Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Now it’s time to shift gears. This is the last Insuring Your Health column. But it isn’t the last time you’ll hear from me at Kaiser Health News. I’ll continue writing regularly about consumer health care for KHN, just not every Tuesday. With the added flexibility I want to be able to now and then take a broader look at some of the consumer health areas I’ve been writing about over the years. I hope you will keep reading and giving me feedback.

I couldn’t do this work without a lot of help. Thanks to the many, many smart and thoughtful pros who’ve carved out time to talk with me again and again to help me understand the devil-in-the-details of medicine, health law and policy. I expect I’ll be calling on some of you this week to chat.

Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

Most of all, I’d like to thank the many people who’ve shared their stories with me over the years and allowed me to write about them. People like Kristen Catton, who faced thousands of dollars in bills when her health plan changed how it covered her multiple sclerosis drug. Or Phyllis Petruzzelli, who avoided a hospital stay for pneumonia by being “admitted” to her living room through a hospital-at-home program. Those experiences explain health policy in personal terms for readers, and I’m so grateful to the many people who’ve trusted me to tell their stories.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at Andrews.KHN@gmail.com. I look forward to hearing your thoughts and ideas.

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Defensores de salud de las mujeres aplaudieron la disponibilidad de un nuevo que podría usarse hasta por un año. Pero algunos cuestionaron la aprobación de que ayuda a las mujeres a evitar el embarazo registrando su temperatura corporal y ciclo menstrual, un tipo de anticoncepción llamada “conciencia de fertilidad”.

Los críticos mencionaron sobre cerca de tres docenas de mujeres en Suecia que quedaron embarazadas a pesar de monitorear su ciclo con la aplicación. También temen que esta aprobación de la FDA lleve a que las pacientes piensen que los , que incluyen una variedad de prácticas para monitorear la ovulación y evitar el sexo sin protección durante ese tiempo, son tan buenos para prevenir el embarazo como algunas formas altamente efectivas de control de la natalidad, como el dispositivo intrauterino o DIU. Si bien los métodos “naturales” pueden ser exitosos, generalmente requieren de una atención diaria muy cercana.

Todavía hay mucho por hacer para que mujeres y hombres usen a pleno los métodos anticonceptivos. Según un publicado en New England Journal of Medicine, casi la mitad de los 6,1 millones de embarazos en los Estados Unidos (45%) en 2011 no se planificaron. Esa cifra es inferior a la tasa del 51% en 2008, pero es más alta que la tasa en muchos otros países industrializados.

La FDA ha aprobado casi dos docenas de métodos anticonceptivos, que incluyen la píldora, el parche, los DIU y los implantes e inyecciones hormonales, entre otros. Las mujeres deben tener seguro de salud para obtener un método aprobado por la FDA sin pagar nada de su bolsillo.

El nuevo anillo vaginal, , libera hormonas que previenen la ovulación y debe removerse después de tres semanas durante siete días, para luego volver a colocarlo. Se puede usar por un año. El dispositivo no estará en el mercado hasta finales de 2019, y el fabricante no ha revelado el precio.

La aplicación enseña a las mujeres a tomar su temperatura a la misma hora cada mañana cuando se despiertan y anotarla en la aplicación. También deben registrar información sobre su ciclo menstrual. En función de los ligeros cambios de temperatura en torno a la ovulación, la aplicación señala cuándo las mujeres deben evitar las relaciones sexuales sin protección. Cuesta alrededor de $80 por año.

Los dos nuevos métodos requieren más atención por parte del usuario que, por ejemplo, un DIU, que una vez colocado, la mujer puede olvidarse, y está diseñado para evitar un embarazo durante cinco a 10 años, dependiendo de la marca.

Aun así, algunos expertos en salud femenina se preocupan de que el sello de aprobación de la FDA pueda ser malinterpretado por algunas mujeres.

“La gente interpretará que esto significa que la FDA lo aprueba y cree que es un buen método”, dijo el , vicepresidente de actividades de práctica del Colegio Estadounidense de Obstetras y Ginecólogos.

“Es por eso que el asesoramiento es tan importante”, dijo, y señaló que los médicos deberían analizar todas las formas de control de la natalidad con las mujeres, y que la conversación debe incluir la eficacia de los diferentes métodos.

Pero la doctora Gillian Dean, directora sénior de servicios médicos de Planned Parenthood Federation of America, celebra la aprobación de ambos métodos.

“Siempre es mejor tener más opciones”, dijo. “No es una talla única para todos, y más opciones aumentan la probabilidad que las mujeres encuentren un método que funcione para sus necesidades”.

Dean enfatizó que el anticonceptivo correcto depende de los objetivos de la mujer, incluidos sus planes reproductivos, cómo es su ciclo menstrual, la cantidad de parejas que tiene y lo importante que es no quedar embarazada. Dijo que la mayoría de las mujeres que visitan las clínicas de Planned Parenthood solicitan y reciben píldoras anticonceptivas, pero un número cada vez mayor pide métodos anticonceptivos reversibles de acción prolongada, como los DIU y los implantes hormonales.

El DIU y los implantes hormonales tienen una “tasa de fracaso” de menos del 1%, lo que los convierte en (al mismo nivel de la esterilización permanente). Las píldoras anticonceptivas, el parche y el anillo vaginal tienen tasas de eficacia de alrededor del 91%, según los Centros para el Control y Prevención de Enfermedades (CDC).

Los métodos de conciencia de la fertilidad, por otro lado, tienen una tasa de falla de alrededor del 24%, según los CDC. Pero esa cifra es ampliamente malentendida, dijo , investigadora principal del Instituto Guttmacher, una organización de investigación y defensa de la salud sexual y reproductiva.

Polis fue coautora de un basados ​​en la conciencia de la fertilidad que se publicó en agosto en la revista Obstetrics and Gynecology.

Agregó que la cifra del 24% refleja principalmente la tasa de fracaso esperado para las mujeres que usaron el método del ritmo, un enfoque basado en el calendario para calcular cuándo ocurre la ovulación, en lugar de nuevos métodos biométricos que registran la temperatura corporal, la mucosa cervical o las hormonas urinarias. Algunos de esos métodos pueden ser más efectivos, aseguró.

Con base en una revisión de estudios, Polis y sus colegas informaron que la aplicación Natural Cycles tenía una tasa de embarazo no deseado de 9.8%. El anuncio de la FDA, que incluye los resultados de un estudio adicional, señaló una tasa de 6.5%.

Polis dijo que indica que alrededor del 3% de las mujeres que usan anticonceptivos utilizan métodos basados ​​en el conocimiento de la fertilidad, ya sea solos o combinados con otros, y su número está creciendo.

“Creo que [la aprobación de la aplicación] es en gran medida un paso positivo hacia adelante”, dijo Polis. “Me alivia que la FDA tenga una vía regulatoria para evaluar estos usos y reclamos”.

La cobertura de KHN de los problemas de salud de las mujeres es apoyada en parte por .

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Women’s health advocates applauded the availability of that could be used for up to a year. But some questioned the that helps women avoid pregnancy by tracking their body temperature and menstrual cycle, a type of contraception called “fertility awareness.”

Critics that three dozen women in Sweden got pregnant despite monitoring their cycle with the app. They also fear that the FDA approval of the app may encourage patients to think that , which include a range of practices to track ovulation, and avoid unprotected sex during that time, are just as good at preventing pregnancy as some highly effective types of birth control, like the intrauterine device, or IUD. While “natural” methods can be successful, they generally require close daily attention.

There’s still room for improvement in contraceptive use by women and men. Nearly half of the 6.1 million pregnancies in the United States — 45 percent — in 2011 were unplanned, published in the New England Journal of Medicine. That figure is lower than the 51 percent rate in 2008, but is higher than the rate in many other industrialized countries.

The FDA has approved nearly two dozen contraceptive methods, including the pill, the patch, IUDs and hormonal implants and shots, among others. Insurance is required to cover all FDA-approved methods without charging women anything out-of-pocket.

The new vaginal ring, releases hormones that prevent ovulation and after three weeks for seven days, then reinserted. It can be used for a year. The device will not be on the market until at least late 2019, and the price hasn’t been released by the manufacturer.

°Õ³ó±ðÌý instructs women to take their temperature at the same time every morning when they awake and record it in the app. They also track information about their menstrual cycle. Based on slight temperature changes around ovulation, the app signals when women should avoid unprotected sex. It costs about $80 a year.

Both of the new methods require more attention on the part of the user than say, an IUD, which once inserted can be ignored and is designed to prevent pregnancy for five to 10 years, depending on the brand.

Still, some women’s health experts worry that the FDA stamp of approval may be misinterpreted by some women.

“People will interpret this to mean that the FDA approves this and thinks it’s a good method,” said , vice president of practice activities for the American College of Obstetricians and Gynecologists.

“That’s why counseling is so important,” he said, noting that doctors should discuss all forms of birth control with women, and the conversation should include the efficacy of different methods.

But Dr. Gillian Dean, senior director of medical services at Planned Parenthood Federation of America, welcomes the approval of both new methods.

“More options are always better,” she said. “It isn’t one size fits all, and more options increases the likelihood that women will find a method that works for their needs.”

The right contraceptive depends on a woman’s goals, Dean said, including her reproductive plans, what her menstrual cycle is like, the number of partners she has and how important it is for her not to get pregnant. She said most women who visit Planned Parenthood clinics ask for and receive birth control pills, but an increasing number are asking for long-acting reversible methods of contraception, such as IUDs and hormonal implants.

The IUD and hormonal implants have a “failure rate” of less than 1 percent, making them among the most effective (on par with permanent sterilization). Birth control pills, the patch and the vaginal ring have effectiveness rates of about 91 percent, according to the federal Centers for Disease Control and Prevention.

Fertility awareness methods, on the other hand, have a failure rate of about 24 percent, according to the CDC. But that figure is widely misunderstood, said a senior research scientist at the Guttmacher Institute, a sexual and reproductive health research and advocacy organization.

Polis co-authored of fertility awareness-based contraceptive methods that was published in August in the journal Obstetrics and Gynecology.

The 24 percent figure, she said, primarily reflects the expected failure rate for women who used the rhythm method, a calendar-based approach to calculating when ovulation occurs, rather than newer biometric methods that track body temperature, cervical mucous or urinary hormones. Some of those methods may be more effective, she said.

Based on a review of published studies, Polis and colleagues reported that the Natural Cycles app had a 9.8 percent unintended pregnancy rate. The FDA announcement, which includes the results of an additional study, noted a 6.5 percent rate.

Polis said that about 3 percent of women who use contraception practice fertility awareness-based methods, either alone or with other types of birth control, and their numbers

“I think [the app approval] is largely a positive step forward,” Polis said. “I’m relieved that the FDA has a regulatory pathway to evaluate these uses and claims.”

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A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy states may have had, said a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

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Q: Can getting a genetic test interfere with being able to buy long-term-care insurance in the future? If you do get a plan, can the insurer drop you after you find out the results of a genetic test?

In general, long-term-care insurers can indeed use genetic test results when they decide whether to offer you coverage. The federal Genetic Information Nondiscrimination Act prohibits health insurers from asking for or using your genetic information to make decisions about whether to sell you health insurance or how much to charge. But those rules don’t apply to long-term-care, life or disability insurance.

When you apply for long-term-care insurance, the insurer may review your medical records and ask you questions about your health history and that of your family. It’s all part of the underwriting process to determine whether to offer you a policy and how much to charge.

If the insurer asks you whether you’ve undergone genetic testing, you generally have to disclose it, even if the testing was performed through a direct-to-consumer site like 23andMe, said Catherine Theroux, a spokeswoman for LIMRA, an insurance industry trade group.

Consumers applying for a long-term care policy should release any medically relevant information, she said.

Some states provide extra consumer protections related to genetic testing and long-term-care insurance, said Sonia Mateu Suter, a law professor at George Washington University who specializes in genetics and the law. But most follow federal law.

If you get genetic testing after you have a policy, the results can’t affect your coverage.

“Once the policy has been underwritten and issued, the insurer doesn’t revoke the policy if new medical information comes to light,” Theroux said.

Q: Can I switch Medigap insurance companies midway through the year? I found a less expensive policy.

It depends. Under federal law, when people turn 65 and first enroll in Medicare Part B  to sign up for a Medigap plan. Medigap plans pick up some of beneficiaries’ out-of-pocket costs for services under , which covers hospitalization, and , which covers outpatient services. During that six-month period, insurers have to accept people even if they have health problems.

If you’re still in that six-month period now and you want to switch plans, go right ahead.

But if you’re past the six-month window, under federal law insurers are required to sell you a plan only in certain circumstances, such as if you lose your retiree coverage or Medicare Advantage plan. If you don’t meet the criteria, insurers can decline to cover you or charge you more for preexisting medical conditions.

Many states have provided more robust protections, however. Three states — Connecticut, Massachusetts and New York — have year-round open enrollment and require insurers to offer coverage. And Maine requires a one-month “guaranteed issue” open-enrollment period every year.

Some states guarantee current policyholders a chance to switch Medigap plans at certain points during the year. Other states have additional qualifying events that allow people to switch Medigap plans, from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“The first thing the person should do is check with her state insurance department to find out her rights related to buying a Medigap plan,” said Brandy Bauer, associate director at the Center for Benefits Access at the National Council on Aging. If someone decides to go ahead and switch, it is wise to sign up for a new plan before terminating your current policy, she said.

Q: I did not enroll in Medicare Part B when I turned 65 because I already have a regular plan that covers everything. I was told that the insurer would keep paying as usual, but now the company says it will pay only part and that I have to buy Medicare Part B. I didn’t want to pay for two policies. Is there anything I can do to avoid that?

From your description, it’s hard to know exactly what’s going on, but we can make educated guesses. Typically, when people turn 65, it makes sense to sign up for Medicare unless they or their spouse are working and getting health insurance from an employer. For others, at age 65, Medicare typically becomes their primary insurer and any other coverage they have becomes secondary, filling in gaps in Medicare coverage.

That’s how it generally works with retiree coverage, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation.

If you have an individual policy that you bought on the health insurance exchange and decide to hang on to it instead of signing up for Medicare, your premiums and other costs could be higher than they would be on Medicare, depending on your income.

But if you’re not receiving employee coverage and you don’t enroll in Medicare Part B, you could be subject to a of 10 percent for every 12 months that you could have signed up for Part B but didn’t. You could also owe a premium penalty for not signing up for a Part D prescription drug plan. (Most people don’t owe any premium for Medicare Part A, so there’s no penalty for late sign-up.)

“Without knowing more, it sounds like she should drop the [current] plan and sign up for Part B and D,” Neuman said. “But we need more information to know for sure.”

Your best move now may be to call 800-Medicare or visit your local to help sort out your coverage issues.

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La “inseguridad alimentaria”, como se la llama, es más prevalente en colegios comunitarios, pero también de carreras largas. Activistas estudiantiles y defensores de la comunidad educativa han llamado la atención sobre el problema en los últimos años, y los que se han creado en cientos de colegios son quizás el signo más visible.

Algunas escuelas también están utilizando el programa , que permite a los estudiantes donar sus cupones del plan de comidas no utilizados a otros estudiantes para que los usen en los comedores del campus o en los bancos de alimentos.

Esos “pases gratuitos para cenar me han dado la oportunidad de comer cuando pensé que no podría”, escribió un alumno al programa. “Solía ​​pasar hambre y eso dificultaba que me concentrara en la clase o para estudiar. [Los pases] realmente me ayudaron a estudiar, y pueden haberme ayudado a levantar mi GPA “.

Las despensas y los pases de comida son buenas vendas, pero se necesitan más soluciones para todo el sistema, dicen defensores.

“Si mando a mi hijo a la universidad, quiero más que un banco de alimentos”, dijo Sara Goldrick-Rab, profesora de políticas de educación superior y sociología en la Universidad de Temple en Filadelfia, quien fundó el . “Quiero saber que están abordando los altos precios de los alimentos en el campus y tomando medidas para garantizar que ningún estudiante pase hambre”.

Parte de la desconexión puede derivarse de una percepción errónea sobre cómo son realmente los estudiantes de hoy, dijo Katharine Broton, profesora asistente de política educativa y estudios de liderazgo en la Universidad de Iowa, quien ha publicado investigaciones sobre inseguridad alimentaria y vivienda en universidades. Muchos de ellos no se ajustan al perfil de un estudiante “típico” que asiste a una institución por cuatro años a tiempo completo, sin trabajar, explicó Broton. Más bien, alrededor del 40% de los estudiantes de hoy trabajan además de ir a la universidad, y casi .

El acto de malabarismo puede ser difícil de mantener. “Hallamos que la mayoría de los estudiantes están trabajando y recibiendo ayuda financiera, pero todavía están luchando con la inseguridad alimentaria”, agregó Broton.

Además del estrés está el hecho que, si bien la matrícula y las tarifas continúan aumentando, la ayuda financiera no ha seguido el mismo ritmo. En el , después de considerar la ayuda financiera y los beneficios impositivos, los estudiantes de tiempo completo en universidades de dos años tuvieron que cubrir, promedio, $8,070 en alojamiento y comida, mientras que aquellos en instituciones públicas de cuatro años enfrentaron un promedio de $14,940 en alojamiento, comida, matrícula y honorarios.

Defensores contra el hambre dan crédito a los estudiantes por elevar la alarma en los campus sobre este problema y, en algunos casos, ofrecer soluciones ingeniosas.

Rachel Sumekh, quien fundó el programa Swipe Out Hunger con un grupo de amigos en la UCLA hace varios años, dijo que querían hacer algo útil con los créditos no utilizados de los planes de comidas que debían comprar. Ahora, 48 universidades participan del programa, y Sumekh dijo que en el último año han visto un aumento “dramático” en el número de universidades que se están comunicando con ellos para involucrarse.

La Universidad de California-Berkeley es parte de , ya que el programa es conocido. Es una estrategia más en un esfuerzo múltiple dirigido a estudiantes que pueden necesitar apoyo adicional para satisfacer sus necesidades básicas de vivienda, alimentos y de otro tipo, dijo Rubén Canedo, empleado de la universidad que preside el comité de necesidades básicas del campus. (También es copresidente de un comité similar para los 10 campus de la Universidad de California).

Según una encuesta de estudiantes de Berkeley, el 38% de los estudiantes de pregrado y el 23% de los estudiantes de posgrado enfrentan inseguridad alimentaria en algún momento durante el año académico, dijo Canedo. La escuela se enfoca en grupos específicos de estudiantes: los que son primera generación en ir a la universidad, los que son padres, los que tienen bajos ingresos o pertenecen a la comunidad LGBT.

Canedo dijo que un enfoque clave este otoño será inscribir a los estudiantes elegibles en CalFresh, la versión de California del , conocido anteriormente como cupones para alimentos.

Bajo las reglas federales, los estudiantes generalmente deben trabajar al menos 20 horas a la semana para calificar para SNAP, algo que muchos no pueden manejar. Pero los estados tienen flexibilidad para designar lo que cuenta como programas de empleo y capacitación, dijo Elizabeth Lower-Basch, directora de ingresos y apoyo laboral en CLASP, una organización de defensa contra la pobreza. En California, por ejemplo, los estudiantes que participan en ciertos programas educativos en la escuela son para CalFresh.

“Esa es nuestra primera línea de defensa”, dijo Canedo. “A los estudiantes se les da alrededor de $192 por mes”.

Para los estudiantes que no califican para CalFresh, la escuela patrocina un que también brinda beneficios.

Hay un banco de alimentos que ofrece demostraciones de cocina regularmente. Pero de lo que Canedo dijo estar particularmente orgulloso es de un curso de ciencias de la nutrición de 15 semanas que los estudiantes pueden hacer, que les enseña sobre alimentación saludable, preparación de alimentos, presupuesto y compra de comestibles, entre otras cosas.

Algunas de esas habilidades pueden ayudar a los estudiantes a aprender a administrar su dinero y comida para que puedan pasar el tiempo en la universidad sin sufrir de escasez.

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“Food insecurity,” as it’s called, is most prevalent at community colleges, but it’s as well. Student activists and advocates in the education community have drawn attention to the problem in recent years, and the  that have sprung up at hundreds of schools are perhaps the most visible sign.

Some schools are also using the program, which allows students to donate their unused meal plan vouchers, or swipes, to other students to use at campus dining halls or food pantries.

Those “free dining passes have given me chances to eat when I thought I wouldn’t be able to,” one student wrote to the program. “I used to go hungry and that would make it hard to focus in class or study. [The passes] really helped my studying and may have helped me get my GPA up.”

Pantries and food passes are good band-aids, but more system-wide solutions are needed, advocates say.

“If I’m sending my kid to college, I want more than a food pantry,” said Sara Goldrick-Rab, professor of higher education policy and sociology at Temple University in Philadelphia, who founded the . “I want to know that they’re addressing high food prices on campus and taking steps to ensure no student goes hungry.”

Part of the disconnect may stem from a misperception about what today’s students are really like, said Katharine Broton, an assistant professor in educational policy and leadership studies at the University of Iowa who has published research on food and housing insecurity in colleges. Many of them don’t fit the profile of a “typical” student who attends a four-year institution full time and doesn’t have a job, Broton said. Rather, about 40 percent of students today are working in addition to going to school, and nearly .

The juggling act can be hard to maintain. “Most of the students, we find, are working and receiving financial aid, but still struggling with food insecurity,” Broton said.

Adding to the stress is the fact that while tuition and fees continue to rise, financial aid hasn’t kept pace. In the , after accounting for grant aid and tax benefits, full-time students at two-year colleges had to cover $8,070 in room and board on average, while those at four-year public institutions faced an average $14,940 in room, board, tuition and fees.

Anti-hunger advocates credit students with both sounding the alarm about hunger on campus and in some cases offering ingenious solutions.

Rachel Sumekh, who founded with friends at UCLA several years ago, said they wanted to do something useful with the unused credits from the meal plans that they were required to buy. The program now counts 48 schools as participants, and Sumekh said in the past year they’ve seen a “dramatic” increase in the number of colleges that are reaching out to them about getting involved.

The University of California-Berkeley , as the program is known. It’s one element in a multipronged effort that targets students who may need extra support to meet their basic housing, food and other needs, said , a university employee who chairs the campus’s basic needs committee. (He also co-chairs a similar committee for all 10 UC campuses.)

According to a survey of Berkeley students, 38 percent of undergraduates and 23 percent of graduate students deal with food insecurity at some point during the academic year, Canedo said. The school targets particular types of students, including those who are first-generation college-goers, parents, low-income or LGBT.

Canedo said a key focus this fall will be to enroll eligible students in CalFresh, the California version of the federal (SNAP), formerly known as food stamps.

Under federal rules, students generally must work at least 20 hours a week to qualify for SNAP, something many cannot manage. But states have flexibility to designate what counts as employment and training programs, said Elizabeth Lower-Basch, director of income and work supports at CLASP, an anti-poverty advocacy organization. In California, for example, students who participate in certain educational programs at school for CalFresh.

“That’s our first line of defense,” Canedo said. “Students are being awarded about $192 per month.”

For students who don’t qualify for CalFresh, the a parallel food assistance program that also provides benefits.

There’s a food pantry that offers regular cooking demonstrations. But what Canedo said he’s particularly proud of is a 15-week nutritional science course that students can take that teaches them about healthy eating, prepping food, budgeting and grocery shopping, among other things. Some of those skills can help students learn to manage their money and food to get them through their time at school without running short.

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Inmigrante indocumentada de El Salvador, la mujer trabajó en una cantina frecuentada por inmigrantes. Su trabajo consistía en lograr que los clientes la invitaran con bebidas y bailar con ellos, pero se espera que muchas trabajadoras en esos lugares también ofrezcan sexo. Su novio no quería que ella trabajara allí, y eso generó la pelea, recordó un médico.

Como parte del proceso de admisión, el personal de emergencia le hizo a la mujer de 36 años una serie de preguntas sobre si alguna vez había tenido relaciones sexuales por dinero, o si tenía que darle a otra persona parte de lo que ganaba, entre otras cosas. Las preguntas de detección fueron parte de , un sistema de 23 hospitales en el área metropolitana de Nueva York, que incluye a Huntington, para capacitar al personal y proporcionarles herramientas para identificar y apoyar a las víctimas de la trata de personas.

No hay cifras concretas sobre cuántas personas están involucradas en el (o trata de personas), el término que se usa cuando se obliga a las personas a trabajar o tener relaciones sexuales para el beneficio comercial de otra persona. Polaris, una organización sin fines de lucro con sede en Washington, DC que defiende a las víctimas y tiene líneas telefónicas de ayuda, dijo que las llamadas y los mensajes de texto a sus líneas directas nacionales han aumentado constantemente en los últimos años: .

Pero los proveedores de atención médica con frecuencia no reconocen la situación de estos pacientes. Según una realizada con cerca de 100 sobrevivientes de tráfico sexual, el 88% dijo que, mientras estaban siendo víctimas de este tráfico, habían tenido contacto con un proveedor de atención médica, por lo general, alguien en una sala de emergencias.

“Cuando las víctimas de tráfico pasan por el sistema de atención médica pero no las identificamos, es una gran oportunidad perdida”, dijo el doctor Santhosh Paulus, médico de familia, director del programa de residencia de medicina familiar del Hospital de Huntington y fundador del programa en Northwell.

Northwell es uno de un número creciente de hospitales y sistemas de atención médica que están implementando este tipo de programas. El objetivo es entrenar al personal para que estén atentos a la trata de personas, al igual que cuando observan señales de abuso infantil, violencia doméstica y abuso de ancianos.

Desde la primavera pasada, casi 300 miembros del personal del Hospital Huntington y una clínica familiar recibieron capacitación sobre cómo identificar a las víctimas de tráfico humano y cómo ayudarlas.

La capacitación se imparte no solo a médicos y enfermeras, sino también a personal que realiza la inscripción de pacientes, asistentes en la recepción, trabajadores sociales y guardias de seguridad. , una organización que ayuda a las personas atrapadas en el tráfico sexual, proporcionó la capacitación inicial al personal clave, y un grupo de trabajo del hospital capacita a los demás. Durante los próximos años, se desplegarán esfuerzos similares en los 23 hospitales de Northwell, dijo Paulus.

Identificar a las víctimas de la trata de personas no es diferente de identificar a las víctimas de otras formas de violencia, explicó la doctora Wendy Macías-Konstantopoulos, directora de la en el Hospital General de Massachusetts.

Una de las grandes señales de alarma es cuando las personas demoran en llegar a la sala de emergencias o al consultorio para recibir atención médica, como esperar semanas para cuidar de un tobillo lesionado o una infección de transmisión sexual, dijo Macias-Konstantopoulos. O puede ser un patrón de lesiones que no tiene sentido. A veces las personas son reacias a explicar su lesión, o llegan con un acompañante que parece autoritario.

“Tener un alto índice de sospecha es el primer paso”, dijo. “Si no preguntamos, nunca vamos a saber”.

A partir de octubre, los proveedores de atención médica también pueden usar nuevos códigos de diagnóstico en sus registros que diferencian el tráfico de otros tipos de abuso. Esto ayudará a rastrear el número de víctimas y proporcionar el tratamiento adecuado.

Sin embargo, solo preguntar puede no ser suficiente. Dependiendo de lo que esté sucediendo en sus vidas, estos pacientes pueden no estar dispuestos o listos para reconocer que necesitan ayuda, dijo Holly Gibbs, directora del programa de respuesta a la trata de personas de Dignity Health, un sistema de atención médica con casi 40 hospitales en California, Nevada y Arizona.

Gibbs conoce bien el tema. Ella misma fue en Atlantic City, New Jersey, después de conocer a un hombre en un centro comercial cuando tenía 14 años, y huir con él. El hombre convenció a Gibbs para que lo acompañara con promesas de una vida nueva y glamorosa como cantante   o modelo. Gibbs dijo que en aquél momento pensó que todo lo que le estaba pasando era culpa suya, por las malas decisiones que había tomado. Ningún profesional de salud u oficial del orden la vinculó con servicios sociales que podrían haberla ayudado a comprender lo contrario. La policía la encontró y devolvió a su familia, y el hombre fue arrestado y hallado culpable en una corte.

Dignity Health implementó un programa de respuesta a la trata de personas en las salas de emergencia y áreas de trabajo, y en las salas de parto, de cada uno de sus hospitales. Ahora también está desplegando el programa en clínicas y consultorios médicos.

Una prioridad clave es ayudar a los médicos a saber cómo hablar con los pacientes sobre cualquier tipo de violencia que puedan estar enfrentando, y cómo conectarlos con ayuda externa.

Pero al final, si estos pacientes no quieren asistencia, “respetas sus deseos”, dijo Gibbs. “Es posible que no estén listos para aceptar ayuda ahora, pero puedes plantar la semilla para que la acepten más adelante”.

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An undocumented immigrant from El Salvador, she worked at a local “cantina” frequented by immigrants. Her job was to get patrons drinks and to dance with them, but many workers in those jobs are expected to offer sex, too. Her boyfriend didn’t want her to work there, and that led to the fight, one doctor recalled.

As part of the intake process, the emergency staff asked the 36-year-old woman a series of questions about whether she’d ever had sex for money, or whether she had to give someone else part of what she earns, among other things. The screening questions were part of a , a 23-hospital system in the New York metro area that includes Huntington Hospital, to train staff and provide them with tools to identify and support victims of human trafficking.

There are no hard figures for how many people are involved in , the term used when individuals are forced to work or have sex for someone else’s commercial benefit. Polaris, a Washington, D.C.-based nonprofit that advocates for these people and runs help lines for them, said calls and texts to its national hotlines have steadily ticked up in recent years, 13 percent between 2016 and 2017, to 8,759.

But health care providers frequently fail to recognize these patients’ situation. According to a of about 100 survivors of sex trafficking, 88 percent said that while they were being trafficked they had contact with a health care provider, typically someone in an emergency department.

“When trafficking victims come through the health care system but we don’t identify them, it’s a big missed opportunity,” said Dr. Santhosh Paulus, a family physician who is the site director of the Huntington Hospital’s family medicine residency program and who started the program at Northwell.

Northwell is one of a growing number of hospitals and health care systems that are putting such programs in place. They want to alert staff to be on the lookout for trafficking, much as they watch for signs of child abuse, domestic violence and elder abuse.

Since last spring, nearly 300 staff members at Huntington Hospital and a family clinic have received training in how to spot trafficking victims and how to help them.

Training is given not only to doctors and nurses but also to registration and reception staff, social workers and security guards. Restore NYC, an organization that assists people caught up in sex trafficking, provided the initial training to key staff, and a hospital task force trains the others. During the next few years, similar efforts will be rolled out at all of Northwell’s 23 hospitals, Paulus said.

Identifying victims of trafficking is not unlike identifying victims of other forms of violence, said Dr. Wendy Macias-Konstantopoulos, director of the at Massachusetts General Hospital.

One of the big red flags is when people delay coming in for medical care, such as waiting weeks to come in to get an injured ankle or sexually transmitted infection checked out, Macias-Konstantopoulos said. Or it may be a pattern of injuries that don’t make sense. Sometimes people are reluctant to explain their injury, or they come in with someone who seems overbearing.

“Having a high index of suspicion is the first step,” she said. “If we’re not asking about it, we’re just not going to see it.”

Starting in October, health care providers can also use in their records that differentiate trafficking from other types of abuse. This will help track the number of victims and provide appropriate treatment.

Asking may not be enough, however. Depending on what’s going on in their lives, these patients may not be willing or ready to acknowledge that they need help, said Holly Gibbs, human trafficking response program director for Dignity Health, a health care system with nearly 40 hospitals in California, Nevada and Arizona.

Gibbs knows the issue well. She was in Atlantic City, N.J., after meeting a man at a shopping mall as a 14-year-old and running away with him. The man persuaded Gibbs to go with him with promises of a new, glamorous life as a musician or model. At the time, Gibbs said, she thought that what happened to her was her own fault, a result of choices she made. No health care or law enforcement professional connected her to social services that could have helped her understand otherwise. She was reunited with her family by law enforcement personnel, who arrested the man. He was was later convicted.

Dignity Health has implemented a human trafficking response program in the emergency departments and labor and delivery areas of each of its hospitals. Now it’s rolling out the program at clinics and physicians’ offices as well.

A key priority is to help clinicians know how to talk to patients about any violence they may be facing and to connect the patients with outside sources of help.

But in the end, if these patients don’t want assistance, “you respect their wishes,” Gibbs said. “They may not be ready to accept help now, but you may plant seeds so they’ll be able to accept it later on.”

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But the two approved therapies, with price tags of hundreds of thousands of dollars, have roiled the insurance approval process, leading to delays and, in some cases, denials of coverage, clinicians and analysts say.

The therapy involves collecting patients’ own T cells, a type of white blood cell, genetically modifying them, and then infusing them back into patients, where they hunt down and kill cancer cells. Known as , it has been called a “living drug.”

Two drugs, Kymriah and Yescarta, were approved last year to treat patients whose blood cancers haven’t responded to at least two other rounds of treatment. Kymriah is with a form of acute lymphoblastic leukemia, the most common cancer in children.  and are both approved for adults with advanced lymphomas.

Researchers report that some critically ill patients who received the therapy have remained cancer-free for .

“This is what patients need,” said Dr. Yi Lin, a hematologist who oversees the CAR-T cell practice and research for the Mayo Clinic. “With the likelihood of getting patients into durable survival, we don’t want to deny them the therapy.” She said she receives no personal financial support from the drugs’ makers.

But it comes at a cost. The drugs are hugely expensive. Kymriah and Yescarta cost $373,000 to treat adults with advanced lymphomas, while Kymriah costs $475,000 to treat acute lymphoblastic leukemia in children and young adults. In addition, many patients experience serious side effects that can land them in a hospital intensive care unit for weeks, pushing treatment costs more than $1 million.

All of this gives government and private insurers pause.

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time, said cancer experts. Large insurers that are already familiar with  complicated therapies like stem-cell transplants are getting speedier at handling CAR-T treatment requests, they said. But that’s not always the case at smaller or regional plans, where delays can add weeks to the approval process.

“A request for CAR-T may end up with somebody on the payer authorization team who doesn’t understand the technology or the urgency of the request, when somebody has only weeks or months to live,” said Stephanie Farnia, director of health policy and strategic relations at the American Society for Blood and Marrow Transplantation.

Farnia is in contact with many of the more than 50 medical centers that are authorized to provide treatment. The process of getting to a treatment center and evaluated for therapy is involved, she said, “to then be substantially delayed due to paperwork is incredibly frustrating” for patients.

Medicare and Medicaid often pose greater coverage challenges than do private insurers, according to insurance experts.

Some Medicaid programs don’t cover the treatment, said Dr. Michael Bishop, director of the cellular therapy program in the hematology-oncology section at the University of Chicago. Medicaid, the state-federal health program, covers children in low-income households and some adults.

“Medicaid has been very tough,” he said. “Certain states just deny coverage, even states with balanced budgets.”

Matt Salo, executive director of the National Association of Medicaid Directors, said states have to evaluate the . “Medicaid is a finite pot of money, and it’s stretched threadbare even on a good day,” he said.

People who are on Medicare, the health insurance program for people age 65 and older and some people with disabilities, typically haven’t faced coverage denials to date, clinicians say. But the government’s reimbursement rates are raising concerns for providers.

Last spring, Medicare announced payment rates for providers who administer Yescarta and Kymriah on an outpatient basis. The payments would more than cover the costs of the drugs. Medicare beneficiaries’ out-of-pocket costs would be capped at $1,340 plus their Part B deductible, if it hasn’t been met, the agency said.

The problem with this plan: Facilities typically provide treatment on an inpatient basis, because of the potential for severe, systemic side effects.

“There’s a lot of toxicity and questions about whether it can even be provided in an outpatient setting,” said Gary Goldstein, the business manager at the blood and marrow transplant program at Stanford Health Care in Stanford, Calif.

For inpatient care, “CAR T-cell therapy … would be paid at a much lower amount compared to outpatient hospital use,” according to officials at the Centers for Medicare & Medicaid Services.

The agency is considering how to handle payment for inpatient CAR-T care for the upcoming fiscal year that starts in October. For now, some medical centers are absorbing whatever Medicare doesn’t pay.

“How can you tell a patient who’s 66, ‘If only you’d gotten lymphoma when you were 64’? Goldstein asked.

But the current approach can’t continue indefinitely, he said.

“Even if there aren’t any centers that are making that decision today, if coverage doesn’t change for Medicare, it absolutely is going to be a problem tomorrow,” said Goldstein.

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