A Free-for-All From Readers and Tweeters, From Medical Debt to Homelessness

KHN gives readers a chance to comment on a recent batch of stories.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

It is appalling that an article like this even has to be written. Our "healthcare" system is broken.How to get rid of medical debt — or avoid it in the first place https://t.co/EIo7lHps8k

— Karin Wiberg (@kswiberg) July 1, 2022

— Karin Wiberg, Raleigh, North Carolina

Lifesaving Information

I just want to thank you from the bottom of my heart for the work you do that exposes the utter brokenness of America’s health system (“Diagnosis: Debt: How to Get Rid of Medical Debt — Or Avoid It in the First Place,” July 1). You are helping to fix it!

— Ruth Worley, Athens, Ohio

Recovering from being sick or caring for a sick loved one should not ruin any American’s finances. Here are some tactics to navigate the system. https://t.co/ykvDkUecj0

— Bayeté (@BayeteKenan) July 10, 2022

— Bayeté Ross Smith, Harlem, New York

Patients Left Holding the Bag

Your “Diagnosis: Debt” articles are interesting and serve as further examples of how the health care industry is set up for the health care system and not the people who use it.

In the USA, medical debt should not be an issue, but we don’t teach people how to save or understand how to navigate the system. I am a nurse blogger/advocate and see the repercussions of what people go through who have inadequate insurance and lack savings or the ability to understand what is happening to them when they are thrust into the complex health care system. But, in reality, none of us really think about our health or the health care system till we are in the middle of a crisis. If we are honest, none of us are really prepared for a catastrophic event, and this is what we need to work on going further through education and advocacy.

I will continue to educate the public in my small way so people can understand their role in our health care system so they are prepared for a medical event and know that they can use their voice to speak up and advocate for themselves.

— Anne Llewellyn, Plantation, Florida

Portland has become a wasteland! Where are the environmentalists at least? Oh yeah, they're all in their gated communities, worrying about climate change and plastic straws for the rest of us. (hope you can see this LA Times article)https://t.co/WrboM9vtPs

— Bob Beddingfield (@bobbeddingfield) June 23, 2022

— Bob Beddingfield, Houston

Destination: Disaster

We visited Portland, Oregon, a year ago for a vacation and we will never go back: stores that don’t give baskets because people use them to steal. Stores that put poles on carts to keep people from racing out of the store with them full of merchandise. Closed storefronts. Homeless people everywhere (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21).

It was like a Third World country. I’m not a Republican, very far from it, but accepting the idea that anyone who wants can live on the streets, dump their trash, and get subsidized by the city cannot end well. And this problem is not limited to Portland. San Francisco is in a very similar situation with crime, drug abuse, and homelessness.

There is no one-size-fits-all solution. Throwing money at the problem and then ignoring the continuing unresolved problem hasn’t worked and, I think, never will.

The idea that a city can host an unlimited number of drug and alcohol addicts at public expense won’t work.

The idea that shoplifting, car break-ins, robberies, etc. are allowed, not arrested, not prosecuted, not punished can never work out well.

And people wonder why the Democrats are in such deep, deep trouble in spite of the horrible ideas the Republicans promote.

This will not end well.

— David Alexander, Palo Alto, California

Quite possible the best news story about our local homeless challenges I have read recently. 'Not safe anymore': Portland confronts the limits of its support for homeless services #homless #Portland https://t.co/Ujr5KzhYAi

— Ben Brown Jr. (@BenBrownJunior) June 22, 2022

— Ben Brown Jr., Beaverton, Oregon

On Wheelchair Repairs, Steering Clear of Error

As the CEO of National Seating & Mobility (NSM), I applaud the work of KHN in providing in-depth reporting about important issues in health care, including the complex rehabilitation technology (CRT) industry.

However, the recent article “Despite a First-Ever ‘Right-to-Repair’ Law, There’s No Easy Fix for Wheelchair Users” (June 2) presented several inaccuracies, misrepresentations, and errors in its characterization of NSM and our work.

The article stated that NSM and other CRT providers have limited their investments in service and repair to increase profits. NSM leadership has continuously invested in our service and repair business, including establishing a career path and certification program to professionalize the service technician role, improving onboarding and ongoing training programs, reorganizing our funding team to introduce repair-specific funding specialists to better assist clients in the repair process, investing in market analysis on competitive wages that resulted in a 15%-20% hourly pay increase for technicians, and more. In 2022, NSM has almost 500 service technicians on staff, which is 22% more technicians per count of client-delivered orders versus 2019. Our investment in service and repair is long-standing and will continue.

The article also suggested that Medicare’s use of competitive bidding favors large companies, often at the expense of quality and customer service. NSM was not part of the previous bidding session for durable medical equipment (DME) to establish current rates and was not awarded any Medicare contracts as a result. Most of the products we provide are considered CRT and are exempt from the competitive bid process and pricing. Due to section 16005 of the 21st Century Cures Act and House Bill H.R. 1865, product codes that can be used for CRT or basic DME are paid at the normal rate for CRT instead of competitive pricing.

Finally, the article makes false assumptions about our company: that we keep a limited inventory of parts, and we have little incentive to hire technicians or pay for training because we lose money with repairs.

Each mobility solution — and therefore each repair—is highly customized to a client’s needs. This customization means parts that are replaced less frequently across our client population aren’t likely to be stocked versus those parts that are frequently replaced. The current global supply chain disruption has also affected our inventory; the amount of stock we have on hand is entirely dependent upon availability. Additionally, the labor shortage our country is experiencing has created a challenge across all industries, ours included.

Repair reimbursement is a loss-leader for the CRT industry, exacerbated recently due to inflation in the supply chain and labor markets. While other companies are forced to turn down repairs due to these challenges, NSM continues to provide repairs because it is the right thing to do.

NSM is a customer service business, earning our business in every client interaction. We recognize improvements are needed, and we are committed to investing in advocacy, programs, and collaborative industry efforts to lead our industry in a new direction to improve the lives of those we serve.

— Bill Mixon, CEO of National Seating & Mobility, Franklin, Tennessee

This needs to change! It should not be so complicated to get simple repairs made to #wheelchairs!https://t.co/MpTAyeBEms via @KHNews #DisabilityRights

— W. Ron Adams (@WRonAdams) June 11, 2022

— W. Ron Adams, Erlanger, Kentucky

These folks have also worked so hard to get landmark legislation passed across the country, including a really important first step in Colorado on the right to repair wheelchairs: https://t.co/xaZPRnaYDD

— Hayley Tsukayama (@htsuka) June 3, 2022

— Hayley Tsukayama, San Francisco

Clearing the Air on Vaping vs. Smoking

I just listened to your piece on the FDA banning Juul (“KHN’s ‘What the Health?’: The FDA Goes After Nicotine,” June 23). One of your panelists mentioned she’d read (actually, she said she’d read only the headline) about diacetyl (she didn’t want to even try to pronounce this) and popcorn lung.

I believe it is irresponsible for so-called scientific experts to comment on things they haven’t read properly and things they clearly have no knowledge about. Diacetyl is present in cigarette smoke in concentrations hundreds of times higher than in vape products and yet there hasn’t been a single case of popcorn lung attributed to smoking. Anything to do with the toxicity of a chemical present must surely make reference to the concentrations, putting it in context. The fact that a chemical is detectable obviously doesn’t mean that it’s harmful in the concentrations present.

There is a terrible misunderstanding among consumers and indeed health care professionals regarding the relative harms of vaping vs. smoking — given that the vast majority of vapers are ex- or current cigarette smokers, this is the relevant point.

I suggest that the scientific credibility of your program is compromised by such sloppy and inaccurate commentary.

— Mark Dickinson, Twickenham, Middlesex, United Kingdom

Be wary when big companies come in to "save" local institutions, whether it be the hometown newspaper, local education or the hospital.https://t.co/gV4ZJDkR71

— Dave Gragg (@DaveGragg) June 15, 2022

— Dave Gragg, Republic, Missouri

Shoring Up Rural Care

Since 2010, 138 rural hospitals have closed, leaving many communities without access to health care. In rural areas, this can create a domino effect of other hardships — a hospital often serves as the largest employer, and when these facilities shut down, the hardware store or restaurants often face similar fates. Put simply, when a rural hospital shutters, it becomes harder for the town itself to survive (“Patients for Profit: Buy and Bust: When Private Equity Comes for Rural Hospitals,” June 15).

Then there is the most critical aspect: Without hospitals, rural Americans lose timely access to lifesaving medical care. On average, the distance between a rural hospital and the closest facility with 100 or more acute care beds is 28.9 miles. Preserving access to care in our rural communities and ensuring hospitals remain the cornerstone of the economy is essential. This is why addressing the hospital closure crisis must be a top priority in Congress.

To determine what needs to be done, it can be helpful to examine the cause of the crisis. Multiple factors have contributed to the high number of rural hospital closures over the past decade, with two major factors being slim or negative hospital operating margins and workforce shortages. The covid-19 pandemic has further strained the health care industry, leading to increased levels of provider burnout and perpetuating the workforce shortage.

On top of this, rural providers continue to feel the strain of Medicare sequestration, which reduces eligible payments to rural hospitals from Medicare by 2%. Relief from Medicare sequestration during the pandemic expired on April 1, contributing to the financial burdens rural hospitals already face. With many rural hospitals already operating on negative margins, these decreased reimbursements could be disastrous.

Further, due to recent statutory changes, provider-based rural health clinics affiliated with small rural hospitals are not eligible for cost-based reimbursement as they historically were. Unless Congress addresses this shortcoming, it may not be financially feasible for small rural hospitals to provide primary care in these settings, and care gaps in rural communities may widen.

Reps. Sam Graves, a Republican from Missouri, and Jared Huffman, a Democrat from California, worked together to introduce the Save America’s Rural Hospital Act. This legislation will help rural health care providers keep their doors open and ensure rural communities have access to the care they need and deserve.

For example, it will permanently eliminate Medicare sequestration for rural hospitals, allowing these facilities to be reimbursed for the entirety of their eligible cost. It will make permanent increased Medicare payments for ground ambulance services in rural and super rural areas. Further, this bill will reauthorize the Medicare Rural Hospital Flexibility Program to provide new grants to help eligible rural providers transition to new models and evolve to meet community needs in their changing health care environments.

To address potential primary care shortages, it will also create a voluntary quality measure reporting program for provider-based rural health clinics. If these facilities choose to participate, they will receive increased reimbursement in exchange.

Health care access is critical to preserving the rural way of life for more than 60 million rural Americans. This legislation must be considered to ensure stability in our communities, which will ultimately benefit the country as a whole.

— Alan Morgan, CEO of NRHA, Kansas City, Missouri

In short, our system is not set up for the unique needs of rural hospitals, making them financially stretched. Private equity swoops in, buys the hospital, takes the COVID-19 relief money, closes the hospital, then runs. #ruralhealth https://t.co/qZBHG7yeeH

— Whitney Zahnd (@WhitneyZahnd) June 15, 2022

— Whitney Zahnd, Iowa City, Iowa

A Pitch for Integrated Behavioral Health

I am a clinical psychologist who works at a large, safety-net academic health center in Colorado. I am writing about your recent article “Patients Seek Mental Health Care From Their Doctor but Find Health Plans Standing in the Way” (June 8). I appreciate the focus of this article on some of the barriers patients face in trying to access mental health care in the U.S. However, I was a little concerned that your article did not mention the rapidly growing field of integrated behavioral health. Although I understand that not all primary care providers’ offices employ an integrated behavioral health clinician, the numbers are growing quickly across the country. For example, in the hospital where I work, there is at least one IBH clinician in every community primary care center, and in most of the specialty clinics (e.g. oncology, OB-GYN) as well.

While I think PCPs are certainly able to dispense basic-level mental health advice (e.g., abdominal breathing exercises for anxiety), I don’t think the answer is to turn over mental health care to medical professionals, any more than I believe it would be a good idea to turn over a patient’s diabetes management to a psychologist, even if that psychologist had some basic training in how to treat diabetes. Instead, I believe it is in patients’ best interests to continue to advocate and nurture a team-based approach that includes both medical and mental health specialists within the same clinic.

— Trina Seefeldt, Denver

This madness must stop. Most of us in primary care do address/treat mental health problems. #insurance #healthcare #SinglePayer would solve this. Patients Seek Mental Health Care From Their Doctor But Find Health Plans Standing in the Way https://t.co/YyAzJ0GylL via @khnews

— Andrea DeSantis DO (@adesantisb) June 10, 2022

— Dr. Andrea DeSantis, Charlotte, North Carolina

In Defense of Free Clinics

I was reading with interest — and then dismay — at your article published June 23 on the Hispanic insurance gap (“Trump’s Legacy Looms Large as Colorado Aims to Close the Hispanic Insurance Gap”). In the opening paragraphs, you reference a man who had symptoms that “free clinics told him were hemorrhoids but were actually colon cancer.”

In that one phrase, you single-handedly and forcefully implied that free clinics deliver poor care and are not to be trusted. With the next sentence about his tragic death, you solidify that implication.

As a charitable clinic with more than 26 years of serving the uninsured in our community, I take great exception to this careless mischaracterization of a sector that has delivered high-quality care to millions of people who have fallen through the cracks.

Most free and charitable clinics care for people with absolutely no insurance. This can significantly limit the amount of outside testing and diagnostics that can be done with patients, even if they are symptomatic. Up until this year, our clinic had absolutely no option for sending someone to a gastroenterologist for a colonoscopy unless they were willing to pay out-of-pocket — upward of $5,000. We have to regularly tell people that we do not have any good options for them because we cannot access certain specialists or tests. Do they need it? Yes. Can we provide it to them? No. Does this incredible inequity and frustration with the health care system that prevents our patients from getting the advanced care they need weigh on us every day? Absolutely.

Free and charitable clinics are not part of the problem. They are part of the solution. And the broad generalization you made impacts how the public perceives this incredibly important piece of the health care sector.

For more information on free and charitable clinics, I invite readers to learn about the National Association of Free and Charitable Clinics at https://nafcclinics.org/.

— Suzanne Hoban, executive director of Family Health Partnership Clinic, Crystal Lake, Illinois

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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Readers and Tweeters Weigh In on America’s Medical Debt, Obesity Epidemic, and Opioid Battles

KHN gives readers a chance to comment on a recent batch of stories.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

So, you're American, you have a lousy health insurance plan, you get cancer. You survive cancer. But can you survive your massive medical $$$ debt?https://t.co/e6Jzw9W4SR

— Laurie Garrett (@Laurie_Garrett) June 17, 2022

— Laurie Garrett, New York City

Medical Debt as the Ultimate Medical Mystery

I read your investigation about health care and debt on NPR’s site (“Diagnosis: Debt: 100 Million People in America Are Saddled With Health Care Debt,” June 16). However, it seems the story’s focus is wrong. It shouldn’t be about how we pay for these astronomical medical bills but why are they so high to begin with? How do hospitals get away with their fees? For example, my daughter, who is 7, has been to the hospital/emergency room five times in her life. Each bill has been completely different with no rhyme or reason. The latest one was $7,000 for about a three-hour ER visit and for two IVs! It’s the highest bill we have ever seen, and that includes a two-night stay at a hospital. In addition to this bill, collections called us — and it hadn’t even been 60 days since our visit and had been only a few weeks since the hospital visit. So now our credit score could be affected, and we haven’t even had a chance to review or figure out how to pay this bill. Would love all this explained.

— Ilyssa Block, Kansas City, Missouri

A Hard-Learned History Lesson

Although I liked the article by Noam N. Levey and Aneri Pattani on people burdened by medical debt (“Diagnosis: Debt: Upended: How Medical Debt Changed Their Lives,” June 16), it uses the term “grandfathered in.” This term was used as a rule to prevent Black people from voting after the Civil War. Please make an effort to refrain from using this offensive term.

— MB Piccirilli, Portland, Oregon

Upended: How Medical Debt Changed Their Lives https://t.co/IbJwJoOt3N @khnews This has to stop! NFP healthcare systems destroying the lives of the people they are designed to serve?!? Unethical. STOP! #healthcare #UniversalHealthCare #MedicareForAll #bankruptcy

— Andrew Gallan PhD ⛳️🇺🇦 (@agallan) June 20, 2022

— Andrew Gallan, Boca Raton, Florida

Steering Clear of Predatory Billing

Every month I see and hear these “Bill of the Month” stories on NPR’s webpage or broadcast on the NPR affiliate station in my area (“Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” May 31). Every month I pat myself on the back for having decided that there is no way I am ever going to put myself through so-called screenings, which are just one more avenue for the U.S. health delivery system to screw people over as that health delivery system is well aware that there is no oversight for this type of predatory billing. I can tell you at my age and with only Social Security retirement as sole income, I couldn’t ever hope to hire legal help to dispute a bill like those featured in “Bill of the Month” — a bill like that would either cause me to have an immediate heart attack or file bankruptcy or both. Nope. No screenings. I actually have decided that, if I have any choice in the matter, I will simply forgo any so-called medical care. Obviously, if I keel over and pass out and someone hauls my sorry self into the emergency room, I won’t have the choice (except to walk out once “revived”). Given the state of health care and the predatory behaviors of the bottom-lining money-hungry hospitals, clinics, and even just doctors, my choice is simply to opt out. KHN needs to use its voice to tell the U.S. medical community that people are so tired of the garbage that they simply refuse care.

— Jan Baldwin, Coburg, Oregon

First colonoscopy: $0Second colonoscopy: $2kAnother example of how the fine print can put patients on the hook for bills that should be covered, especially in this case of a preventative screening. Patients deserve better.https://t.co/v55XVdGAeB

— Terry Wilcox (@Terrilox) June 2, 2022

— Terry Wilcox, Vienna, Virginia

In Michelle Andrews’ story about unexpected costs after a polyp removal during a colonoscopy, she states the anesthesiologist “merely administers a sedative.” This is an understatement. Anesthesiologists perform a review of the patient’s chart, see the patient pre-procedure, monitor their vitals during the procedure, and assess them post-procedurally. Furthermore, anesthesiologists are prepared to manage unexpected emergencies, including unexpected aspiration, allergic reactions, cardiac arrest, etc. This is more than “merely administering a sedative.”

We keep folks from dying or having complications and train a long time to do so. The flippant manner in which our actions are framed in the article is unfortunate.

— Dr. Elizabeth Leweling, Chicago

Preventive care, like screening colonoscopies, are free of charge to patients under the Affordable Care Act. @DrLindaMD @AlexMMTri @EvanKirstel @FriedbergEric @nkagetsu @rstraxMDhttps://t.co/qLP9l5SSPl

— Ian Weissman, DO (@DrIanWeissman) June 1, 2022

— Dr. Ian Weissman, Milwaukee

As president of the American Society for Gastrointestinal Endoscopy, I listened with interest to a recent segment on “All Things Considered” regarding patient cost sharing for a screening colonoscopy. The segment featured patient Elizabeth Melville, who received a bill for her screening colonoscopy that involved a removal of a polyp.

I was dismayed by the segment, which included several factually incorrect and misleading statements by Dr. Elisabeth Rosenthal, and which were incredibly damaging to efforts to eliminate impediments and misinformation about screening colonoscopy. ASGE has been at the forefront of policy efforts to eliminate patient out-of-pocket costs for screening colonoscopy, including those screenings that involve the removal of a polyp or other tissue. As the segment correctly noted, the Affordable Care Act provides for coverage without patient cost sharing of preventive services that have an “A” or “B” rating from the U.S. Preventive Services Task Force, which includes colorectal cancer screening. Recognizing that colonoscopy is the only cancer screening modality that also allows for actual removal of precancerous lesions in real time (and thus preventing the cancer), it is particularly important that patients and consumers understand the facts.

Following passage of the ACA, legislative and regulatory corrective actions have been necessary to ensure that patients who undergo a screening colonoscopy that includes a polyp removal are not stuck with a surprise bill. As noted, screening colonoscopy is a unique preventive service in that it not only detects cancer, but it can prevent it through removal of suspicious or potentially precancerous polyps or lesions. In 2020, Congress passed legislation that would phase out by 2030 cost sharing for Medicare beneficiaries when a screening colonoscopy turns diagnostic during the screening encounter. That means, if a Medicare beneficiary has a screening colonoscopy today and a polyp is removed, that patient is likely to have an out-of-pocket payment obligation.

The difference in cost-sharing rules for commercially insured patients and Medicare beneficiaries has created confusion for patients, and the changes in regulation have created complex billing scenarios. Dr. Rosenthal referred to billing for colonoscopy as a “gray area.” This is not a gray area to ASGE, as coding rules are clear. But there are scenarios that could impact whether a patient has an out-of-pocket obligation for a colonoscopy. For example, often insurers will not cover a screening colonoscopy without cost sharing if the screening occurs less than 10 years after the patient’s previous colonoscopy. These shorter screening intervals typically occur when a patient is considered high-risk, or if there was a finding during the previous colonoscopy, such as a polyp, as used in your illustration. Many insurers regard these colonoscopies as “surveillance” or “high-risk” colonoscopies and will not cover them as a preventive screening without cost sharing. This is not the decision of the physician or hospital; this is a decision made by the insurance company.

I was particularly struck by Dr. Rosenthal’s comment that “it is not OK to change the game in the middle of the test,” which leads to a patient getting a bill. I want to be very clear that when a patient is scheduled for a screening colonoscopy, the physician performing the colonoscopy has no idea whether a polyp or tissue will be found and will need to be removed. This is not a “gotcha” game that physicians are playing with patients, as insinuated by Dr. Rosenthal’s remarks; there are coding and billing rules that must be followed when facilities and physicians are submitting claims to insurance companies. ASGE continually works to ensure that we educate and promulgate coding rules and updated guidance for our 15,000 members worldwide.

The cost-sharing policy for colorectal cancer screening, and screening colonoscopy specifically, is complex and confusing. We are disappointed that NPR did not use the segment as an opportunity to work through the complexity to provide consumers with a better guide of questions to ask their insurance company before scheduling a colonoscopy, including whether a screening colonoscopy performed at an interval of less than 10 years will be covered under their health plan without cost sharing.

— Dr. Bret T. Petersen, ASGE president, Rochester, Minnesota

Great Bill of the Month reporting today by @mandrews110 for @KHNews. Nobody likes getting a colonoscopy. Patients shouldn't be penalized for doing the right thing and getting recommended cancer screenings: https://t.co/cNlEj85IZ4

— Ryan Holeywell (@RyanHoleywell) May 31, 2022

— Ryan Holeywell, Washington, D.C.

Taking the Doctor’s Advice

Dr. Taison Bell was wonderful to listen to (“Watch: UVA Doctor Talks About the State of the Pandemic and Health Equity,” May 26). I really appreciated his presentation and the valuable things he had to say. Thanks for including it in your KHN mailing!

— Jan McDermott, San Francisco

I spoke with ⁦@hnorms⁩ from ⁦@KHNews⁩ about the state of the pandemic and health equity. There is still a lot to be done to movement smart policies that help high risk communities of color. https://t.co/LAf2WCIN0X

— Dr. Taison Bell (@TaisonBell) May 26, 2022

— Dr. Taison Bell, Charlottesville, Virginia

Mad Over ‘New MADD’ Coverage

This article is grossly inaccurate and insulting (“The New MADD Movement: Parents Rise Up Against Drug Deaths,” May 23). Most fentanyl users are not all-star athletes or honor students. Their parents are not more educated than the parents of addicts. And the parents of addicts have been mobilized for years, with many feeling that the fentanyl movement has distracted attention away from needed health care. The article says that the drugs are being introduced by Mexican cartels that seek vengeance against low-level dealers, many of whom are just friends getting things for one another. The article distinguishes between drug users and fentanyl “victims,” creating and reinforcing the stigma these groups claim to be trying to eliminate. It does a great disservice to those of us who lost children to addiction and overdose, and is insulting to our children and to us as parents. Thank you.

— Susan Elamri, Detroit

Interesting read detailing the lack of accountability for drug dealers selling fentanyl laced counterfeit pills resulting in death/overdoses. Consequences and rehabilitation should not be mutually exclusive solutions, we can do both. https://t.co/KlvBH3O1kq

— Chief Paco Balderrama (@BalderramaPaco) May 23, 2022

— Paco Balderrama, chief of police, Fresno, California

When ‘Overweight’ Is ‘Normal’

Quoting from the article “‘Almost Like Malpractice’: To Shed Bias, Doctors Get Schooled to Look Beyond Obesity” (May 24): “Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories.”

Perhaps the answer is to change the scale of weight. Why do 25% of adults get to be called “normal” and 75% of adults are “overweight”? Let’s base the decision on reality-based observation!

— Leslie Rigg, Lake Worth Beach, Florida

1) Anti-fat bias is real and certainly an issue. For physicians and others who treat people with #obesity, the question becomes where to draw the line. 'Almost Like Malpractice': To Shed Bias, Doctors Get Schooled to Look Beyond Obesity https://t.co/ap127widIs via @khnews

— Stewart Lonky, MD (@LonkyMD) May 24, 2022

— Dr. Stewart Lonky, Los Angeles

Innocent Until Proven Otherwise

I wanted to raise a concern about the story “‘Desperate Situation’: States Are Housing High-Needs Foster Kids in Offices and Hotels” (June 1) — and it’s certainly not unique to your story. It says:

“These children already face tremendous challenges, having been given up by their parents voluntarily or removed from their homes due to abuse, neglect, or abandonment.”

Sometimes, of course, that’s true. But no reporter would write that every person in jail is a criminal. Many are awaiting trial and can’t make bail. Similarly, children can be in foster care for weeks, even months before any court ever determines if they have been “abused” or “neglected.” Until then, they are in foster care because their parents have been *accused* of abuse or neglect.

(Also, by the way, neglect laws are so broad and vague that often what the parent really is guilty of is poverty — but that’s another issue.)

— Richard Wexler, executive director of the National Coalition for Child Protection Reform, Alexandria, Virginia

[Editor’s note: Thanks so much for your insight. The article has been updated to reflect that the parents are absent “due to accusations of abuse, neglect, or abandonment.”]

.@sclaudwhithead looks at "hoteling," Georgia's practice that makes high-need foster kids sometimes sleep in hotels or offices. The pandemic made the problem worse, but state lawmakers spent more to try to pay extra for foster parents to take kids. #gapol https://t.co/xRXbKCSVEM

— Jeff Amy (@jeffamy) June 1, 2022

— Jeff Amy, Atlanta

Key to Harm Reduction: Buy-In From People With Addiction

With overdose deaths skyrocketing to never-before-seen levels, the United States needs harm reduction strategies to protect the health and wellness of Americans. In 2020, 41 million Americans needed substance use treatment within the previous year; however, of those who needed such treatment but did not receive it at a specialty facility, a staggering 97.5% did not feel they needed it. Although America has a troubling treatment gap exacerbated by systemic legal and regulatory barriers to evidence-based addiction care, most people who need substance use treatment don’t want this treatment as it is currently being offered.

To support our friends and family members living with addiction, our system must also embrace harm reduction approaches that engage people who use drugs (PWUD) before they are ready for abstinence-based treatment (“As Biden Fights Overdoses, Harm Reduction Groups Face Local Opposition,” June 14).

Harm reduction saves lives. Drug checking services and naloxone distribution prevent overdose deaths, while syringe and related service programs help stop the spread of infectious diseases such as HIV/AIDS and hepatitis. These are all worthy ends in themselves, but harm reduction has the further benefit of building a meaningful alliance between health care professionals and PWUD. With this therapeutic relationship, PWUD have facilitated access to high-quality, evidence-based treatment and services when they become ready for this help. It’s an obvious point, but too many people overlook the fact that a person can’t receive treatment or enter recovery if they’re dead.

As a physician, I swore an oath to do no harm — not to do nothing. Failing to embrace and expand harm reduction efforts, by definition, leaves too many of our friends, family members, and loved ones at an unacceptable risk of dying. The dichotomy between offering more addiction treatment and providing PWUD with the tools they need to live healthier lives is a false choice. The United States must simultaneously invest in treatment expansion and increase the availability of low-threshold harm reduction services; otherwise, I fear the country’s addiction and drug overdose crisis will continue to get worse.

— Dr. Brian Hurley, president-elect of the American Society of Addiction Medicine’s Board of Directors, Los Angeles

. @POTUS wants to expand #harmreduction programs as part of strategy to reduce #drug #overdose deaths, but idea faces complicated reality on the ground as programs operate on fringes of legality, w/ scant budgets, & fierce opposition. @renurayasam @khnews https://t.co/qbSBtMkn38 pic.twitter.com/pYV8mB1nEc

— Deni Carise (@DeniCarise) June 21, 2022

— Deni Carise, Philadelphia

How to Beat the Opioid Epidemic

Do you want to control the scourge of fentanyl in America (“The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations,” May 25)? There are two options:

1. Distribute the drug solely by the government, ensuring its purity, proper dosage, and safe setting for the user, providing real-time overdose care and optional consulting for anyone who wants to quit, all for free.

2. Make some nonaddictive antidepressants (generally SSRIs, or selective serotonin reuptake inhibitors) less restrictive. You know, how health care in your country is expensive, visiting a psychiatrist or psychologist, refilling, blah-blah. I know, the nation who can’t agree on banning AR-15s from being sold to 18-year-olds won’t agree on this.

What if you let people have some SSRIs over the counter? These are not recreational, are generally safe (way safer than opioids), and do help with anxiety. Hey, what drives people to opioids? Aren’t anxiety levels at their highest all across the globe?

Also, the drugmaker mafia will support it.

Just as we have embraced over-the-counter drugs for widespread diseases like colds, we might adopt the same concept in mental health care as well. Anxiety is becoming more widespread compared with colds (my gut says).

— Alireza Mohamadi, Tehran, Iran

Fentanyl spreads west, including to the Blackfeet Nation.https://t.co/ZrykuZQ06c

— Keith Humphreys (@KeithNHumphreys) May 25, 2022

— Keith Humphreys, Stanford, California

Dust-Up Over Pollution Coverage

This article appears written from a lopsided viewpoint (“Some People in This Montana Mining Town Worry About the Dust Next Door,” June 8).

Very few cities pass the World Health Organization’s unrealistic threshold of 5 micrograms per cubic meter, and why would you get a mechanical engineer to provide input on environmental issues? Why, because the real environmental specialist said this was not an issue? As for dust on a picnic table, that is a horrible example. We get dust on our picnic table anytime the wind blows, and we don’t live by a mine. Maybe WHO should recommend that the wind stop blowing because it causes dust.

From the WHO’s website: “In 2019, 99% of the world population was living in places where the WHO air quality guidelines levels were not met.” This is not a reasonable standard and was selected by bureaucrats that are out of touch with life and the real world. All of the real information and statistics say there is not a problem, but your article makes a problem where one does not exist and people who are not willing to fact-check you will think there is a problem. All these people with health issues are unfortunate and that’s very sad, but people everywhere have sad health issues. Stick to the scientific facts and real monitoring numbers, and don’t drag “The Sky Is Falling” people into news articles. Facts matter!

— John Utaz, Salt Lake City

Cultivating an interest in ‘dusts’ at the moment and this article includes extractive industries/ mining. https://t.co/JsXCA7rxkD

— Cat Rushmore (@CatRushmore) June 9, 2022

— Cat Rushmore, Glasgow, Scotland

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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California’s New Attack On Opioid Addiction Hits Old Roadblocks

State officials in California have achieved some success in promoting the use of medication-assisted treatment for people with opioid addictions, but they are bumping up against familiar resistance and constraints.

Jennifer Stilwell, a 30-year-old mother of two young children, kicked heroin cold turkey five years ago, but she got hooked again last fall.

Stilwell, an accountant in Placerville, California, tried to quit a second time, but she couldn’t tolerate the sickening withdrawal symptoms. She resisted going to the emergency room because “I thought they’d treat me like a drug addict and not a patient in pain,” she said.

Instead, she kept smoking heroin to keep the agony at bay. Then, in February, a county mental health worker told her about a new program that promised stigma-free treatment for her addiction.

She went to the ER at Marshall Medical Center in Placerville, where a doctor put her on buprenorphine, one of three drugs approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency.

Her ongoing treatment includes intensive counseling and social support, providing what is known in the recovery field as “whole person” therapy.

“It’s still early in my battle,” Stilwell said. “But my withdrawals are gone. Now I can concentrate on being a mother.”

Marshall is one of a growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s MAT Expansion Project, which started in 2018 and is financed by $265 million in federal grants.

Numerous studies have shown that relapse and overdose rates are lower among opioid users who get MAT than those who don’t. From 2016 to 2018, for example, the overdose death rate in Humboldt County — one of California’s highest ― dropped by about half, which officials attributed in large part to the MAT Expansion Project.

In February, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

But the number of new people brought into treatment is only a small fraction of those who need it. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment, according to a study by the Urban Institute.

The state effort faces many of the same obstacles that have hindered wider acceptance of MAT for years: the stigma of addiction, federal regulations that depress the number of MAT providers, and hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction.

Moreover, the addiction treatment industry has become a magnet in recent years for unscrupulous operators who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.

Now there’s another, hopefully temporary, challenge. The COVID-19 crisis and related social-distancing measures are forcing MAT practitioners to scramble for new ways to accommodate patients, said Eric Hill, a “substance navigator” at Marshall Medical Center who helps guide patients through their MAT treatment.

Hill said MAT patients entering the program through emergency rooms are now given prescriptions for up to a month, rather than a week. He said he is following up with clients by phone rather than in person, and he and others are trying to arrange video calls between doctors and patients for prescription renewals.

The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign.

But patients who take anti-addiction drugs can have difficulty finding housing and recovery therapy, which are integral to their treatment. They are often shunned by groups adhering to traditional 12-step theories of sobriety that require participants to be free of drugs — including MAT drugs.

“MAT patients will say that the treatment was working. They were just starting to feel better, going to support groups, back at their jobs, but they had a hard time finding a place to live,” said Hill.

Many patients who stop taking their MAT drugs in order to get a roof over their heads have relapsed, Hill said.

Marlies Perez, a division chief at the state health care department, said the agency “is taking a strong stand against such stigma that prevents patients from their continued recovery.” Through its media campaign, Choose Change California, it seeks to alter perceptions within the recovery community and persuade more doctors and patients to embrace MAT.

The state expansion project puts a strong emphasis on building MAT capacity in emergency rooms, where opioid users often face suspicion.

Of the 320 acute care hospitals with emergency rooms statewide, 52 currently offer MAT. In those hospitals, staff members like Hill help patients get the care they need, including the psychological and social dimensions. Health care department officials say they plan to quadruple the number of participating hospitals to more than 200 over the next few years.

(Photo Courtesy of Jennifer Stilwell)

Opioid misuse is not nearly as deadly in California as in the rest of the U.S., even though the rise of fentanyl has begun to cause bigger problems in the Golden State.

In 2018, the rate of opioid overdose deaths in California stood at 5.8 per 100,000 residents, far below the national average of 14.6 per 100,000. In some rural counties of California, however, opioid death rates exceed the national average. The two states with the highest rates were West Virginia, at 42.4 per 100,000, and Delaware at 39.3.

Another obstacle to MAT expansion, one squarely in the sights of California health authorities, is that many doctors are hesitant to participate because they must undergo federally mandated training for a waiver that allows them to prescribe buprenorphine.

“Doctors can prescribe OxyContin with abandon but not buprenorphine, which has been shown to be helpful to opioid addicts,” said Dr. Aimee Moulin, a director at the California Bridge Program, which helps administer the state’s MAT program.

Buprenorphine is less powerful and less likely to cause fatal overdoses than methadone, another drug commonly used to fight opioid addiction. And doctors who get the waiver for buprenorphine can prescribe it in their offices, while methadone must be administered in federally certified treatment programs.

The state’s health care department said the expansion project has thus far trained 395 new MAT prescribers. But as of July 2019, just 3.2% of prescribers in the state were authorized to prescribe buprenorphine, according to the Urban Institute study.

Dr. Peter Liepmann, a Pasadena-based family physician with an interest in addiction medicine, said it can be difficult to find a buprenorphine prescriber. Not long ago, when he was thinking about opening a practice in Glendale, California, he consulted the Substance Abuse and Mental Health Services Administration’s (SAMHSA) listings of physicians who offer MAT.

“If you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive,” Liepmann said.

The state’s Perez said some doctors may not fully understand the benefits of MAT because medical schools devote little time to addiction training. Another element of the MAT project, she said, is to fund a substance-use-disorder curriculum at training hospitals.

Perez counseled patience: “We didn’t get into this opioid dependency situation overnight, and we’re not going to find a total solution overnight either.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.