KHN’s ‘What the Health?’: Health Spending? Only Congress Knows

Top negotiators in Congress have agreed to a framework for government spending into next year, but there are details to iron out before a vote — such as the scheduled Medicare payment cuts that have providers worried. Also, the Biden administration reopens its program allowing Americans to request free covid-19 home tests, as hopes for pandemic preparedness measures from Congress dim. Rachel Cohrs of Stat, Alice Miranda Ollstein of Politico, and Rebecca Adams of KHN join KHN’s Mary Agnes Carey to discuss these topics and more. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too.

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Congress has a tentative framework for government spending through this fiscal year. Now, lawmakers must fill in the blanks, including on key health care provisions, and get it passed. The Biden administration will send more free covid-19 home tests to Americans after initial fears the program was running out of money.

And there’s plenty of news coming in from the states, where this week a Texas judge tossed out a lawsuit based on the state’s so-called vigilante abortion law, and the governor of Florida is asking for a grand jury investigation into harm caused by covid vaccines.

This week’s panelists are Mary Agnes Carey of KHN, Rachel Cohrs of Stat, Alice Miranda Ollstein of Politico, and Rebecca Adams of KHN.

Among the takeaways from this week’s episode:

  • Congressional appropriators have settled on an omnibus framework that would set government spending through next fall and hope to pass it by the end of next week. But lawmakers still have details to iron out. While health measures like extended flexibilities for telehealth are likely to get approved — and others, like more money for pandemic response, are not — the outcome is less clear for some key provisions. Will lawmakers relax or even nix Medicare pay cuts for doctors scheduled for next year?
  • Pharmacy chains CVS and Walgreens announced a major settlement this week in lawsuits alleging they mishandled opioid prescriptions. Most of the settlement money awarded in ongoing opioid epidemic litigation is earmarked to pay for opioid-related treatment, and families of victims are also asking for compensation for the harm opioids have caused. Meanwhile, federal lawmakers have shown little urgency to respond to the country’s epidemic of opioid-related overdoses.
  • Abortion fights continued to play out in the states this week, including in Iowa, where a judge blocked an effort to ban most abortions in the state. In Texas, a judge dealt a blow to the state’s so-called vigilante law, ruling that an individual who is not directly affected by an abortion may not sue for violations of the state’s ban. Watch for the legal challenges to continue, especially as some state legislatures return to session in January for the first time since the Supreme Court overturned Roe v. Wade.
  • In pandemic news, the Biden administration plans to reopen its program allowing Americans to request free covid home tests through the U.S. Postal Service. And the House of Representatives select committee investigating the pandemic wrapped up its work this week, with Democrats and Republicans coming to different conclusions and issuing recommendations unlikely to come to pass — a reflection of partisan tensions and a loss of public interest in the pandemic.
  • And Gov. Ron DeSantis of Florida, a Republican who is considered a possible 2024 presidential candidate, has called for a grand jury to examine alleged “crimes and wrongdoing” related to the covid vaccines.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Mary Agnes Carey: Scientific American’s “Kindness Can Have Unexpectedly Positive Consequences,” by Amit Kumar

Rachel Cohrs: The Washington Post’s “From Heart Disease to IUDs: How Doctors Dismiss Women’s Pain,” by Lindsey Bever

Alice Miranda Ollstein: Stat’s “Watch: With Little More Than a Typewriter, an Idaho Man Overturns the Entire State’s Policy on Hepatitis C Treatment in Prison,” by Nicholas Florko

Rebecca Adams: KHN’s “Mass Shootings Reopen the Debate Over Whether Crime Scene Photos Prompt Change or Trauma,” by Lauren Sausser

Also mentioned in this week’s podcast:

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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them

Some people say it’s reasonable for densely populated areas to receive more settlement funds, since they serve more of those affected. But others worry this overlooks rural communities disproportionately harmed by opioid addiction.

Tim Buck knows by heart how many people died from drug overdoses in his North Carolina county last year: 10. The year before it was 12 — an all-time high.

Those losses reverberate deeply in rural Pamlico County, a tightknit community of 12,000 on the state’s eastern shore. Over the past decade, it’s had the highest rate of opioid overdose deaths in North Carolina.

“Most folks know these individuals or know somebody who knows them,” said Buck, the county manager and a lifelong resident, who will proudly tell anyone that four generations of his family have called the area home. “We all feel it and we hate it when our folks hurt.”

Now, the county is receiving money from national settlements with opioid manufacturers and distributors to address the crisis. But by the time those billions of dollars are divided among states and localities, using formulas partially based on population, what trickles down to hard-hit places like Pamlico County can be a trifling sum.

Out of one multibillion-dollar national settlement, Pamlico County is set to receive about $773,000 over nearly two decades. By contrast, Wake County, home to the capital city of Raleigh, is set to receive $36 million during the same period, even though its opioid overdose death rate for the past decade ranked 87th in the state.

Buck said his county’s share “is not a lot of funds per year. But I’m glad we have something to try to reduce that overdose number.”

Rural communities across America were harbingers of the opioid crisis. In the 1990s, misleading marketing by opioid companies helped drive up prescription rates, particularly in coal, lumber, and manufacturing towns across Appalachia and Maine. As painkillers flooded communities, some residents became addicted. Over time, they started using heroin and fentanyl, and the deadly epidemic spilled into suburbs and cities across the nation.

State and local governments filed thousands of lawsuits against drug companies and wholesalers accused of fueling the crisis, resulting in a plethora of settlement deals. The largest to date is a $26 billion settlement that began paying out this year.

As the funds arrive, some people say it’s reasonable for densely populated cities and counties to receive more, as they serve a greater number of residents. But others worry such an approach misses an opportunity to use that money to make a difference in rural communities that have been disproportionately affected for decades.

“You could really diminish what is effectively generational, more than 20 years of harm in rural areas,” said Robert Pack, co-director of East Tennessee State University’s Addiction Science Center.

Just because rural areas are less populated doesn’t mean it’s cheaper to provide health services there. Research suggests the per-person cost can be greater when counties can’t capitalize on economies of scale.

In West Virginia, Attorney General Patrick Morrisey has rejected several national opioid settlements because of their distribution methods and pursued separate lawsuits instead, saying the state needs a deal that reflects the severity of its crisis, not the size of its population.

Allocations from the $26 billion national settlement were determined by each state's population and the portion of overdose deaths, residents with opioid use disorders, and prescription painkillers it contributed to the nation’s total. Many states used similar formulas to distribute funds among their cities and counties.

Although the goal was to reflect the severity of each area’s crisis, those statistics tend to scale up by population. Further, some experts say wealthier communities with higher rates of prescription drug use may benefit while poorer communities affected by heroin and fentanyl may lose out.

Pennsylvania took a different route, devising its own formula to distribute funds among 67 counties — taking into account opioid-related hospitalizations and first responders’ administration of naloxone, an overdose reversal medication. When that formula left 11 rural counties without “enough money to make an impact,” the state decided each county would receive a minimum of $1 million over the 18-year settlement period, said Glenn Sterner, an assistant professor at Penn State who helped develop the state formula and co-authored a paper on it.

In other parts of the country without guaranteed minimums, some local officials say their share of the settlement funds won’t cover one psychologist’s salary, let alone the creation of treatment facilities.

But medical treatment — among the most expensive interventions — is just one piece of the puzzle, said Nidhi Sachdeva, who leads health and opioid initiatives for the North Carolina Association of County Commissioners. She recommends that rural counties explore lower-cost, evidence-based options like distributing naloxone, funding syringe service programs, or connecting people to housing or employment.

Another option is to pool resources among counties. In eastern North Carolina, Martin, Tyrrell, and Washington counties plan to funnel their settlement dollars into a long-standing regional health department, said David Clegg, manager and attorney for Tyrrell County. With a combined population of 36,000, the three counties have used a similar approach in combating covid-19 and sexually transmitted infections.

When it comes to funding, “we’re always the caboose of the train,” Clegg said of his county. “We couldn’t function if we didn’t partner for lots of different services.”

In Colorado, pooling funds is built into the state’s model for managing opioid settlement money. The lion’s share of funds is going to 19 newly formed regions, about half of which comprise multiple counties.

Regions 18 and 19 together have a population of less than 300,000 spread across an area in southeastern Colorado bigger than Connecticut, New Jersey, and Vermont combined. Since 2016, residents of those regions have landed in the emergency room for opioid overdoses at rates higher than those elsewhere in the state. And in the past decade, people in Regions 18 and 19 have died of opioid overdoses at rates rivaled only by Denver. But combined they are receiving only about 9% of all funds being distributed to the regions.

“It is what it is,” said Wendy Buxton-Andrade, a Prowers County, Colorado, commissioner and chair of the opioid settlement board for Region 19. “We get what we get, we don’t throw a fit, and you just figure out ways to make it work.”

Region 18 was allocated less than $500,000 for six southern Colorado counties for the first year. Lori Laske, an Alamosa County commissioner and chair of the region’s opioid settlement committee, said its members hope to recruit private entities to fill in gaps the funding won’t cover. For example, as of mid-November, her county was in the process of selling a building behind the sheriff’s office to an organization with plans to turn it into a 30-bed recovery center.

“Nobody has paid any attention to our rural areas and this problem for years,” Laske said. The money “is never enough, but it's more than we had, and it's a start.”

The state has set aside 10% of its opioid settlement dollars for what it’s dubbed “infrastructure,” which can include workforce training, telehealth expansion, and transportation to treatment. Any region can apply for that money. The idea “is to provide additional funds for those areas of the state that are hardest hit,” said Lawrence Pacheco, a spokesperson for the Colorado attorney general.

Pack, the expert from East Tennessee State University, said partnering with private companies can help sustain programs after settlement funds run out. For example, a county could build a treatment facility, then find a local hospital to staff it. Or it could partner with local banks and real estate developers to find unused buildings to renovate as recovery houses.

“We need to be creative and make a good business case for those kinds of partnerships,” Pack said.

For counties that aren’t sure where to start, Samantha Karon, who oversees substance use disorder programs for the National Association of Counties, suggested analyzing data and interviewing community members to identify and prioritize gaps in services.

Surry County in northwestern North Carolina, along the Virginia border, undertook this process last year. County staffers and volunteers conducted 55 in-depth interviews, gathered more than 700 responses to an online survey, and reviewed national, state, and local data. They cross-referenced the results with a list of allowable uses for the $9 million in settlement funds they’ll receive over 18 years to create a priority grid.

“It’s a graphic representation of where we should go first,” said Mark Willis, director of the county’s Office of Substance Abuse Recovery.

To his surprise, residents’ top priority wasn’t simply more treatment facilities, but rather a continuum of services to prevent addiction, treat it, and help people in recovery lead stable and successful lives. As a result, his office is considering creating a community recovery center or funding more peer support specialists. The county also plans to continue the assessment process in coming years and shift efforts accordingly.

Meanwhile, in Pamlico County, Buck said he and other leaders are open to all ideas to decrease the overdose deaths that have racked their community.

Although building a treatment center is unrealistic, they’re looking at low-cost programs that can deliver more bang for the buck. They’re also considering investing other county funds into a project early on and reimbursing themselves with settlement payouts in later years, if the agreement allows that.

“We don’t want anybody to die a tragic death,” Buck said. “Our challenge is figuring out what role we can play in preventing that with the funds we have.”

Methodology

For North Carolina counties, the rates of opioid deaths were calculated by dividing the sum of opioid deaths from 2010 to 2020 by the sum of the annual population estimates from 2010 to 2020. Counts of “illicit opioid deaths” came from the state health department’s Opioid and Substance Use Action Plan Data Dashboard. Deaths involve heroin, fentanyl, fentanyl analogues, or prescription opioids. Data is based on the county of residence, which may differ from where the death occurred. Population estimates came from national Census Bureau data.

Funding estimates for each county come from the North Carolina Opioid Settlements data dashboard and reflect funds from the settlement with Johnson & Johnson and the “Big Three” drug distributors (AmerisourceBergen, Cardinal Health, and McKesson).

For Colorado, regional rates for opioid deaths were calculated by dividing the sum of opioid deaths from 2010 to 2020 by the sum of annual population estimates from 2010 to 2020. Deaths came from Colorado’s Vital Statistics Program, with cause of death listed as “drug overdose involving any opioid (prescription or illicit, including heroin).”

Regional rates for opioid-related emergency department visits were calculated by dividing the sum of such visits from 2016 to 2021 by the sum of annual population estimates from 2016 to 2021. Emergency department visit counts come from the Colorado health department’s drug overdose dashboard and are for drug overdoses with “any opioid (includes prescription sources, fentanyl and heroin).” They are provided by the patient’s county of residence and were originally compiled by the Colorado Hospital Association.

For both the death rate and emergency department visit rate, regional populations were calculated by adding up the Census Bureau’s annual county totals for member counties. The regions are defined in Exhibit C of Colorado’s Memorandum of Understanding. Regional funding estimates come from the Colorado attorney general’s opioid settlement dashboard and reflect funds from settlements with McKinsey & Co., Johnson & Johnson, and the “Big Three” drug distributors (AmerisourceBergen, Cardinal Health, and McKesson).

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Addiction Treatment Proponents Urge Rural Clinicians to Pitch In by Prescribing Medication

The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years, and treatment advocates hope to see that trend continue.

MARSHALLTOWN, Iowa — Andrea Storjohann is glad to see that she’s becoming less of a rarity in rural America.

The nurse practitioner prescribes medication to dozens of patients trying to recover from addiction to heroin or opioid painkillers.

The general-practice clinic where she works, housed in a repurposed supermarket building, has no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it.

“You could be coming here for OB-GYN care. You could be coming here for a sore throat. You could be coming here for any number of reasons,” and no one in the waiting room would know the difference, she said.

Privacy is an important part of the treatment. And so is the medication Storjohann prescribes: buprenorphine, which staves off cravings and prevents withdrawal symptoms for people who have stopped misusing opioid drugs. The central Iowa clinic, owned by the nonprofit agency Primary Health Care, has offered buprenorphine since 2016. “We were kind of a unicorn in this part of the state,” Storjohann said, but that’s changing.

Unlike methadone, the traditional medication to wean people off heroin or other opioids, buprenorphine can be prescribed at primary care clinics and dispensed at neighborhood pharmacies. Federal and state authorities have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine for patients trying to overcome opioid addiction. Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified to offer the service.

The opioid crisis has deepened in the past decade with the illicit distribution of fentanyl, a powerful, extremely addictive opioid. Its prevalence has complicated the use of medication to treat opioid addiction. Patients who have been misusing fentanyl can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment.

In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Federal agencies are spending millions to expand access to medication to treat addictions, including in rural areas. The Health Resources and Services Administration, which aims to improve health care for underserved people, offers many of these grants.

Carole Johnson, the agency’s top administrator, said she hopes increased training on treating opioid addiction encourages health care providers to learn the latest ways to treat other kinds of addiction, including methamphetamine dependence and alcoholism, which plague many rural states. “We’re sensitizing people to substance use disorder writ large,” she told KHN.

In 2016, just 40% of rural counties nationwide had at least one health care provider certified to prescribe buprenorphine, according to a University of Washington study. That figure climbed to 63% by 2020, the study found.

The study credited the rise to changes in federal rules that allow nurse practitioners, physician assistants, and other midlevel health care providers to prescribe buprenorphine. In the past, only physicians could do so, and many rural counties lacked doctors.

Buprenorphine is an opioid that pharmacies most often sell as a tablet or a film that both dissolve under the tongue. It does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs. Without that help, many people relapse into risky drug use.

The idea of opioid “maintenance treatment” has been around for more than 50 years, mainly in the form of methadone. That drug is also an opioid that can reduce the chance of relapse into misusing heroin or painkillers. But the use of methadone for addiction treatment is tightly regulated, due to concerns that it can be abused.

Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine.

Federal regulators approved Suboxone in 2002, opening an avenue for addiction treatment in towns without methadone clinics.

Storjohann said buprenorphine offers a practical alternative for Marshalltown, a town of 27,000 people surrounded by rural areas.

The nurse practitioner spends about half her time working with patients who are taking medications to prevent relapse into drug abuse. The other half of her practice is mental health care. A recent appointment with patient Bonnie Purk included a bit of both.

Purk, 43, sat in a small exam room with the nurse practitioner, who asked about her life. Purk described family struggles and other stressors she faces while trying to abstain from abusing painkillers.

Storjohann asked whether Purk felt hopeless. “Or are you just frustrated?”

Purk thought for a moment. “I went through a week where I was just crying,” she said, wiping her eyes with a tissue. But she said she hasn’t been seriously tempted to relapse.

Storjohann praised her persistence. “You’re riding a roller coaster,” she said. “I think you need to give yourself some grace.”

Purk knows Suboxone is not a miracle cure. She has taken the medication for years, and twice relapsed into misusing pain pills. But she has avoided a relapse since spring, and she said the medication helps.

In an interview after her monthly appointment with Storjohann, Purk said the medicine dulls cravings and blocks withdrawal symptoms. She recalled terrible night sweats, insomnia, diarrhea, and jitters she suffered when trying to stop abusing pills without taking Suboxone.

“You focus on nothing but that next fix. ‘Where am I going to get it? How am I going to take it?’” she said. “You just feel like a train wreck — like you’ll die without it.”

Purk said mental health counseling and frequent drug tests have also helped her remain sober.

Patients can stay on buprenorphine for months or even years. Some skeptics contend it’s swapping one drug dependence for another, and that it should not be seen as a substitute for abstinence. But proponents say such skepticism is easing as more families see how the treatment can help people regain control over their lives.

Dr. Alison Lynch, a University of Iowa addiction medicine specialist, warned about the risks of fentanyl and buprenorphine in a recent lecture to health professionals in training.

Lynch explained that fentanyl remains in the body longer than other opioids, such as heroin. When someone with fentanyl in their system takes buprenorphine, it can cause a particularly harsh round of nausea, muscle pain, and other symptoms, she said. “It’s not dangerous. It’s just miserable,” she said, and it can discourage patients from continuing the medication.

Lynch noted drug dealers are lacing fentanyl into other drugs, so people don’t always realize they’ve taken it. “I just make the assumption that if people are using any drugs they bought on the street, it’s probably got fentanyl,” she said. Because of that, she said, she has been using smaller initial doses of buprenorphine and increasing the dosage more gradually than she used to.

Nationwide, the number of health professionals certified to prescribe buprenorphine has more than doubled in the past four years, to more than 134,000, according to the federal Substance Abuse and Mental Health Services Administration. Efforts to expand access to the treatment come as drug overdose deaths have more than doubled in the U.S. since 2015, led by overdoses of fentanyl and other opioids.

Storjohann would like to see more general clinicians seek training and certification to prescribe buprenorphine at least occasionally. For example, she said, emergency room doctors could prescribe a few days’ worth of the medication for a patient who comes to them in crisis, then refer the patient to a specialist like her. Or a patient’s primary doctor could take over the buprenorphine treatment after an addiction treatment specialist stabilizes a patient.

Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration, said he sees potential in expanding such arrangements, known as a “hub and spoke” model of care. Family practice providers who agree to participate would be assured that they could always send a patient back to an addiction treatment specialist if problems arose, he said.

Gandotra said he hopes more primary care providers will seek certification to prescribe buprenorphine.

Johnson, the Health Resources and Services Administration administrator, said states can also increase access to medication-assisted treatment by expanding their Medicaid programs, to offer health insurance coverage to more low-income adults. The federal government pays most of the cost of Medicaid expansion, but 11 states have declined to do so. That leaves more people uninsured, which means clinics are less likely to be reimbursed for treating them, she said.

Health care providers no longer are required to take special classes to obtain federal certification — called a “waiver” — to treat up to 30 patients with buprenorphine. But Lynch said even veteran health care providers could benefit from training on how to properly manage the treatment. “It’s a little daunting to start prescribing a medication that we didn’t get a lot of training about in medical school or PA school or in nursing school,” she said.

Federal officials have set up a public database of health care providers certified to offer buprenorphine treatment for addiction, but the registry lists only providers who agree to include their names. Many do not do so. In Iowa, only about a third of providers with the certification have agreed to be listed on the public registry, according to the Iowa Department of Health and Human Services.

Lynch speculated that some health care professionals want to use the medication to help current patients who need addiction treatment, but they aren’t looking to make it a major part of their practice.

Storjohann said some health care professionals believe addiction treatment would lead to frustration, because patients can repeatedly relapse. She doesn’t see it that way. “This is a field where people really want to get better,” she said. “It’s really rewarding.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).