fair amount of money got saved because of that, and it got saved at the expense of our clients, who only got sicker.”

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Lindsey believes he’s above ground, and still playing point guard down at the Mormon church, because of Northern Cochise. Last Christmas, he suffered a severe stroke in his home. He survived, he said, because his wife, Zenita, got him to the hospital within minutes. If it hadn’t been there, she would have had to drive him 85 miles to Tucson Medical Center.

There are approximately 2,300 rural hospitals in the U.S., most of them concentrated in the Midwest and the South. For a variety of reasons, many of them are struggling to survive. In the last five years, Congress has sharply reduced spending on Medicare, the federal health insurance program for the elderly, and the patients at rural hospitals tend to be older than those at urban or suburban ones. Rural hospitals in sparsely populated areas see fewer patients but still have to maintain emergency rooms and beds for acute care. They serve many people who are uninsured and can’t afford to pay for the services they receive.

Several months ago, Northern Cochise sought to strengthen its chances for survival by joining an alliance with Tucson Medical Center and three other rural hospitals in southwestern Arizona. Together, the Southern Arizona Hospital Alliance is negotiating better prices on supplies and services. And the Tucson hospital has promised to help its rural partners with medical training, information technology and doctor recruitment.

“We are committed to remaining autonomous for as long as we can,” said Jared Wilhelm, director of community relations at Northern Cochise. “We think this gives us the best leverage to do so.”

Northern Cochise and the other rural hospitals in the alliance, which is similar to ones in Kansas, Mississippi, Washington state and Wisconsin, hope that by joining they will avoid theÌýof 56 rural hospitals that have closed since 2010. Another 283 rural hospitals are in danger of closing, according to the National Rural Health Association ().

Right now, some Arizonans in the region are learning what it’s like to lose a hospital. Cochise Regional Hospital, in Douglas, near the Mexican border, closed earlier this month, following Medicare’s decision to terminate payments because of repeated violations of federal health and safety rules. The hospital was part of a Chicago-based chain and its closing leaves Arizona residents in the far southeastern portion of the state up to 75 miles away from the closest hospital emergency room.

Sam Lindsey shudders to think what a long drive to Tucson would have meant for him last Christmas.

“If I’d have had to go 85 miles,” he said, “I don’t think I’d be here today.”

Multiple Advantages

The alliance offers the rural members multiple advantages. One of the most important is in purchasing. Their combined size will enable them to get discounts that are beyond them now. For example, instead of being a lone, 49-bed hospital with limited bargaining leverage, alliance member Mount Graham Regional Medical Center, in Safford, is suddenly part of a purchasing entity with more than 700 beds.

“If I’m just Mount Graham and I’m going to buy one MRI every seven years, the sales people will say, ‘Oh, that’s very nice,’ ” said Keith Bryce, Mount Graham’s chief financial officer. “But as part of this alliance that they want to do regular business with, they are going to give us a much better price.”

Bryce said that he expects the added purchasing power alone will save Mount Graham “in the six figures” every year.

Similarly, the hospitals expect the combined size of the alliance to result in lower costs for employee benefits, workers’ compensation and medical malpractice insurance.

The alliance also helps the rural hospitals recruit doctors and other medical providers, many of whom are reluctant to work, let alone live, in isolated areas. Rural hospitals rarely have the contacts and relationships that help urban hospitals find doctors. “We’ve been trying to recruit another primary care doctor to this community for the last year with no success,” said Rich Polheber, CEO of Benson Hospital, another alliance member.

Tucson Medical Center has pledged to use its own recruiting muscle to help its rural partners find providers who are willing to live in rural areas, or at least regularly see patients there. As an incentive, Tucson will offer interested doctors help in managing the business aspects of their practices.

The rural alliance members also want Tucson’s help with medical training and IT. Some have dipped into telemedicine, which is particularly valuable for rural hospitals underserved by specialists, and are looking to expand those efforts. Copper Queen Community Hospital, in Bisbee, the fourth rural member of the alliance and probably the rural hospital in the best financial shape, is the most advanced user of telemedicine. Its networks in cardiology, neurology, pulmonology and radiology can connect doctors and their patients to specialists at major institutions such as the Mayo Clinic and St. Luke’s Medical Center, in Phoenix.

The alliance also will make it easier for patients who have surgery in Tucson to be transferred back to their home hospitals for recovery and rehabilitation, saving them and their families from traveling long distances.

A Defensive StrategyÌý

Despite the numerous advantages for the rural partners, the idea for the alliance began with the Tucson hospital, which approached the others with the proposal last spring. At the outset, some of the rural hospitals were skeptical.

“At first, we were like, ‘OK, so why are they doing this? What’s in it for them? Do they want to absorb us?’ ” said Bryce, the Mount Graham CFO.

But after a series of meetings, the suspicions disappeared and the rural hospitals eagerly signed on.

The Tucson hospital was frank about its motivation: to remain independent in an industry moving toward consolidation. As a result of acquisitions in the last few years, it is the last locally owned, independent hospital in Tucson.

“All of a sudden, we were in a situation where [Tucson Medical Center] found itself isolated and facing its own competitive market pressures because the environment had so dramatically changed,” said Susan Willis, executive director of market development at the hospital and president of the new alliance.

Nearly a quarter of Tucson’s patients come from outside the city, many from the areas served by the rural hospitals in the new alliance. Cementing the relationship with those hospitals, Willis said, will help Tucson maintain a flow of patients who need medical services that are beyond the capabilities of the rural hospitals. The rural members have laboratories, diagnostic equipment and therapeutic services, but some have little or no surgical or obstetrical services. Not one is equipped to perform complicated surgeries.

“Certainly you could describe it as a defensive strategy,” Willis said.

Decades of Pressure

Many of theÌýproblems plaguing rural hospitals date to 1983, when Medicare began paying hospitals a set fee for medical services and procedures rather than reimbursing them for the actual costs of providing that care. From 1983 to 1998, 440 rural hospitals closed in the U.S., according to the NRHA. That prompted Medicare to begin reimbursing certain rural hospitals for their actual costs, which helped stabilize them.

But the recession hit rural hospitals especially hard, as did 2011 budget cuts that reduced Medicare payments by 2 percent. Because the rural population tends to be older, rural hospitals rely heavily on Medicare payments. The pressure increased in 2012, when the federal government reduced by 30 to 35 percent its reimbursements to hospitals for Medicare patients who don’t cover their share of the bill.

“That’s an example of how a little policy change that seems insignificant in Washington can have profound effects in the rural areas,” said Brock Slabach, NHRA’s senior vice president for member services.

Finally, more insurance plans are increasing copayments and other out-of-pocket costs. Many of the patients at rural hospitals have low incomes. And when they can’t cover their costs, the hospitals have to pick up the tab. “We don’t have cash reserves,” said Polheber, the Benson Hospital CEO. “We live on the edge, day to day, week to week. [The alliance] seemed like the best way to keep us going.”

Given the threats to the nation’s rural hospitals, many are eager to learn from any models that work, which is why the Arizona alliance has attracted notice.

Slabach, for one, calls it a promising model, although one that may not be replicable everywhere. “You have to have willing partners willing to collaborate and provide assistance to each other,” he said. “You need partners that share a cultural fit with you.”

The rural members of the alliance are major employers in their communities and assets in attracting other employers and residents, including the snowbirds, who flock to the area every winter. But hospital leaders, workers and patients say saving lives is the main reason the hospitals must remain open.

“In medicine, distance lessens the chances of survival,” said Pam Noland, director of nursing at Northern Cochise. “Even if a patient has to be transferred to [Tucson Medical Center] or somewhere else, stabilizing them here is the difference between life and death.”

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At least seven states — Delaware, Louisiana, Maine, Maryland, Montana, New York and Vermont — limit the out-of-pocket payments of patients in private health plans. Montana, for instance, caps the amount that patients pay at $250 per prescription per month. Delaware, Maryland and Louisiana set the monthly limit at $150 and Vermont at $100. Maine sets an annual limit of $3,500 per drug.

New York prevents insurers from listing specialty drugs in a separate category that allows for charging higher payments out of pocket.

In an effort to hold down prices, legislators in other states, including California, Massachusetts and North Carolina, have proposed requiring companies to make broad financial disclosures justifying their high drug prices. So far, no such law has passed.

Critics of pharmaceutical pricing say that while the measures would help bring financial relief to some patients, they would fail to control spiraling drug prices set by drugmakers. As expensive specialty drugs proliferate, consumers likely will incur higher out-of-pocket payments and health insurance premiums.

“None of those measures is going to be very effective in my view because they don’t get at the underlying issue of how drug prices are set,” said John Rother, president and CEO of the National Coalition on Health Care, a nonprofit that focuses on improving health care while lowering costs.

Expensive class of drugs

Specialty drugs are in a class called biologics, extremely complex medicines made from organic materials. They are often used to treat serious, chronic diseases, including some advanced forms of cancer, autoimmune diseases such as rheumatoid arthritis and diseases of the central nervous system such as multiple sclerosis. They also are used to treat hepatitis C, which afflicts approximately 2.7 million Americans, according to the Centers for Disease Control and Prevention.

In most cases, biologics are far more effective and cause fewer side effects than conventional drugs, leaving patients with no alternative but to take them.

But the price for these drugs far exceeds that of conventional drugs, largely because they have little or no competition. They also require special handling, such as refrigeration, and often must be administered intravenously, adding to their costliness.

On average, biologics cost 22 times what conventional medicines do. A 2011 AARP Public Policy Institute said that the average specialty medicine cost more than $34,550 for a year’s course of treatment.

“The cost of these drugs is simply unsustainable,” said Leigh Purvis, director of health services research in AARP’s Public Policy Institute.

Biologics also are gaining a growing share of the prescription market. According to a report last year from , a large prescription management company, specialty drugs already represent nearly a third of the spending on pharmaceuticals in the U.S., although they represent only 1 percent of all prescribed medications. Within two years, Express Scripts projects that spending on specialty drugs will account for $4.40 out of every $10 spent on medicine.

Coinsurance limits

At least seven states are tackling the problem of high out-of-pocket payments for expensive specialty drugs by limiting coinsurance payments.

Insurers use coinsurance and copayments to impose cost-sharing on beneficiaries. Copayments are a set price — often $5, $10, or $15 — that patients pay for medicine, whatever the cost of the drug. With coinsurance, patients are required to pay a percentage of the actual cost of the drug. That means that the higher the cost of the drug, the more the patient has to pay out of pocket.

Coinsurance payments for specialty drugs range nationally from 28 to 50 percent of the price of a drug, according to a 2013 by Chad Brooker, a lawyer with the Connecticut health exchange.

The state-imposed caps apply both to copayments and to coinsurance. They provide some price protection for the patients taking the drugs, but also spread the high cost of the drugs to a wider population of consumers in the form of higher insurance premiums.

“The caps don’t actually lower the costs of the medicine, it just raises the premiums for everyone,” said Rother of the National Coalition on Health Care.

Covered California, that state’s health exchange, this year became the first state exchange in the country to impose a coinsurance cap on specialty drugs of $250 per prescription per month.

James Scullary, a spokesman for Covered California, said the cap would result in an overall premium increase of no more than 1 percent in the first year and no more than 3 percent in the first three years.

New York has taken a slightly different approach. It won’t allow insurers to put biologics in their own special category of drugs. Insurers place medications in separate tiers depending on whether they are generics, preferred prescription drugs or specialty drugs. The higher the tier, the greater the cost-sharing burden for the patient. New York has prohibited the use of the specialty tier.

In Delaware, the state forbids insurers from putting all specialty drugs for aÌýparticular disease in the specialty tier, so that patients are given at least one lower-cost alternative.

Neither method gets around the problem of higher premiums for everyone, Rother said. He and other critics call for another method of setting the price of prescription medicine.

Right now, drug prices are set by manufacturers subject to mandated discounts for various federal health plans and Medicaid, and through negotiation with other health plans. Critics have argued for a system of pricing based on the relative effectiveness of each drug.

‘Shaming’ drugmakers

A bill currently before the California Assembly would require drugmakers to report their costs for the development and manufacture of any drug with a price tag of more than $10,000 for a course of treatment. Massachusetts and North Carolina are considering similar measures.

The purpose of disclosure measures is to create pressure on the drug companies to lower their prices, AARP’s Leigh Purvis said.

“It’s meant to be educational and also to be used in kind of a shaming way,” she said. “If the manufacturer can’t produce information that makes the prices seem justifiable, it may give people more ammunition to say that they’re not.”

The pharmaceutical industry argues that transparency laws, which it opposes, would not provide a fair representation of what it costs drugmakers to develop new drugs. For every drug that makes it to market, the industry says, nine or 10 do not. Nor would disclosure provide information on what costs patients would have to bear, it says.

“All of [the proposed transparency laws] would create an inaccurate and misleading overview of costs of providing treatment, and don’t provide information on costs patients will have to pay out of pocket,” said Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America.

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Their tax burden likely would have been lower if the state of Texas had elected to expand Medicaid, the federal-state health insurance program for low-income people. If more low-income patients at Parkland had been covered by Medicaid, then federal and state taxpayers would have picked up more of the costs.

Elsewhere in Texas and in most of the 20 states that have chosen not to expand Medicaid, residents pay local taxes to help support hospitals that care for uninsured people. On top of that, they pay a portion of the federal taxes that help subsidize Medicaid in the 29 states and District of Columbia that did expand the program to cover more people — places where residents can expect to see lower local taxes as more people become insured.

“Taxpayers (in non-expansion states) are not going to get off the hook any time soon,” said Linda Quick, president of South Florida Hospital and Healthcare Association. Florida is one of the non-expansion states where localities pay property taxes to support indigent care.

Under the Affordable Care Act, and a subsequent U.S. Supreme Court decision, states have the option of extending Medicaid eligibility to all non-elderly adults who make less than 138 percent of the poverty line (an annual income of less than $16,242 for an individual). For the first three years, the federal government will pay 100 percent of the costs associated with new enrollees. After that, the federal share gradually declines until it reaches 90 percent in 2020 and beyond.

Nationwide, the cost of caring for uninsured people in non-expansion states between now and 2024 is projected to reach $266 billion if no new states decide to expand Medicaid, according to a in April from the Kaiser Family Foundation. If all states decided to expand, that cost would drop by a third.

The Urban Institute in a study for the Kaiser Family Foundation that states and localities spent nearly $20 billion for uncompensated care in the United States in 2013. The federal government paid $33 billion and the private sector $700 million.

Last year, Texas hospitals spent $5.5 billion for uncompensated care, according to the Texas Hospital Association. The federal government reimburses hospitals for part of that cost through a $1 billion-a-year Medicaid subsidy known as the Disproportionate Share Hospital Allotments or DSH. As part of the Affordable Care Act, the DSH program will be sharply reduced starting in 2018. A recent Health Affairs projected that Texas hospitals could see a 20 percent drop in DSH payments in the first year.

Lance Lunsford, a vice president with the Texas Hospital Association, said without that federal money, residents would have to foot the bill in the form of higher insurance premiums and, in jurisdictions with public hospitals like Dallas County, higher taxes. “Hospitals have no choice but to limit their exposure,” he said. “That means cost-shifting to consumers and taxpayers.”

Texas also receives $29 billion through a five-year Medicaid demonstration program, with about half of that money going to care for the uninsured. That program expires next and the state is negotiating with the federal government over its renewal. The Obama Administration in April that it prefers Texas insure more people by expanding Medicaid than continuing to reimburse hospitals that serve the uninsured.

Despite that, the Texas Legislature ended its session earlier this month with no action on Medicaid expansion. If the federal government withholds funding for hospitals, local taxpayers will likely have to make up the difference.

“If you have the federal funding source going away, the money has to come from somewhere. These people aren’t going away,” said Teresa Coughlin, a senior fellow at the Urban Institute.

Texas Leaders Oppose Expansion

Texas Gov. Greg Abbott, a Republican, and the heavily Republican Texas Legislature remain opposed to Medicaid expansion.

Abbott calls Medicaid, “an already broken and bloated … program.” In March, members of the Republican Senate caucus wrote to President Obama reiterating their opposition to expansion. They noted that the “Texas Medicaid program has grown from 11 percent of the state budget in 1987 to 29 percent in 2015,” a trajectory they labeled “clearly unsustainable.”

The senators urged the Obama administration to grant the state more flexibility to control spending in Medicaid as it currently operates in the state. They asked that the state be able to impose work requirements on recipients, introduce “personal accountability requirements” such as cost-sharing, fees for missed appointments, the creation of health savings accounts, and the use of asset testing to determine eligibility for the program.

The decision not to expand has left Texas with more uninsured people than any other state: 1.7 million non-elderly adults. Texas also has the highest rate, 28 percent, of uninsured non-elderly adults.

The Urban Institute that if Texas had expanded Medicaid in 2014, over the next 10 years it would have spent $5.7 billion as its share of Medicaid expenses for the newly eligible population, while drawing down nearly $66 billion in matching federal Medicaid funds.

The decision also means a continued tax burden for local citizens, including those in Dallas County. “Our taxpayers pay more to Parkland for uncompensated care than for all of our other services combined,” said Dallas County Judge Clay Lewis Jenkins, who presides over the five-member commission that governs the county. “It is also the fastest growing budget item.”

Jenkins, a Democrat, is among the highest profile politicians in the state to champion the case for expanding Medicaid, saying it would bring relief to county taxpayers by reducing what the county pays for uncompensated care.

Dallas County estimates that expansion would have extended Medicaid eligibility to an additional 133,000 county residents and would have brought an additional $580 million in Medicaid reimbursement. That money would not have eliminated all expenditures for uncompensated care because some, including undocumented workers, would remain uninsured.

In Harris County, where Houston is located, residents pay more than $500 million a year in real estate taxes for uncompensated care at its public hospitals. Bexar County, home of San Antonio, pays just short of $300 million a year for uncompensated care.

Texas Not Alone

Texas isn’t the only state where local taxpayers cover the costs. Thirteen of the 21 states that have not expanded Medicaid have public hospital districts where local tax dollars pay for uncompensated care.

Grady Memorial Hospital in Atlanta, for example, receives $57 million a year from local taxpayers. The federal government’s expected cuts in uncompensated care reimbursement could eventually cost the hospital $45 million a year. Hospital CEO John Haupert said he does not expect the two counties that Grady serves to make up that loss, which could mean a cut in services.

“We would have to reevaluate the clinical services we could continue to supply and the clinical services that we couldn’t,” Haupert said. Georgia currently is working on a proposal that would keep some federal uncompensated care funds flowing in the expectation that more of the uninsured would receive comprehensive health care.

Mayors and county executives in other non-expansion states, including Republicans, have urged their states to expand coverage. One, Republican Mayor Adam O’Neal of Bellhaven, North Carolina, marched to Washington, D.C., twice in support of expansion.

Some legislators in some other non-expansion states have expressed concerns that continuing to provide indigent care will endanger the survival of many rural hospitals. Since 2010, 55 rural hospitals have already closed, according to the North Carolina Rural Health Research Program. (The list is .)

The Human Cost

DeShawn Bunton is one of Dallas County’s uninsured, who would qualify for Medicaid if the state expanded. A tiny, 51-year old, unemployed woman living in a one-bedroom, West Dallas apartment, Bunton has three ways of dealing with her lack of health insurance: visiting the emergency room, scavenging leftover medicine from friends or doing without treatment.

When her untreated diabetes makes her especially shaky and she gets a terrible taste in her mouth well known to diabetics, she goes to the nearest emergency room for treatment. During bad asthma attacks, she counts on friends to let her use one of their inhalers.

When she was hospitalized after having a heart attack on a train last year, Bunton passed on having a recommended stress test because she couldn’t afford it. She also left a prescription for a heart medicine unfilled.

Recently, she enrolled in a program at Parkland that allowed her to get back on all her medications. She is vastly relieved. “I was scared I was going to get sick at any time,” she said. “I had to watch my stress levels to make sure nothing upset me.”

The Parkland program is supported by local taxes. And Bunton now volunteers for the Texas Organizing Project, a grassroots organization pushing for expansion.

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The Affordable Care Act gave states federal dollars to raise Medicaid reimbursement rates for primary care services—but only temporarily. The federal spigot ran dry on Jan. 1. Fearing that lowering the rates would exacerbate the shortage of primary care doctors willing to accept patients on Medicaid, the 15 states are dipping into their own coffers to continue to pay the doctors more.

It seems to be working.

In Indiana, which is spending about $40 million a year in state dollars to keep the higher reimbursement rate, an additional 335 doctors have started accepting Medicaid patients since the beginning of this year. So have more than 600 other medical providers, such as nurse practitioners and physician assistants.

“We’ve seen good results,” said Joe Moser, the state’s Medicaid director. “We are interested in seeing if the results continue, and we have every reason to think that it will.”

Colorado has had a similar experience. There the number of new providers participating in Medicaid is increasing by about 100 each month, according to Marc Williams, spokesman for the Department of Health Care Policy and Financing.

In addition to Indiana and Colorado, Alabama, Iowa, Maryland, Mississippi and New Mexico are keeping reimbursement rates where they were before the federal bump ended. Connecticut, Delaware, Hawaii and Maine, Michigan, Nebraska, Nevada, and South Carolina also are continuing to pay higher rates, though they aren’t as high as they were before the federal money disappeared, according to a March to Congress from the Medicaid and CHIP Payment and Access Commission (MACPAC).

In the 23 states that have indicated they won’t continue to make the higher payments, payments for primary care will fall 47 percent on average this year, an Urban Institute estimates.

David Schultz, a family physician who runs a clinic with a high percentage of Medicaid enrollees in southwestern Indiana, said low Medicaid reimbursement rates had made it increasingly difficult to maintain the practice.

“Frankly, we were losing money and losing personnel,” he said. “We had to increase the numbers of people we saw every day, stayed open much longer, worked through lunches, not taking half-days off.”

The higher rates haven’t changed his life enormously, he said, but the office has at least been able to cut back on the heavy scheduling.

Rejecting Medicaid

In 2012, a third of primary care doctors didn’t accept new patients with Medicaid coverage, according to a previous MACPAC to Congress. Only 25 percent of patients covered by Medicare, the government health program for seniors, were turned away. And only 15 percent with private insurance were.

Before the federally subsidized higher reimbursements were paid, Medicaid paid only 59 percent of what Medicare did for primary care services, according to the Henry J. Kaiser Family Foundation.

When the federal subsidy ended, states had to decide whether to continue to pay higher rates with little hard data on whether doing so would persuade more doctors to accept Medicaid patients. Other factors, such as the relatively long time it takes doctors to receive their Medicaid payments, also may contribute to their reluctance to take on Medicaid patients.

A multistate on the impact of the reimbursement increase published in the New England Journal of Medicine in February found that the availability of primary care appointments for Medicaid patients had increased 7.7 percent with the higher payments. But the study did not examine how many more doctors were accepting Medicaid patients.

There was, however, anecdotal evidence from individual states. Alaska, for example, has long paid Medicaid reimbursement rates that are higher than those for Medicare. Margaret Brodie, director of the Division of Health Care Services, said she believes that’s why the state hasn’t had a shortage of Medicaid providers.

And in Connecticut, the number of primary care doctors participating in Medicaid was 3,589 at the start of this year, up from 1,622 on Jan. 1, 2012, the year before the fee bump, according to David Dearborn, a spokesman for the Department of Social Services.

Paying for the Bump

The states that are continuing the higher payments are turning to a variety of sources to finance them.

Indiana will do it with an increase in the cigarette tax and an eventual increase in taxes on hospitals.

Nebraska is using state general funds for the $8.9 million it needs to pay the higher rate. Maine is redirecting $7.4 million in state tobacco settlement money to help pay the higher rates. To get the $18 million it will cost to fund the increase for six months, Colorado is relying on an advantageous recalibration of its federal-state Medicaid match.

Maia Crawford, a program officer at the Center for Health Care Strategies, a nonprofit that focuses on improvements in publicly financed health care, argues that maintaining the higher rates isn’t a heavy price for states to pay in return for “garnering good will among Medicaid providers and working to ensure that Medicaid stays well stocked with providers.”

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The Utah legislature took a step last week into territory where state lawmakers rarely tread.

It passed a giving children conceived via sperm donation access to the medical histories of their biological fathers. The law itself stirred no controversy. The oddity was that the legislature ventured into the area of “assisted reproduction” at all.

Assisted reproductive technology (ART) helps infertile couples to conceive. Compared to many other industrialized nations, neither the U.S. nor state governments do much to oversee the multibillion-dollar industry.

“The United States is the Wild West of the fertility industry,” Marcy Darnovsky, executive director of theÌýÌýsaid, echoing a description used by many critics of the regulatory environment surrounding ART.

The federal government requires laboratories engaged in assisted reproduction to be certified by organizations, such as the American College of Pathologists, and to report certain data to the Centers for Disease Control and Prevention (CDC). (One exception to minimal federal intervention: President George W. Bush’s ban in 2001 on the use of newly created embryonic stem cell lines in research.)

States are split about whether surrogacy contracts, usually between prospective parents and an egg donor, are permissible. But other aspects of ART are simply unaddressed by the states. For example, states don’t regulate how many children may be conceived from one donor, what types of medical information or updates must be supplied by donors, what genetic tests may be performed on embryos, how many fertilized eggs may be placed in a woman or how old a donor can be.

Lawmakers are wary of touching assisted reproduction, Darnovsky said, because of the incendiary politics that surround the issue of abortion, which touches on conception and embryos.

In terms of the number of people involved, the issue is significant. The CDC reports that about 12 percent of women of childbearing age have used infertility services and that 1.5 percent of all infants born in the U.S. are conceived using ART.

The first infant conceived through ART in the U.S. was born in 1981. Since then, assisted reproduction has experienced enormous growth. The CDCÌýÌýthat in 2012, more than 65,000 live births in the U.S. resulted from ART, which generally refers to fertility treatments in which either eggs or embryos are handled. That number does not include artificial insemination, which experts believe results in far more births.

Other countries, such as Canada, the United Kingdom, Sweden, Germany and Australia, heavily regulate many aspects of reproductive technology. Many scholars, as well as some who have been through the assisted reproduction process in the U.S., believe this country should do the same.

“I think in the United States we need more regulation of assisted reproductive technologies to protect the rights of children, donors and parents,” said Naomi Cahn, a law professor at George Washington University and co-author ofÌý the book “Finding Our Families: A First-of-Its-Kind Book for Donor-Conceived People and Their Families.”

Cahn believes donor-conceived children should at least have access to full medical information about biological parents, if not information about ethnicity and country of origin. Parents, she said, should have the right to know how many times a donor’s sperm or eggs were used to conceive a child. And donors should have a right to know what happens to their sperm or eggs.

Lack of Regulation Disputed

TheÌýÌý(ASRM) takes umbrage at the suggestion that ART is lightly regulated.

“I used to call it the ‘myth of un-regulation,’ but it’s actually a malicious and often deliberate falsehood most often conveyed by folks with ideological opposition to reproductive medicine,” Sean Tipton, the ASRM’s chief lobbyist, wrote in an email message. “Reproductive medicine is one of the most heavily regulated fields of medicine in the US.”

As evidence, Tipton points out that the federal government regulates all drugs and medical devices, as well as the reproductive tissues used in ART. States, he said, license practitioners (as they do all medical professionals). But the heart of his argument is that “the professional self-regulation is extensive.”

ASRM does issue lengthyÌýÌýto its membership, which consists of fertility clinics and sperm banks. However, critics point out, it does not sanction those who are in violation of guidelines.

Critics argue that ASRM’s main function is to advance the business interests of its members, unfettered by government regulation.

“It’s a field characterized by strong anti-regulatory sentiment because it evolved as a business, not a research enterprise,” said Arthur Caplan, director of the division of Medical Ethics at New York University’s School of Medicine.

Debra Mathews of the Berman Institute of Bioethics agrees that the industry is lightly regulated because “assisted reproduction has grown up as a medical services business not under the auspices of medical research.” The federal government ensured that situation would continue when, in 1996, Congress passed an amendment banning the use of federal funds in research related to the creation of embryos.

There are also political reasons politicians have little interest in taking up ART legislation.

“It is unregulated because it touches on two, ‘third-rail’ issues,” said NYU’s Caplan. “It touches on abortion and also the creation of embryos, which politicians run away from because too many people still disagree about the right to use reproductive technologies, particularly who should pay for them and how much.”

The lack of regulation does have some benefits, critics say. Without regulation, for instance, gay couples and single people don’t face any built-in barriers to using ART to produce children.

But others see disadvantages, none more loaded than a lack of restrictions on the number of children that can be produced by any single donor. The concern is that offspring of a frequent donor could inadvertently meet and fall in love, raising the possibility of “accidental incest.”

Donor-conceived children also argue that donors should be subjected to better medical screenings. Generally, donors are only tested for sexually transmitted diseases. There are no laws requiring medical testing for genetic diseases or requiring that donors – usually in their 20s at the time of donation – update medical information as they age and inherited diseases may surface.

Many donor-conceived offspring believe that they, like their counterparts in Britain, should have a right to more than medical information and that the identity of biological parents should be revealed to them.

Many of those who donated eggs and sperm did so in the expectation of a lasting anonymity. They didn’t want unknown offspring to one day knock on their door.

But in the Internet age, the expectation or anonymity is increasingly diminished. Several websites, such asÌýÌýandÌý, enable those who share the same DNA to connect with one another. Through those websites and other Internet searches, thousands of people have been able to circumvent the anonymity offered by sperm banks and fertility clinics to identify biological parents, half-siblings or cousins.

Donors, Offspring May Drive Action

If there is more regulation in assisted reproduction, it will probably come from those who have gone through the process or were the result of it.

That is what happened in Utah. The sponsor of the bill, Republican Rep. Dixon Pitcher, was buttonholed by an old friend who in her late 60s learned that the beloved, now-deceased man who raised her was not her biological father. The truth unraveled after a nephew with health problems underwent DNA testing.

“It was devastating,” she said. “I think I cried for about three months.” The woman, who asked that she only be identified as “Marie” to avoid embarrassing others, said she has since learned of eight half-siblings, some of whom she has now met.

Through the DNA research and other clues, Marie said that it became clear that the father of all of them was her mother’s doctor. Geneticists say that prior to modern fertility technology, doctors of women with infertile husbands often provided the sperm that enabled their patients to conceive.

Marie said she had hoped Pitcher’s bill would enable donor-conceived children to learn the identities of their biological parents, but she is pleased that at least some medical information will be made available as a result of the new law.

Other people also are clamoring for information about their donations or their biological parents.

Katie Graves of northern Virginia, for instance, said that 17 years ago, she underwent egg retrievals four times, and was paid about $3,000 each time. Later, she said, she was unable to learn from the clinic the dosages of hormones and medications that had been used in her case. And she said she was denied any information about whether her donation had resulted in any births. Through a DNA matching website, she learned in January that she had a 16-year-old biological daughter.

Martin Garrison made donations to a sperm bank that was recruiting students at UCLA when he was a student there in the 1980s. He made $500 a month for making three donations a week. “It was work you could do that wasn’t painful,” he said. When he tried later to learn how many children he had fathered as a result of his donations, he kept getting different answers, ranging from one to 10 children. He said the bank never contacted him to ask him for a medical update.

Lisa Swanson, a lawyer, learned at age 30 that she was donor-conceived. When she tried to learn about her biological father, she ran into a dead-end with the clinic that arranged her conception.

“They told me all the records had been destroyed,” she said. “They also said they had no idea how to reach the doctor.”

“I know nothing about half of my genetic health information,” she said. More should be required of the industry, she said. Physicians “are creating human beings but destroying our ability to know where we came from.”

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The emphasis on “patient-centered care”—the idea that physicians should follow the wishes and preferences of patients, and treat patients holistically, rather than just treating their symptoms—have been the hallmarks of osteopathic medicine since its founding in the 19th century by a frontier doctor.

Those ideas are ingrained in the Affordable Care Act, which uses financial incentives to promote certain kinds of patient-centered medical services. Meanwhile, the new health care law is expected to exacerbate a shortage of primary care doctors by extending health coverage to millions more Americans.

The ACA’s Teaching Health Center Graduate Medical Education program, a 5-year, $230 million initiative designed to increase the number of primary care residents and dentists trained in community-based settings, also meshes well with osteopathic medicine.ÌýA number of the programs that have received grants thus far are accredited as osteopathic residency programs.

Interest in osteopathic medicine was surging even before the ACA, but many believe the new law will accelerate the trend.

In 1970, there were 13,022 osteopathic practitioners in the U.S., and most were clustered in the middle of the country. Today, there are more than 82,000 doctors of osteopathic medicine (D.O.s), according to a report of the American Osteopathic Association (AOA). By contrast, the estimates there are about 790,000 M.D.s in the U.S.

Osteopathic practitioners say they haven’t changed. Instead, American health care is coming to appreciate what has always been central to osteopathic medicine.

“The fact that there is more emphasis on patient-centered care and on the whole person is in keeping with what has always been true of osteopathic medicine,” said Robert S. Juhasz, head of the AOA and president of Cleveland Clinic’s South Pointe Hospital.

Castor Oil And Leeches

The founder of osteopathic medicine, Andrew Taylor Still, was a Kansas abolitionist and friend of famed abolitionist John Brown. He believed that traditional medicine as then practiced, featuring such curatives as castor oil, arsenic, leeches, and opium, often did more harm than good.

Still had great faith in the body’s ability to heal itself and the capacity of doctors to diagnosis and treat with their hands, tenets that remain strong in osteopathic medicine today. As it developed over the years, with its attention to diet, lifestyle, and mental wellness, its emphasis on preventive health and affinity for hands-on diagnoses and healing, osteopathic medicine anticipated approaches to health care that are now fully accepted in American medicine.

Osteopathic doctors are in every state and colleges of osteopathic medicine have sprouted up in all regions, some in collaboration with public universities. According to the (AACOM), more than 20 percent of medical students now train in osteopathic medicine.

Most Americans are probably unaware that two tracks of medical training exist, both of them producing fully licensed physicians. Although osteopathic medical graduates can and do go on to all the medical specialties when they become residents, osteopathic medical colleges discourage early specialization and emphasize general medicine.

In osteopathic medicine’s first 60 years, osteopathic doctors often found themselves unwanted in many residency programs and hospitals, and they were not allowed to practice in the military. But those limitations began to disappear in the 1950s and were virtually gone by the end of the 1970s.

Any enmity between the two types of medicine were put to a symbolic end last spring when the AOA, AACOM and the Accreditation Council for Graduate Medical Education (ACGME) jointly announced a plan to develop a single accreditation system for all graduate medical education.

Community Oriented

Colleges of osteopathic medicine—there are now 42, including branch campuses — are seldom attached to teaching hospitals. Most send their students to community medical centers for training. The schools tend to be located in areas that are medically underserved, and they encourage their graduates to work in such areas.

In the past, that has meant building osteopathic medical programs in rural areas, like Appalachia and the Great Plains. But recently, they have also located in underserved urban and suburban areas as well.

The Touro College of Osteopathic Medicine opened in Harlem in 2007 in the expectation that it would produce doctors interested in working in poorer city neighborhoods that other doctors avoided. Another Touro College of Osteopathic Medicine has now opened in the New York City suburb of Middletown.

“You had an economically depressed, medically underserved area here in Harlem surrounded by a larger population area that had no shortage of doctors,” said Robert Goldberg, dean of Touro’s Harlem campus.

Goldberg said Touro admission officers look for students who have shown genuine commitment to serving the disadvantaged and appear inclined to continue to do so as physicians.

Connecting To Patients

Training students to communicate effectively with patients has always been central to education in osteopathic medicine, Goldberg said. A released last year by the Foundation for Osteopathic Research and Continuous Education found that students in traditional medical programs demonstrated a drop-off in empathy for patients after their second year of medical training, a decline not identified among students of osteopathic medicine.

Goldberg pointed out that fewer than 10 percent of the graduates from the medical school at nearby Columbia University end up in primary care, and well over 50 percent of his graduates do.

Already, nearly 20 percent of Americans live in areas with too few primary care doctors, with the shortages particularly pronounced in rural areas, according to the . The Annals of Family Medicine that the U.S. will face a shortage of 52,000 primary care doctors by the year 2025.

The emphasis on empathy is what attracted Carisa Champion-Lippmann to osteopathic medicine. She attends the College of Osteopathic Medicine at Nova Southeastern University in Davie, Florida, where she is also in degree programs for law and public health.

“I wanted something different than what I saw in other medical schools,” Champion-Lippmann said. “I wanted a program that was about really respecting where patients were coming from and also looked at all the things that affected a person’s health – from the physical to the mental to the spiritual. Finally, I found out about osteopathic medicine.”

Clif Knight, an M.D., and vice president for education at the American Academy of Family Physicians, said that while some allopathic medical schools are strong in family medicine, others are not, perhaps to the point of not even having departments of family medicine.

“Osteopathic medicine has a much more consistent focus on primary care,” he said. Osteopathic education, he added, also gives students early exposure to patients to emphasize the importance of forging strong relationships with them. Many allopathic schools are now adopting that approach, said Knight.

New Collaborations

Recently some large universities have collaborated with osteopathic programs to launch new osteopathic medical schools.

That happened between Virginia Tech and the Edward Via Virginia College of Osteopathic Medicine. It was so successful that Auburn University, a public university in Alabama, entered into a similar agreement with Edward Via Virginia to start another school there. The first class will arrive next fall. Edward Via Virginia also has a campus in South Carolina with a looser affiliation with three colleges in the area.

Edward Via Virginia’s current provost and founding dean, Dixie Tooke-Rawlins, is largely responsible for that growth. She says she has turned aside proposals from other universities interested in similar collaborations, only because there’s only so much expansion Edward Via Virginia can do.

But she is not surprised by the contacts she has received given the national emphasis these days on patient-centered care. “I’m 60 years old,” she said, “and when I first heard that term, I thought, ‘Well, what else is there?’”

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“On a feeling level, people want a safe, respectful place, to ponder the tons of questions that come begging in hard times,” said Glenn Williams, a pastoral counselor in Kentucky and chair of the Kentucky Association of Pastoral Counselors.Ìý“Where is God? ÌýWhy did this happen? ÌýIs it karma, sowing-reaping, happenstance? ÌýWhat purpose does this suffering serve?”

Williams, who works at the St. Matthews Pastoral Counseling Center outside Louisville, said many of his patients are quite “intentional” about their preference for pastoral counselors over other mental health professionals.

Kentucky recently became the sixth state (joining Arkansas, Maine, New Hampshire, North Carolina and Tennessee) to allow pastoral counselors to become licensed mental health counselors. As of now, Kentucky only has 20 licensed pastoral counselors. But the hope is that licensing will increase those numbers by making it easier for pastoral counselors to receive health insurance reimbursement and by adding luster to the field.

Kathy Milans, a pastoral counselor in Wilmore, Kentucky and chairman of the , said many pastoral counselors wanted the new law so they would be on an equal footing with other mental health professionals. “It just moved us up a notch professionally,” she said. “All the other helping professions had that license after their names, and we did not.”

But some are skeptical. Martin Cortez Wesley, chairman of the Kentucky Board of Licensed Professional Counselors and dean of counseling at University of the Cumberlands, said he wasn’t opposed to the new law but was puzzled by it. “To me, pastoral counseling is just a specialization,” he said. “We have specialization for people who counsel Latinos, but we don’t have separate licensing for counseling Latinos. I don’t see why they want it here.”

Counselors of a Different Stripe

Douglas Ronsheim, executive director of the , said efforts to pass licensing laws in some other states, including Pennsylvania and New York, failed in part because clergy feared it might prevent them from providing the spiritual counseling they regard as essential to their calling.

But many pastoral counselors regard themselves as just another stripe of mental health professional, a group that includes licensed mental health counselors, marriage and family therapists, clinical social workers, psychologists and psychiatrists. Counselors of all kinds use some of the same treatment techniques, but their approaches also reflect the bent of their own disciplines. Most pastoral counselors operate outside of churches, and may see patients of different denominations or even different faiths.

Whatever their particular beliefs, spirituality is central to many Americans’ lives. For some of them, pastoral counseling can be the most effective approach, Ronsheim said. “For a long time, it seemed that mental health counselors were more comfortable addressing one’s sexual life than one’s spiritual life,” Ronsheim said. Pastoral counselors, he said, can fill that gap.

Addressing a Shortage

State Sen. Alice Forgy Kerr, the Lexington Republican who spearheaded passage of the Kentucky bill, said boosting the number of mental health providers, particularly in rural areas, was a major motivation. “Of course, any parishioner can now go and seek advice from his or her pastor, but we are talking about a professional degree,”

According to the , which tracks the health care workforce, Kentucky is among the states with the lowest per capita number of psychologists and mental health counselors. Nationally, the shortage of mental health service providers is more acute than other medical areas. According to HRSA, 89.3 million Americans live in federally-designated Mental Health Professional Shortage Areas, compared to 55.3 million Americans living in primary-care shortage areas and 44.6 million in dental health shortage areas. A Kaiser Family Foundation found that the current mental health workforce is only able to meet about half of the nation’s demand for behavioral health services.

And demand is only expected to increase, thanks to mandates for mental health benefits in the Affordable Care Act and the implementation of the federal Mental Health Parity and Addiction Equity Act.

Pastoral counselors are not nearly as plentiful as other mental health professionals; the American Association of Pastoral Counselors has about 1,940 members, compared to roughly 7,000 members in the American Mental Health Counselors Association.

Even before the licensing law, “fee-based” pastoral counselors in Kentucky had to be certified by the state. The new law does not change those requirements.

Like other mental health professionals in Kentucky, pastoral counselors must be trained in psychotherapy and clinical practice. They also must have a master of divinity degree from an accredited program and an additional advanced degree related to mental health counseling. And they must complete 1,375 hours of supervised pastoral counseling, 250 hours of direct clinical supervision, and pass a written state examination.

The requirements are tougher than what some other mental health professionals in Kentucky, including marital and family counselors, must complete. Some pastoral counselors in Kentucky already had licenses as mental health or marriage and family counselors, but believe that pastoral counseling should be recognized as its own discipline.

Uncertain Coverage

Until now, many pastoral counselors have charged their patients sliding fees based on their income.

Even though insurance reimbursement was a major factor in Kentucky’s decision to license pastoral counselors, the insurance picture remains murky. Few, if any, insurance payers reimburse for mental health treatment from unlicensed pastoral counselors, but having a license doesn’t guarantee payment.

Medicare does not cover pastoral counseling, and under Medicaid it is a state-by-state decision (Kentucky Medicaid does not cover it). The Veterans Health Administration does not pay for pastoral counseling, and TriCare, the health plan for active military personnel and their families, only covers it if the counselor is supervised by a physician.

Because the law in Kentucky went into effect only a few weeks ago, it’s too early to tell what private insurers will do. Next door in Tennessee, which has longer experience with licensing, there is continuing resistance. Chris O’Rear, president of the Tennessee Association of Pastoral Therapists and executive director of the Pastoral Counseling Centers of Tennessee, said “it is a very slow process for insurance companies to recognize pastoral therapists.” O’Rear noted that some insurers never got rid of clauses that specifically excluded pastors from being eligible for insurance reimbursement.

But Williams said he is hopeful that Kentucky’s new law will make a difference.

“You get the sense now that students in the process are thinking that maybe I can make a go of it now, whereas heretofore, if you wanted to be a pastoral counselor, you were going to be in a tough sort of deal,” Williams said.

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