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What Happens After You Get That Mammogram

NPR Health Blog - 4 hours 38 min ago
What Happens After You Get That Mammogram December 17, 2014 3:47 PM ET

This graphic lays out the possible outcomes for 10,000 women if they start getting annual screening mammograms at age 50 and continue that for 10 years.

Courtesy of JAMA

Women and their doctors have a hard time figuring out the pluses and minuses of screening mammograms for breast cancer. It doesn't help that there's been fierce dissent over the benefits of screening mammography for women under 50 and for older women.

To make it easier to grasp the big picture, Dr. Jill Jin, an associate editor of JAMA, the journal of the American Medical Association, put together this graphic on the odds of various outcomes from screening mammography. It's based on a review of studies on the risks and benefits of mammography earlier this year and was published Wednesday in JAMA.

Because mammograms aren't perfect screening tests, they can miss some cancers and falsely diagnose cancer that's not there. Those false positives can lead to more testing, including biopsies, and needless anxiety.

Mammograms can also lead to overdiagnosis, when a scan finds something that would never become life-threatening but can lead to surgery, radiation and chemotherapy. Some studies estimate that 20 percent of cancers found on mammograms are overdiagnosed and lead to unnecessary treatment, according to Jin.

The graphic looks at the odds of false positives, overdiagnoses and breast cancer diagnosis for 10,000 women over 10 years, if each started getting annual mammograms at age 50, the age recommended by the U.S. Preventive Services Task Force. About 3,568 women will have normal exams, while 6,130 will have at least one false positive result. About 302 will be diagnosed with cancer, and 10 deaths will be averted because of screening.

Bottom line: Mammograms are the best tool we have for early detection of breast cancer, but they're not perfect. It's best to know the likelihood of possible harms, as well as the benefits.

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Managed Care Plans Make Progress In Erasing Racial Disparities

NPR Health Blog - 6 hours 55 min ago
Managed Care Plans Make Progress In Erasing Racial Disparities December 17, 2014 1:30 PM ET


Lisa Aliferis

A nurse checks a man's blood pressure during a health clinic In Los Angeles.

Patrick Fallon/Bloomberg via Getty Images

Years of efforts to reduce the racial disparities in health care have so far failed to eliminate them. But progress is being made in the western United States, due largely to efforts by managed care plans to identify patients who were missing out on management of chronic diseases like diabetes and heart disease.

While management of blood pressure, cholesterol and blood sugar improved nationwide, African-Americans still "substantially" trailed whites everywhere except the western U.S., an area from the Rocky Mountains to the Pacific as well as Alaska and Hawaii.

"We were certainly hoping we would see indications of progress in eliminating disparities in the country as a whole," said Dr. John Ayanian, who heads the Institute for Healthcare Policy and Innovation at the University of Michigan and was lead author of the study. While it was "disappointing" that disparities persisted, he said, "it's also heartening to see that ... in the West, the disparities had been eliminated, and that was both surprising and encouraging."

To find that out, Ayanian and his colleagues looked at 100,000 Medicare patients who were enrolled in HMOs, called "Medicare Advantage" plans, from 2006 to 2011. The study was published last week in the New England Journal of Medicine.

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Disparities in health care have long been noted in American health care. The researchers wrote that, in 2008, "life expectancy was 5.4 years shorter for black men and 3.7 years shorter for black women than for white men and white women." Heart disease and diabetes — diseases that can be better managed by controlling blood pressure, cholesterol and blood sugar, the risk factors measured in the study — accounted for 38 percent of the gap in mortality between black and white men, and 54 percent of the gap among women, the researchers said. That's why closing the racial gap on these measures is so critical.

"It's one of the first large studies to show that it's possible to eliminate deeply ingrained racial disparities in important risk factors," Ayanian said. He said that outcomes for Hispanics, and Asians and Pacific Islanders were "also encouraging."

Nationwide, black enrollees in the study were substantially less likely than white enrollees to have adequate control of blood pressure, cholesterol and blood sugar, trailing whites by about 10 percent.

Hispanics were 1 to 3 percent less likely than whites to have blood pressure, cholesterol or blood sugar under control. Asians and Pacific Islanders were more likely than whites to have good control of blood pressure and cholesterol. Blood sugar control was about the same.

Specifically, the researchers pointed to Kaiser Permanente health plans as being successful in eliminating disparities. Kaiser includes "nearly half" of Medicare HMO enrollees in the western region of the U.S., Ayanian said.

"Our findings in the West of nearly identical control of three major risk factors among black Medicare enrollees and white Medicare enrollees in Kaiser health plans and control of (blood sugar) in other health plans show the potential to achieve equity in these key health outcomes," the researchers wrote.

Kaiser representatives said they did not have any advance knowledge of the publication of the study.

Dr. Joseph Young, who leads Northern California Kaiser's clinical hypertension program, said that Kaiser adopted a population management approach to managing chronic conditions in 2006. Kaiser has created registries for people with various kinds of conditions, so that patients who might be missing preventive care or better management of disease can be easily identified.

In the area of blood pressure control, Kaiser changed its drug formulary to allow a "combined pill — a single pill that includes two drugs, to make it easier for patients to take their medication.

These population-based strategies resulted in big improvements in overall outcome for Kaiser patients. Young said that during the 2000s, very serious heart attacks ... fell by 62 percent, and our stroke mortality fell by 42 percent.

Kaiser does have some remaining racial disparities in its non-Medicare population, and Young said they are "actively focusing" on closing those remaining gaps.

"We want clinicians to do what Kaiser is doing and take seriously to provide high quality race-blind clinical care," says Dr. Anthony Iton, who leads the Healthy Communities initiative at the California Endowment. "Kaiser is showing it can be done." He called the study "very hopeful" and believes that Kaiser's approaches are replicable elsewhere.

"Any other system that says it's not doable has to explain how they can justify not providing the same high-quality care to everyone that comes in the door," Iton said.

California probably has "less of a socioeconomic spread between whites and blacks than you do in the southeastern United States," Iton noted. "It's a heavier lift in the Southeast than in the West. But despite that, it's clearly doable."

This story is part of partnership that includes NPR, KQED, and the Kaiser Family Foundation.

Copyright 2014 KQED Public Media. To see more, visit
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Behind The Scenes At The Lab That Fingerprints Microbiomes

NPR Health Blog - 8 hours 19 min ago
Behind The Scenes At The Lab That Fingerprints Microbiomes December 17, 201412:06 PM ET Katherine Harmon Courage

Rob Knight, co-founder of the American Gut Project at the University of Colorado in Boulder, works in the lab where the samples are processed.

The American Gut Project

The gut microbiome may soon reveal important answers to questions about our health. But those answers aren't yet easy to spot or quick to obtain.

The week after I mailed off my family's microbial samples to be analyzed for the American Gut Project, I followed them down the road from my home to the University of Colorado, Boulder. They — and I — came to a massive, futuristic science complex there. Daniel McDonald, a doctoral student studying quantitative biology and computer science, greeted me and brought me up to the workspace, where rows of researchers worked on computers outside of a small lab room.

Shots - Health News Poo And You: A Journey Into The Guts Of A Microbiome Shots - Health News To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo

Inside the lab, where the sealed samples were received, a lone technician sorted through new arrivals, snipping off intentionally fouled swab heads. Each sample kit contains two cotton swabs. One swab head goes directly to the freezers for safe keeping (in case the first sample doesn't provide clear results or for the near future, when sequencing technology is better). The other gets dissolved in a solution so its contents can be carefully analyzed for genetic traces of microbes.

Just down the hall is one of the lab's boxed-in robots, charged with loading samples into individual wells on a tray that will later get fed through the sequencers. The task might seem mundane for such a high-tech tool, but the bot works much faster and more accurately than a human lab helper can.

Still, this is where some of the work can be slow going. The team must wait for hundreds of fecal, oral or skin samples to process together. A single sample could go through the full analysis process in a week, but it would cost thousands of dollars, Rob Knight, a co-founder of the project, estimates, rather than the $99 members of the study pay. For the project to be cost-effective for participants, the research team must wait to collect large groups of samples and analyze them together. (Little did I know then just how long I would be waiting for my family's samples to be processed.)

This robot in the Knight lab can handle many samples simultaneously. To avoid contamination, the lab only processes the same kind of samples at the same time together (fecal with fecal, skin with skin and pet with pet).

Katherine Harmon Courage for NPR

Most of the human microbiome is uncharted territory because many of the microbes that live in our guts can't be grown easily in the lab. Oxygen is toxic to them. Using the tools of genetics to probe the human microbiome has already uncovered many new species, each of which has a full genome of its own.

We're still far from getting quick full genomes from each of the inhabitants. Instead, scientists rely on microbes' telltale 16S gene, a marker that helps identify bacteria from one another. Finding the base pairs —the As, Cs, Ts and Gs — for this gene can help scientists sort out which species are present.

This is where a nifty machine that performs PCR (polymerase chain reaction) comes in. It makes thousands of copies of the genetic material so that the pattern in the genetic code is easier for the sequencers to find.

These sequencers are located on a lower floor of the building in a room that smells a bit like a photography darkroom. Here, each tray of samples takes about 20 hours to process. On a nearby screen, I see a readout of bright genetic points against a dark background, which looks more like a telescopic image of a night sky than the code to microbial life from someone's stomach.

This supercomputer, affectionately known as "Compy," crunches massive amounts of microbiome data at the University of Colorado, Boulder.

Katherine Harmon Courage for NPR

Deciphering this code is just the first step in understanding what is going on in the jungle of your gut. Like many things in biology, it is not just the organisms present — plants, animals or bacteria — but how these organisms interact that is important.

The dynamics among the characters make a play — not just the cast.

For instance, research has shown that many of us are walking around with E. coli in our guts but show no ill effects. In much the same way that weeds or hungry insects might not harm a thriving field or forest but could wreak havoc on an unbalanced ecosystem, we depend on a healthful mix of good microbes to keep the bad ones from taking over.

And to see what our intestinal forests are composed of, we need more than just a few points of genetic data. So after the sequencer spits out the genetic code it has assembled, the data needs to get turned back into intelligible (or at least semi-intelligible) patterns.

To do this, our microbial code gets run through a supercomputer nicknamed Compy, which hums safely in the building's basement beyond two sets of doors and a sticky, dust-collecting floor mat. When I meet her, Compy is busy crunching away on base pairs with her 1,000 processors.

From there, the microbe sequences get reunited with their human host's information from the questionnaires. But figuring out the best way to do this is still a work in progress.

The research group is testing using new software to analyze and display these many layers of information. One colorful display that we examine back up in McDonald's fourth-floor office shows a 3-D plot of microbe species and their sites on the human body. It looks a little like an explosion of Dippin' Dots caught in midair — only the brown blobs don't indicate chocolate.

But these dots aren't our microbes. Our samples are still standing by in a freezer for their turn with the robots and whirring sequencing machines. With our samples in the hopper and the process of turning a messy, poop-swab into a sterile, color-coded microbiome chart a bit demystified, it was now time to wait to see what our swipes would turn up.

This is the third story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

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Too Little, Too Late For Many New Yorkers Seeking Hospice

NPR Health Blog - 15 hours 21 min ago
Too Little, Too Late For Many New Yorkers Seeking Hospice December 17, 2014 5:04 AM ET


Fred Mogul Listen to the Story 6 min 2 sec  

Sandra Lopez (left) and her dog, Coco, greet hospice nurse Heather Meyerend last fall. In the weeks before Lopez died, Meyerend stopped by weekly to check her physical health, pain levels and medications.

Amy Pearl/WNYC

Sandra Lopez and her Chihuahua, Coco, were inseparable. He followed her everywhere, and kept Lopez's mood up when she was in pain — which was often.

On Oct. 15, 2014, Lopez died at age 49 of melanoma that had slowly spread throughout her body over the course of two years.

“ If you're referred to hospice, it means no one expects you to get better. And that is, in my mind, a threshold that's difficult for people to step over.

Lopez was in and out of the hospital in 2014, but during the months she was home, a hospice nurse from the Metropolitan Jewish Health System visited once a week to help manage the pain, backed up by a 24-hour, nurse-staffed phone line that Lopez called often.

"Some days the pain is so excruciating," Lopez told me in August from the couch in her Brooklyn apartment, "that the pain overrides the medication."

But despite evidence that hospices can greatly relieve discomfort, extend life and save money, and despite a generous hospice benefit available through both Medicare and Medicaid, relatively few people in New York take advantage of it, compared with elsewhere in the country.

The reasons for this local gap are complicated, but Jeanne Dennis, senior vice president of hospice and palliative care at the Visiting Nurse Service of New York, says one place to start is with patients' fears. "If you're referred to hospice, it means no one expects you to get better," Dennis says. "And that is, in my mind, a threshold that's difficult for people to step over."

Experts also focus on what they call medical culture, which can vary dramatically from region to region. According to this theory, physicians in the metropolitan area are specialists and sub-specialists, and institutions put a premium on treatments and tests. Even more than in other places, the goal in New York City is to cure patients rather than simply care for them. Treating and testing is just what they do — letting go isn't, says Dennis.

Physicians put off the conversation, she says, with rationalizations like, " 'It's a little too soon'; 'It's a little too early'; 'I don't have enough time today'; 'I'm not sure they're ready for it.' "

New York has 7 out of the 10 hospitals in the country with the fewest hospice referrals. Local academic medical centers — national leaders in research — do better, but still lag behind the rest of the country in their referral rates. It's a big contrast to some hospitals around the country, particularly several in Arizona, Utah and Florida, where more than 75 percent of dying patients take advantage of Medicare's hospice benefit.

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Further, most hospice referrals in New York are for brief stays — a week or less — 2.5 times shorter than the national average. Szoa Geng, a health care consultant from the firm Strategy&, says when hospitals move people to hospice with just a few days left to live, the patients don't get the full hospice experience.

"They're not getting the psychosocial support, and their families are not," Geng says. "It can be a time of closure, and coming to peace with a lot of things in your life, and none of that can happen if you come onto hospice with a day left."

Hospice care mostly takes place at home, but it can also occur in freestanding hospices, nursing homes or designated areas of hospitals. To receive the care, a doctor must predict a patient is in the last six months of life without hope of improving. There's no penalty for outliving that prediction; some patients stabilize and go off hospice care, then return later when they start declining again.

About 25 percent of people in the New York metropolitan area use hospice care in their last six months of life, compared with close to 50 percent nationally. Statewide, the rate is closer to 30 percent. But that still makes New York 49th out of 50 states and the District of Columbia, according to the 2012 Dartmouth Health Atlas, the most recent statistics available.

Sandra Lopez said that before her oncologist told her about hospice care, she frequently called 911 to request an ambulance to take her to the hospital, where she would be admitted and spend days at a time. That happened "dozens and dozens of times" in a year, Lopez said.

At around $210 a day, Lopez's hospice care cost Medicaid tens of thousands of dollars — probably less than her revolving-door trips to the hospital (with all their multinight stays), but still a lot of money.

For Lopez, hospice helped her get ready to walk down the final road.

"I stopped worrying — like the worry box I used to be," she told me in August. "I just live my life normally, like everybody else, because worrying will just probably get me more sick."

Lopez knew that at some point her body would start shutting down, but she would never say how much time her doctors estimated she had remaining, because she didn't dwell on that, she said. She was at peace as she faced death and knew she could stay that way — as long as someone was with her at home, at her bedside, helping to subdue her pain.

This story is part of an NPR reporting partnership with WNYC and Kaiser Health News. Special thanks to WYNC's Data Team.

Copyright 2014 WNYC Radio. To see more, visit
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When You Burn Off That Fat, Where Does It Go?

NPR Health Blog - Tue, 12/16/2014 - 3:58pm
When You Burn Off That Fat, Where Does It Go? December 16, 2014 3:58 PM ET

Lose weight and those pounds shuffle off, unmourned. Good riddance. Please don't come back soon.

But where does weight go when we lose it?

We talk about burning off fat, and it does burn in a way, going through a complex biochemical process. But mass can't be created or destroyed, so the atoms that made the triglycerides that plumped up the love handles have got to be somewhere.

The Salt Cutting Back On Carbs, Not Fat, May Lead To More Weight Loss

That mystery was bedeviling Ruben Meerman, an Australian and former physicist turned TV personality and science educator. Meerman had recently lost 15 kilos (33 pounds), and he was wondering where the fat went.

So he teamed up with Andrew Brown, a lipid researcher at the University of New South Wales, to figure it out. Their results were published Tuesday in the lighthearted Christmas edition of The BMJ, formerly the British Medical Journal.

The adipose sleuths started with this chemical formula, which describes what happens when you burn a molecule of triglyceride, the predominant fat in a human body:

C55H104O6+78O2 —> 55CO2+52H2O+energy.

If you remember your high school chemistry, you've already figured out that when you metabolize fat you end up with carbon dioxide, water and energy.

Oxidizing 10 kilos of human fat requires inhaling 29 kilos of oxygen to produce 28 kilos of carbon dioxide and 11 kilos of water, the authors figure.

The Salt Rethinking Fat: The Case For Adding Some Into Your Diet

That's based on the work of other scientists. Meerman and Brown then fired up their calculators to figure out the proportion of mass that ends up as CO2 versus H2O — 84 percent compared to 16 percent.

Carbon dioxide is a common gas in the atmosphere, so it's pretty obvious where it would go.

Yes, we exhale lost fat. There it helps plants photosynthesize (if you're feeling noble) and contributes to global warming (if you're feeling guilty).

Exhale more CO2, and you'll lose more weight — especially if you're exhaling more frequently because you're running.

The relatively small amount of water produced by fat metabolism could be disposed of through urine, sweat or other bodily fluids, the authors note.

Many people think that fat metabolites are disposed of in feces or converted to muscle, Meerman and Brown write, but that's not correct. "We recommend these concepts be included in secondary school science curriculums and university biochemistry courses to correct widespread misconceptions about weight loss."

And let your fat drift away on the breeze.

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Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab

NPR Health Blog - Tue, 12/16/2014 - 1:19pm
Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab December 16, 2014 1:19 PM ET

The coronavirus responsible for Middle East respiratory syndrome (green particles) seen on camel cells in a scanning electron micrograph.

NIAID/Colorado State University

Imagine that scientists wanted to take Ebola virus and see if it could ever become airborne by deliberately causing mutations in the lab and then searching through those new viruses to see if any spread easily through the air.

Would that be OK?

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The question was posed by David Relman, a microbiologist at Stanford University, at a two-day meeting being held at the National Academy of Sciences in Washington, D.C., to discuss whether some experiments with germs are so risky that the dangers aren't worth the potential benefits.

Researchers call these "gain-of-function" experiments. Take a bug that's bad and give it some genes that just might give the microbes new abilities.

The work has split the scientific community. Some of the most prominent figures in this saga showed up at the historic National Academy of Sciences building this week to have another go at it.

The controversy started a few years ago, with some experiments that took a bird flu virus and altered it so that it spread easily between ferrets, the lab stand-in for people. Critics said the scientists had created a superflu that could cause a pandemic in people if it ever got out of the lab, but the researchers said their work was essential to understanding how flu viruses can jump from animals into people and start devastating flu pandemics.

This disagreement rumbled along until this summer, when some high-profile lab mishaps with other infectious agents prompted the government to temporarily halt certain federally funded research projects that might make three viruses — influenza, SARS and MERS — more pathogenic or contagious.

Officials said they wanted to reassess the risks and benefits, and the meeting that started Monday is part of that effort. "We want to provide a neutral venue for open discussion," said Victor Dzau, president of the Institute of Medicine of the National Academy of Sciences.

The one thing that almost everyone seemed to agree on is that they hate the term "gain-of-function," saying that it doesn't meaningfully describe the kinds of experiments that have some people worried.

"I think the term 'gain-of-function' is being misused more than the viruses," said Michael Imperiale, a microbiologist with the University of Michigan Medical School. "I'd rather that we just take each individual case and call it what it is." Kanta Subbarao of the National Institutes of Health, whose lab works on all three pathogens, said the term is "vague and unsatisfactory."

Virologist Yoshihiro Kawaoka of the University of Wisconsin, Madison, whose lab did one of the flu experiments that caused such controversy, said his work convinced government agencies that they needed to spend the money to replenish the emergency vaccines that have been stockpiled for this particular bird flu virus, because it does indeed seem capable of mutating in ways that could start a pandemic. "This information is important for policymakers," he said, adding that such experiments allow scientists "to obtain information that we could not obtain by other methods unless it actually occurred in nature."

Relman, in response, said that "we already knew enough to be very concerned and motivated to do something" and suggested that if additional motivation was needed, it could have been achieved through experimental approaches that carried less risk.

Meanwhile, scientists who study MERS and SARS, like the University of North Carolina's Ralph Baric, came to the meeting and argued that they weren't doing anything worrisome with these viruses. But they had been dragged into the discussion and had their work halted only because they study respiratory viruses that can be highly pathogenic in people.

The government's review process is expected to last about a year, with another conference planned at the National Academies to discuss draft recommendations on how the government should weigh the risks and benefits of this type of work. Those recommendations will be developed by an advisory committee called the National Science Advisory Board for Biosecurity, which will also be holding public meetings.

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Few Employers Cover Egg Freezing For Women With Cancer

NPR Health Blog - Tue, 12/16/2014 - 8:22am
Few Employers Cover Egg Freezing For Women With Cancer December 16, 2014 8:22 AM ET

Partner content from

Michelle Andrews

As some companies add egg freezing to their list of fertility benefits, they're touting the coverage as a family-friendly perk.

Women's health advocates say they welcome any expansion of fertility coverage. But they say that the much-publicized changes at a few high-profile companies such as Facebook and Apple are still relatively rare, even for women with serious illnesses like cancer who want to preserve their fertility.

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News stories about company-paid egg freezing for female employees have focused on whether the benefit truly gives women and men more options for balancing work and family life or instead sends a message that they're expected to put off having a family if they want to get ahead on the job.

But career advancement isn't the main concern for some women who, because of illness or age, are worried that time is running out for them to have children. After their mid-30s, women can still carry a pregnancy, but their eggs are less viable. Egg freezing allows women to extend their fertile years.

Brigitte Adams, 42, became the face of oocyte cryopreservation, as egg freezing is called technically, when Bloomberg BusinessWeek put her on its cover for a story on the subject last spring.

Divorced in her mid-30s, she froze her eggs three years ago, paying for the $12,000 egg retrieval procedure with personal savings and help from her parents. Adams pays $300 annually to store her eggs, and she's pondering becoming a single mother. Her marketing job at a tech startup in Los Angeles doesn't provide any coverage for egg freezing and storage or the in vitro fertilization that will be required if she decides to go ahead.

Adams is keenly aware that there is no guarantee that the 11 eggs she's storing will result in a pregnancy. "It's not a silver bullet," Adams says, "but it gave me the sense I'd done everything I could, and that has helped me tremendously to just move on."

Two years ago, the American Society for Reproductive Medicine declared that it no longer considered egg freezing to be experimental. Research shows that fertilization and pregnancy rates using frozen eggs are similar to those using fresh eggs, and children born using frozen eggs don't have higher levels of chromosomal abnormalities or birth defects, the ASRM said in its revised practice guideline.

Yet insurance coverage for egg freezing and other infertility treatments remains spotty, says Richard Reindollar, executive director at the ASRM. "Of all the disease processes, insurance coverage is available for essentially all of them, but not for infertility," he says.

America's Health Insurance Plans hasn't surveyed insurers specifically about egg-freezing coverage, says Susan Pisano, a spokesperson for the trade group. However, she said her understanding is that many plans cover egg freezing when there's a diagnosed fertility problem or when an individual is at risk for infertility because of treatments like radiation therapy or chemotherapy. Coverage for nonmedical reasons is much less common, Pisano says.

Roughly a third of companies with 500 or more workers provide no coverage for infertility services, according to benefits consultant Mercer's annual survey of employer health benefits.

High-tech companies are more likely to cover fertility services than other firms, according to Mercer. Forty-five percent of high-tech companies cover in vitro fertilization, and 27 percent cover other advanced reproductive procedures, such as egg freezing, for example. The comparable figures for companies not in the technology sector were 26 percent and 14 percent, respectively.

Infertility advocates would like to see more companies adopt egg freezing policies, especially for women who have cancer, for example, and are likely to become infertile as a result of chemotherapy.

"I think it's amazing for people at these companies, but can we also get this covered for women with cancer?" says Barbara Collura, president and CEO of Resolve, an infertility advocacy group.

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Alaska's Governor Eager To Expand Medicaid

NPR Health Blog - Tue, 12/16/2014 - 3:28am
Alaska's Governor Eager To Expand Medicaid December 16, 2014 3:28 AM ET


Annie Feidt Listen to the Story 2 min 54 sec  

Valerie Davidson was appointed health commissioner by Alaska's Gov. Bill Walker to help him expand Medicaid in the state. She'll look for middle ground with Republicans to get it done, she says.

Lori Townsend/Alaska Public Media

Alaska's new governor won his election in one of the tightest races in the country, a race that was too close to call even a week after election night. Bill Walker, who ran as an independent (unaffiliated with the Republicans or Democrats), took office on Dec. 1, after campaigning on the promise that he would expand Medicaid as one of his first orders of business.

Environment Republican Sweep Highlights Climate Change Politics In Alaska

To make good on that, he'll have to face a Republican-controlled legislature that hasn't been willing to even consider the idea.

But for Walker, it's a no-brainer: Around 40,000 low-income Alaskans would receive health benefits under Medicaid expansion; most of those affected would be childless adults. The federal government would pay 100 percent of the costs until the end of 2016, and after that the state's share would only slowly increase to 10 percent by 2020.

Plus, Walker points out, Alaskans already pay taxes that fund the expansion.

"I always will default back to what is best for Alaskans," he says, "and it's best for Alaskans to have the health care coverage we've already paid for."

The Alaska Chamber of Commerce, the Alaska State Hospital and Nursing Home Association and the Alaska Native Tribal Health Consortium, all support the Medicaid expansion. So far 28 states have expanded their coverage, and most of those governors have had legislative support says Laura Snyder, a policy analyst with the Kaiser Family Foundation.

“ I always will default back to what is best for Alaskans, and it's best for Alaskans to have the health care coverage we've already paid for.

"There have been a few states where the governor has acted on his own through executive authority," she says, "but most states have generally incorporated it into state budgets which usually require legislative signoff."

In the case of Alaska, Gov. Walker will probably need the legislature because the state has to pay some administrative costs that would add up to as much as $10 million per year. Those millions could be a tough sell for the Republican legislature. Republican Sen. Anna MacKinnon says Walker will have to make a strong case.

"It will be a lively debate," MacKinnon says, "but I look forward to working with him to the best of my abilities within the financial constraints that this state is currently facing."

To help his case, Walker has appointed Valerie Davidson as Health Commissioner. She's been a leader in the Alaska Native health care system and a determined advocate for Medicaid expansion since the health law passed. She says she'll rely on a cooperative work ethic as she negotiates with lawmakers over expansion. Davidson's confident Alaska can get it done.

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"It may not be something everyone's 100 percent happy with," she says, "but we may be able to find middle ground that we can all live with.

"I think that's what makes Alaska so great," Davidson adds. "We don't back down just because things get difficult. If it's 40 below we go about our day and get things done. That's just what we do. And we do that with policy issues as well."

Beyond any opposition by the legislature, Alaska faces big technical hurdles before Medicaid expansion can work. The state's payment and enrollment systems aren't functioning properly right now, and Davidson wants to address those issues before any expansion.

This story is part of NPR's reporting partnership with Alaska Public Media and Kaiser Health News.

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To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo

NPR Health Blog - Mon, 12/15/2014 - 3:58pm
To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo December 15, 2014 3:58 PM ET Katherine Harmon Courage

After a quick swipe and online registration, these test tubes were ready to ship back to the lab at the University of Colorado in Boulder for sequencing and analysis.

Katherine Harmon Courage for NPR

Understanding the human microbiome takes much more work than just identifying the organisms that live in a person's gut. A genetic census of these microbes is really only the start of figuring out what they have to do with health and disease.

To find helpful patterns in the microbe populations, researchers also need to gather a host (no pun intended) of information from the people providing the samples. As participants in the American Gut Project, that means we — myself, my mom, my husband and our dog — answered questions about our life history. (Well, we helped the dog with his.)

Katherine Harmon Courage with her husband, David, and their dog, Raz.

Courtesy of Daylene Wilson

Some of the basic questions were like the things I've answered to get a passport:

In what country were you born? U.S.

Some that I find on so many user surveys:

What is your race? Caucasian.

Then there were the questions about health that reminded me of a trip to the doctor's office:

Do you have asthma? No.

Were you born via cesarean section? Yes.

Have you had your appendix removed? Nope.

But the lifestyle questions were all over the map:

Do you take a multivitamin? No.

Do you bite your fingernails? No way.

Do you use fabric softeners? Why, yes, I do, the "natural" type.

For all of us, including the dog, we provided detailed dietary information. We tracked our food intake for a week, which, as anyone who has ever tried this for diet or health purposes knows, is no small task.

So my husband and I diligently logged the contents of our breakfasts (toast, almond butter and fruit), salad (kale, avocado and tahini-and-vinegar dressing), smoothies (oranges, protein powder and bananas), and splurge dinners (chicken tacos, margaritas and ice cream). We also logged our exercise as we trained for our second New York City Marathon together.

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My mother back on the East Coast kept a diary of her diet. On a typical day she had kefir and granola for breakfast, homemade chicken soup for lunch, lasagna and red wine for dinner. The dog diligently chomped his usual kibble, making him the easiest of the bunch to report on.

But as a science journalist, I couldn't help but focus on the missing details.

There was no way to specify whether our toast was made from regular, whole or sprouted grains. Did our salad greens come from the farmer's market or pre-rinsed in a bag from the supermarket.

These factors, I thought, must have some effect on gut flora. Maybe there were extra nutrients from the sprouted grains and perhaps odd organisms lived on recently picked, hand-washed greens.

I asked Rob Knight, at the University of Colorado, Boulder and one of the leaders on the American Gut Project, if there were a million other questions he would like to ask study participants. Had he wondered if skipping details would mean he was going to miss some potentially big lessons about diet and gut health later.

But he had a pragmatic outlook. For now, he said, It's about opening the project to as large a population as possible, not gathering every possible piece of data. A 30-page questionnaire might turn up a few more correlations, but it would undoubtedly deter people, too.

The current eight-page version was, in truth, plenty long. And since these are still the early days of microbiome research, painting the broad strokes — more veggies versus fewer — and trends — chronic gut disease versus good health—is the initial goal. Perhaps future studies will be able to drill down on specific populations to find these more minute differences, he said.

The other trouble, of course, is relying on self-reported data. You can believe me. Honest. But can you rely on what other people say about what they ate and how much they exercised or flossed their teeth?

But, since Knight and the other researchers can't send out monitors to follow each participant around, information provided by the volunteers is the only feasible option. And other validation studies have found that questions like the ones they used result in answers that are close enough at this point in the research.

Our diets tracked, our surveys answered, it was time for the event some of us had been waiting for (me, my mother) — and others had been dreading (my husband) or oblivious to (our dog). It was sample time.

So I ripped into the plain white envelope that had arrived in the mail. Inside there were four clear tubes with two cotton swabs each. I ventured out into the backyard to find a fresh sample from our dog. The other two awaited private time at home.

The trick for collecting fecal samples, according to Knight, is to avoid overloading the swabs with, er, material. That'll just clog the lab's processing machines, he says. The slightest swipe from a used piece of toilet paper captures enough microbial genetic material to paint a detailed picture of your gut's full microbiota.

Samples discreetly taken, we wrote the dates and times on the tubes, wrapped them in clean tissue as instructed, and placed them back in the mail to the American Gut Project's lab at the University of Colorado, Boulder, where I caught up with them and the ones my mom sent from Connecticut the next week.

This is the second story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

Copyright 2014 NPR. To see more, visit
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Prolific Prescribers Of Controlled Substances Face Medicare Scrutiny

NPR Health Blog - Mon, 12/15/2014 - 12:00pm
Prolific Prescribers Of Controlled Substances Face Medicare Scrutiny December 15, 201412:00 PM ET

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Charles Ornstein Ryann Grochowski Jones Listen to the Story 3 min 51 sec  

Number of providers by state who wrote at least 3,000 prescriptions for Schedule 2 controlled substances in 2012 in Medicare Part D.


Despite a national crackdown on prescription drug abuse, doctors churned out an ever-larger number of prescriptions for the most-potent controlled substances to Medicare patients, new data show.

In addition, ProPublica found, the most prolific prescribers of such drugs as oxycodone, fentanyl, morphine and Ritalin often have worrisome records.

In 2012, the most recent year for which data is available, Medicare covered nearly 27 million prescriptions for powerful narcotic painkillers and stimulants with the highest potential for abuse and dependence. That's up 9 percent over 2011, compared to a 5 percent increase in Medicare prescriptions overall. Even taking into account an increase in the number of Medicare enrollees, the prescribing rate rose slightly for these drugs, which are classified as Schedule 2 controlled substances by the Drug Enforcement Administration.

Twelve of Medicare's top 20 prescribers of Schedule 2 drugs in 2012 have faced disciplinary actions by their state medical boards or criminal charges related to their medical practices, and another had documents seized from his office by federal agents.

The No. 1 prescriber — Dr. Shelinder Aggarwal of Huntsville, Ala., with more than 14,000 Schedule 2 prescriptions in 2012 — had his controlled substances certificate suspended by the state medical board in March 2013. He surrendered his medical license four months later. (Aggarwal could not be reached for comment.)

Prescribing high volumes of Schedule 2 drugs can indicate a doctor is running a pill mill, said Dr. Andrew Kolodny, chief medical officer of Phoenix House, a New York-based drug treatment provider. Government regulators should do more to monitor prescribing patterns and intervene proactively if they appear aberrant, he said.

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"We wait 'til these doctors kill people," said Kolodny, founder of Physicians for Responsible Opioid Prescribing, which advocates for tighter regulation of painkillers. "It doesn't make any sense."

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Medicare's drug program, known as Part D, now covers about 38 million seniors and disabled people and pays for more than one of every four prescriptions dispensed in this country. Concerns about oversight of controlled substances date back to at least 2011, when the Government Accountability Office highlighted abuse of opioids in Part D and called on Medicare to take action.

Within the past year, Medicare has started to use prescribing data to identify potentially problematic doctors, as have some state medical boards. Beginning in mid-2015, Medicare will have the authority to kick doctors out of the program if they prescribe in abusive ways.

"It's a real area of concern for us," said Dr. Shantanu Agrawal, director of the Center for Program Integrity within the federal Centers for Medicare and Medicaid Services.

The 2012 data shows the upward trend line for prescriptions of controlled substances before these initiatives took hold.

The Drug Enforcement Administration classifies certain potent drugs based on their potential for abuse and sets limits on prescribing for each group. Drugs classified as Schedule 2 require written prescriptions and cannot be refilled.

ProPublica reported in 2013 that Medicare did not proactively analyze its prescribing data or take action against providers whose patterns were troubling, even if they had been charged with Medicare fraud or kicked out of state Medicaid programs.

Shelinder Aggarwal's Medicare prescribing history had plenty of red flags. The pain medicine specialist has consistently shown up in Medicare's data as a top prescriber of narcotics. By 2012, the year before he stopped practicing, more than 80 percent of his Medicare patients received at least one prescription for a Schedule 2 drug, in many cases oxycodone.

It took complaints from pharmacies near Aggarwal's office to alert the Alabama Board of Medical Examiners to his unusual prescribing habits, said Larry Dixon, the board's executive director. Board investigators subsequently made undercover visits to the doctor's office and videotaped him prescribing drugs without an exam.

"If you paid $1,200 in cash, they would put a VIP stamp on your medical records and you didn't ever have to have an appointment," Dixon said.

Medicare's Part D data draws a roadmap to the doctors who prescribe controlled substances most frequently.

In 2012, 269 providers wrote at least 3,000 prescriptions for Schedule 2 drugs, ProPublica's analysis shows. They were concentrated in a handful of states. Florida led the country with 52 providers, followed by Tennessee with 25. (Look up your doctor using our Prescriber Checkup tool.)

About one in five doctors who wrote at least 3,000 prescriptions for Schedule 2 drugs have faced some kind of sanction or investigation, ProPublica found.

In September, Medicare sent 760 letters to doctors who prescribed far more Schedule 2 drugs than others in their medical specialty and state. Officials hope the initiative will cause doctors to examine their prescribing and make changes.

"Simply being an outlier doesn't establish that you're doing something wrong," said CMS' Agrawal. "What we are trying to do is give physicians the ability to assess themselves, given their comparative data."

Medicare also has sent information on 71 prescribers for possible investigation to the inspector general of the U.S. Department of Health and Human Services, and on one doctor to a state medical board.

Some medical licensing boards are also expanding their efforts to use data to spot problematic prescribing. North Carolina's medical board has proposed new regulations allowing the agency that runs the state's prescription drug monitoring program to share data with the board. The board currently can only access the data when it is pursuing an active investigation into a particular physician.

Similarly, Alabama's legislature recently authorized its medical board to regulate pain medicine clinics and proactively access data from its prescription monitoring database.

Dixon, the Alabama board's executive director, and Henderson said their states' changes are not meant to impede legitimate care by doctors.

"Most of these people are just as genuine as you could possibly hope," Dixon said.

Data, alone, can be misleading. Dr. Mark Ellis, a pain specialist in Athens, Ga., was the third-highest prescriber of Schedule 2 drugs in the country in 2012, with more than 10,000 prescriptions. But unlike many states, Georgia does not allow nurse practitioners and physician assistants to write prescriptions for these controlled substances on their own, requiring them to be signed by a physician. As a result, Ellis said he was credited with the prescribing of four other professionals in his practice. (Ellis was fined by Georgia's medical board in July 2005 for working with a physician assistant without consent from the board.)

With scrutiny of painkiller prescribing on the rise, Ellis said he attempts to ensure that patients are taking, not selling, their pills by requiring frequent drug testing.

Rules put in place by several states have reduced prescribing of narcotics, experts say. New York, Kentucky and Tennessee now require that doctors check databases that track every controlled substance prescription in their states before prescribing such drugs to patients for the first time and at certain intervals afterward. Other states are considering or are in the process of implementing similar rules.

Mandatory checks are "the most-effective single tool we've found yet to address this problem," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

ProPublica is a nonprofit investigative reporting newsroom based in New York.

Copyright 2014 ProPublica. To see more, visit
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Small Businesses Drop Coverage As Health Law Offers Alternatives

NPR Health Blog - Mon, 12/15/2014 - 11:01am
Small Businesses Drop Coverage As Health Law Offers Alternatives December 15, 201411:01 AM ET Jay Hancock

Where are the health insurance deals? On the exchanges, many small businesses have concluded.

Bjorn Rune Lie/Ikon Images/Getty Images

For two decades Atlanta restaurant owner Jim Dunn offered a group health plan to his managers and helped pay for it. That ended Dec. 1, after the Affordable Care Act made him an offer he couldn't refuse.

Subsidies under the health law for workers to buy their own coverage combined with years of rising costs in the company plan made dropping the plan an obvious — though not easy — choice.

"I had a lot of regrets going into it," Dunn, who owns three Italian Oven restaurants in suburban Atlanta, said of his decision. "I don't think I have as many now — only because I've seen the affordability factor for my managers improve."

Dunn and five managers are now covered under individual plans bought on How many other owners make the same decision will help set the future of small-business health insurance. Although the evidence so far is mixed, brokers expect more firms to follow in the next few years.

Companies like Dunn's — those with fewer than 50 workers — provide medical coverage to roughly 20 million people. Unlike larger employers, they have no obligation under the health law to offer a plan. Now they often have good reason not to.

If employees qualify for government subsidies, like the managers who switched from Italian Oven's corporate insurance to individual Obamacare coverage, everybody can win.

Owners don't have to pay premiums, meaning they can give workers raises, invest in equipment or add to profits instead. And employee take-home pay can rise if subsidies — available even to families with middle-class incomes — are worth more than what a company was contributing.

Whether to cancel a company plan and let workers buy insurance on or another online exchange "is something that I would say comes up in every conversation with a small-group" employer, said Adam Berkowitz, a consultant with Caravus, a benefits firm based in St. Louis.

"I just had another [small] business call in today and say, 'You know, we can't do it. We're packing it in,' " said Roger Howell, head of Howell Benefit Services in Wilkes-Barre, Pa.

Anthem, the largest seller of small-business health insurance, lost almost 300,000 members in such plans — many more than expected — in the first nine months of the year. That was 15 percent of the enrollment. Many of those consumers are presumably switching to individual plans sold through exchanges, including those offered by Anthem, officials said.

It's far from clear, however, that most companies will take the same steps as Italian Oven.

Many small employers see health coverage as an essential piece of compensation. They note that premiums in company-sponsored plans are tax-deductible — for workers as well as employers — while the tax advantages of individual plans are limited.

"I feel like we have to have a medical plan in order to hire people and keep them employed," said Dan Allen, head of a 15-worker engineering firm in Decatur, Ill. Allen Engineering renewed its Coventry Health Care plan for 2015 even though the premiums rose 21 percent, he said.

No other major insurer has reported cancellation of small-business plans at the same rate as Anthem.

"We didn't see that," said Rick Allegretti, vice president of marketing at Health Care Service Corp., operator of Blue Cross plans in five states including Illinois and Texas. "We actually saw our [small-group] business grow slightly — mind you, it's probably a tenth of a percent."

Businesses shifting workers into the individual exchanges tend to be the very smallest, employing a handful of people, said Skip Woody, a partner at Hill, Chesson & Woody, a North Carolina benefits firm. "Anything above 15, we haven't had any dropping coverage," he said.

Instead, many small companies are taking advantage of rules letting them maintain insurance bought before the health law took effect. President Obama, who promised consumers they could keep coverage they liked, allowed carriers to extend noncompliant plans after facing fierce criticism over their imminent extinction.

Most, but not all, states approved the adjustment. Because older policies may lack features required by the health law, and because their rates are often set according to employee health history, not communitywide costs, they can be less expensive than compliant plans, say brokers and consultants.

"I haven't sold one of the new plans yet" to a small employer, said John Jaggi, an Illinois broker and consultant. Faced with price increases of as much as a third or more for new plans, all 40 or so of his small-business clients including Allen Engineering renewed older coverage for 2015, he said.

Heavy renewal of old plans plus workers shifting to individual coverage help explain why the health law's online portal for new small-business plans has attracted only modest interest, analysts say.

For some companies there is logic to ending coverage altogether.

For Italian Oven's Dunn, "it made sense to recommend that he drop coverage," said Elena Merino, CEO of the Meridian Group, a benefits firm in Alpharetta, Ga. "It hurts me. But that was the responsible thing to tell him."

Italian Oven employs the equivalent of about 30 people — less than the 50-worker threshold that would get it fined for not sponsoring insurance. The company does not offer coverage to servers and kitchen staff, but full-time managers have always had a plan.

All are eligible for tax credits to buy insurance on, said Dunn. Next year, the subsidies are available for individuals with income of up to $46,680 and families of four with income of up to $95,400.

With subsidies factored in along with unrelated pay increases, the managers "are going to be saving money out of the deal" while getting coverage comparable to what they had before, Dunn said. "My managers actually got excited about it because they're saving money on their health insurance."

Brokers expect more small businesses to make the same move, especially after the ability to extend older, noncompliant plans expires between now and the end of 2017, depending on state policy. Allen, the engineering firm executive, is concerned premiums could rise even higher next year than they did for the 2015 renewal.

"If it's up in the 25- to 30-percent increase [range] — I've heard as high as 40 — we'll just have to drop it," he said. "Turn everybody loose."

Copyright 2014 NPR. To see more, visit
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To Stop Teen Drinking Parties, Fine The Parents

NPR Health Blog - Mon, 12/15/2014 - 3:24am
To Stop Teen Drinking Parties, Fine The Parents December 15, 2014 3:24 AM ET Listen to the Story 4 min 28 sec   Maria Fabrizio for NPR

When it comes to teenage drinking, the typical venue is a party — where some teens play drinking games and binge. It may surprise you to learn that the majority of parents are aware that alcohol is flowing at these events.

On any given weekend, some teenagers receive three to four text messages about parties, says Bettina Friese, a public health researcher at the Prevention Research Center in Oakland, Calif.

Friese recently conducted a study on teen drinking. She interviewed 1,100 teenagers living in Northern California. Most did not host parties with alcohol. But of the 39 percent who did, 70 percent said their parents knew kids at the party were drinking. Twenty-four percent said their parents "probably" knew, leaving just a handful of parents in the dark.

“ The bottom line is you can't provide alcohol to minors, period.

Now some communities across the United States are trying to hold these parents accountable and fine them for allowing underage drinking in their homes.

When Friese interviewed parents about why they allowed alcohol, there were many excuses, she says — everything from concern about alienating their children to worries that imposing strict rules might encourage more dangerous rebellion.

Many parents felt drinking was inevitable, she says. One mother told Friese, "I'd rather they make their mistakes when they're at home than when they're away."

Many parents said they believed it was safer for their child (and even their child's friends) to drink at their house rather than someplace else, Friese says. The biggest concern among the parents was drunken driving; many said they had their child's friends stay the night to avoid driving. Many parents said they knew it was "wrong" to allow alcohol at teen parties. But, Friese says, they felt they had no choice.

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That may be changing. Nationwide, cities and communities are starting to crack down. So far, 28 states have some sort of social host law on the books. These laws hold adults responsible for any underage drinking that happens on their property.

The details of the law vary, community to community and state to state. One of the most stringent laws is in Ventura County in California, says Bernadette Compean, an alcohol beverage control officer with the Ventura Police Department.

"The bottom line is you can't provide alcohol to minors, period," she says, adding that Ventura is the only county in California where all of the cities have similar laws.

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The county's laws are crystal clear: If you're 21 or older and you host a party where alcohol is available to teenagers, you can be fined $1,000 on the spot. If parents aren't home, the teen who's hosting the party gets the ticket. And to make sure tickets don't get ignored, police promptly follow up with a letter to parents informing them about the party, the ticket and the $1,000 fine.

If police are called a second time in one year, the fine doubles to $2,000 plus the cost of city services — which can run into thousands of dollars more if the fire department or other emergency services are involved. Compean says most teens and parents get the message the first time. She hasn't been called back much for second offenses.

Since the law was passed six years ago, underage drinking has declined throughout the county, and teenagers report that it's become more difficult to obtain alcohol.

And it's not just in Ventura that such laws are changing behavior. Public health researcher M.J. Paschall, also with the Prevention Research Center, recently did a study comparing cities in California that had social host laws with cities that did not.

"We found that cities with more stringent and enforceable social host laws had lower levels of drinking at parties among teenagers compared to cities with less stringent laws, or without any kind of social host law," Paschall says.

He plans future research to see if the laws also result in fewer alcohol-related accidents and injuries — especially from drunken driving.

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Confusion Over Job-Based Insurance Can Shortchange Consumers

NPR Health Blog - Fri, 12/12/2014 - 1:35pm
Confusion Over Job-Based Insurance Can Shortchange Consumers December 12, 2014 1:35 PM ET

Partner content from

Michelle Andrews

Misunderstandings about whether some types of job-based coverage disqualify consumers from signing up for subsidized insurance through the health law's marketplaces may lead some people to buy skimpier employer plans instead.

In recent weeks, some of the people called assisters, who help shoppers find coverage, say consumers are being told by employers that their bare-bones plans meet the minimum requirements under the law. That kind of insurance would cover preventive benefits, for instance, but might leave out prescription drugs and emergency care.

The problem is that consumers mistakenly think that having access to skimpy coverage means they don't qualify for subsidies if they want to buy a more complete policy on the exchanges instead.

But that's not necessarily the case.

Rather, they would be ineligible for subsidies if their employer plan is deemed affordable under the law and pays for 60 percent of allowed medical charges, on average. Coverage is considered affordable if it costs no more than 9.5 percent of an employee's income for individual coverage.

Some of the confusion relates to the similar-sounding bureaucratic names for these different legal standards.

Minimum value coverage means the plan pays for 60 percent of allowed medical charges, on average.

Minimum essential coverage, which can include a range of things from grandfathered health plans to some of the prevention-only plans being offered by large employers, refers to what large employers must offer to avoid paying penalties for not offering coverage, as well as what individuals must carry to comply with the law's coverage requirement.

Some consultants have reportedly developed job-based plans that cover very little other than preventive benefits. Unlike small group and individual plans, which are required to provide comprehensive coverage under the health law, no such requirements exist for large group plans.

"It's hard for consumers to understand how a plan that is lousy in their eyes could somehow prevent them from getting subsidies on the exchange," says JoAnn Volk, a senior research fellow at Georgetown University's Center On Health Insurance Reforms.

The federal government recently released guidance saying that plans that don't include coverage of hospitalization services and doctor's visits don't satisfy the minimum value standard even if they manage to meet the 60 percent actuarial value threshold without those benefits. Until final regulations are released next year, workers who are offered such plans won't be barred from qualifying for premium tax credits on the exchanges, the guidance said.

The vast majority of plans are believed to meet the minimum value standard, however. No more than 2 percent of people covered by employer-sponsored insurance — 3.2 million people — are enrolled in plans with an actuarial value of less than 60 percent, according to a 2011 estimate by the federal Department of Health and Human Services. Those affected are more likely to be in low-wage jobs and may not have had health insurance before.

In addition, because the 9.5 percent affordability standard is based on the cost of employee-only coverage rather than family coverage, most plans will be considered affordable, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Having said that, "we know there were some pretty shabby plans being offered out there," Solomon says.

During open enrollment, health plans are all supposed to provide a "summary of benefits and coverage" that explains the details of the plan and also states whether it provides minimum essential coverage and meets minimum value standards.

"We were hearing from assisters that people were having trouble understanding this employer coverage information," says Cheryl Fish-Parcham, private insurance program director at Families USA, a consumer advocacy organization.

Families USA and other advocacy groups sent a letter to the administration requesting that it amend the summary of benefits and coverage requirements to add language informing people that they could be eligible for premium assistance on the marketplace if their employer plan doesn't meet the minimum value standard, Fish-Parcham says.

Workers who are filling out an application for a marketplace plan and are uncertain about whether their on-the-job coverage meets minimum value standards can download an "employer coverage tool" from and ask their employer to complete it.

However, employers aren't required to fill out the form.

"It's a bewildering process," says Fish-Parcham.

Copyright 2014 Kaiser Health News. To see more, visit
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Poo And You: A Journey Into The Guts Of A Microbiome

NPR Health Blog - Fri, 12/12/2014 - 10:24am
Poo And You: A Journey Into The Guts Of A Microbiome December 12, 201410:24 AM ET Katherine Harmon Courage Katherine Streeter for NPR

The trillions of microbes that live in our guts and on our skin have the power to affect our health in big ways — from stomach disorders and autoimmune diseases to acne and mood. The secret life of what scientists call our microbiota has remained largely obscured, however, because many of the organisms in the gut can't be grown in a lab.

Quick and relatively cheap genetic sequencing is at last offering a glimpse of these inhabitants of our bodies. Over the next few posts, I'll investigate what one's microbiome — the genetic profile of these organisms — can tell us about our health as well as what that new view says about us and how we're connected to others.

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Unlike the genome, which is relatively fixed, a person's microbiome is changeable over a lifetime — and perhaps even daily.

Early individual microbiome sequences — which show far greater variety among people than the human genome — are now trickling out, painting the picture of gut communities of minor celebrities, including writer Michael Pollan and ultrarunner Dean Karnazes.

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Results from small group studies are also bringing new insights. We now know, for example, that changes in the microbiome are linked to some intestinal ailments such as inflammatory bowel disease, and other recent findings suggest that particular gut microbe populations might even affect how our bodies break down medications.

As a health journalist, I wanted to know how it all worked — the guts of the process, so to speak — and what a microbiome sequence can really tell us. So I signed up for the American Gut Project, a crowdfunded effort that is collecting microbiota samples — from guts, hands, mouths, dogs and dirt.

The project was founded by Rob Knight, a professor at the University of Colorado, Boulder's chemistry and biochemistry department, and Jeff Leach, of the Human Food Project and the London School of Hygiene and Tropical Medicine. Dozens of other researchers around the country help coordinate the project, which aims to be the biggest of its kind. It's self-sustaining because participants, including me, pay their own way.

And it doesn't cost much. I ponied up $99 to be in one of the early waves of the sequenced. All I needed to do was send in a sample I would collect at home with one of their kits.

Katherine Harmon Courage, her husband, David, and dog, Raz, at home in Colorado. The three had their microbiomes sequenced by the American Gut Project to see the microbes they shared, and those they didn't.

Courtesy of Daylene Wilson

As with the human genome, the big payoff of microbiome analysis — both scientifically and personally — will be in comparing results among different people.

The project has already received thousands of samples. Knight and his colleagues hope not just to make major headway in demystifying the microbiome, but also to help us understand what changes in the gut are linked to sickness and to health, and what links us to each other.

I decided to conduct my own experiment by buying kits for my husband (who was a bit reluctant to involve his microbes, especially after they had made their natural exit), our mutt (who couldn't care less about what happened with his contributions to our backyard), and my mother (who, as a science teacher, couldn't wait to participate).

The big question is, given so much common human DNA — among family and strangers alike — what makes our personal microbiota populations so incredibly different?

We know that doses of antibiotics can change the balance of bacterial populations in our guts (and often not for the better). And studies have shown that we share microbes with people we are around — but also with people we spent a lot of time around as children. This seems to be especially true of our mothers, from whom we pick up our first dose of microbes via the birth canal — and through breast-feeding soon thereafter.

But you don't have to share genetics to share microbes. One study showed that mice could actually "catch" beneficial microbial populations from their cagemates. And according to a study published last year, dog owners not only share microbes with their pooches, but they also share more microbes with other humans in the household than do those in canineless households.

Would I have more microbes in common with Mom or my husband? She breast-fed me and we lived together for the first 16 years of my life, after all. While he and I have lived together for just a couple of years, we share a home, a diet, a lifestyle and a dog. And what might our personal microbial profiles reveal about our individual health and life histories?

To have even a fighting chance at answering some of these questions, I ordered up our microbiome testing kits to probe the deep, juicy secrets of our guts and some of their inhabitants.

This is the first story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

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Birds Of A Feather Aren't Necessarily Related

NPR Health Blog - Thu, 12/11/2014 - 6:39pm
Birds Of A Feather Aren't Necessarily Related December 11, 2014 6:39 PM ET Listen to the Story 3 min 34 sec  

What do a pigeon and a flamingo have in common? Quite a bit, according to a reordering of the evolutionary tree of birds.

One of a series of studies published Thursday in Science is the latest step toward understanding the origins of the roughly 10,000 bird species that populate our planet.

"We're finally reaching some sort of consensus about how we think birds are related to each other," says Sushma Reddy, a researcher at Loyola University who studies bird evolution and was not involved in the new studies.

Understanding the relationships among different types of birds has been a subject of great debate among scientists because of birds' unusual start.

Birds began as dinosaurs. And for a long time, their ancestors were just hanging around with all the other dinosaurs. That all changed roughly 66 million years ago, when a large asteroid impact triggered a mass extinction on Earth.

Though land-based dinosaurs died, a few bird ancestors survived, explains Edward Braun, a biologist who studies bird evolution at the University of Florida and contributed to the new analysis.

With the big dinos out of the way, the birds spread their wings and covered the entire globe. They quickly evolved to live at sea and on land — everywhere from deserts to the arctic.

"The major groups of birds appeared very rapidly," Braun says.

The updated avian tree shows how many different kinds of birds evolved quickly after a mass extinction 66 million years ago.

AAAS/Carla Schaffer

That's why it so hard to tell who is related to whom. Today's bird species all look and sound very different from each other.

"Owls look very distinctively like other owls," Reddy says. "But there are very few characteristics that would put an owl with any other major group of birds."

The confused family tree has been frustrating researchers like Erich Jarvis, who is an architect of the new studies. Jarvis, a neuroscientist at Duke, has been trying to figure out how different birds learn their songs. To do that, he has to know how the birds are related to each other.

He decided the best way to sort this out was to sequence as many bird genomes as possible. "We just, basically, put out a call and had people come together who were sequencing bird genomes," he says.

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More than 200 researchers got involved, sequencing 48 avian genomes. Then they fed that genetic information into supercomputers. The computers crunched the data, and out popped the most likely evolutionary tree for birds. It shows that "only four lineages survived that massive extinction," Jarvis says, "and they gave rise to 95 percent of the species we have on the planet today."

The genetic information reveals other interesting facts about birds, Jarvis says. For example, bird genomes are about a third the size of a mammal genome. Birds appear to have lost a lot of junk DNA, but they also lost some traits to save weight. (For example: They once had teeth but evolved lightweight beaks instead.)

The songbirds Jarvis studies also appear to have independently evolved genes that are similar to those that shape the language areas of the human brain, he says.

The overall tree reveals some surprising relationships among bird species. Parrots are actually close relatives of falcons. Pigeons are more closely related to flamingos than they are to crows. And land fowl, like chickens, are related to ducks.

Julia Clarke, a bird paleontologist at the University of Texas, Austin, thinks the reorganized bird chart that's emerging from all that data crunching is probably correct and is beginning to reveal a clear picture of avian evolution.

"We seem to be sort of converging on a single answer," Clarke says. She's also a bird-watcher and says the genetic studies haven't found their way into bird guides yet.

"A lot of this stuff, I think, should be very compelling to bird-watchers," Clarke says.

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Football Players Drill Without Helmets To Curb Concussions

NPR Health Blog - Thu, 12/11/2014 - 5:01pm
Football Players Drill Without Helmets To Curb Concussions December 11, 2014 5:01 PM ET


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Making and taking a hit chest to chest, instead of skull to skull, is easier to remember if you're not wearing a helmet, say University of New Hampshire Wildcat football players.

Jack Rodolico/New Hampshire Public Radio

The University of New Hampshire Wildcats are heading into a do-or-die quarterfinal football game this week against the University of Tennessee, Chattanooga.

And whether they win or not, there's one thing you can say about the Wildcats: They are likely the only football team in America trying to reduce concussions by practicing without helmets.

Football has a concussion problem, from the National Football League down to Pee-Wee teams. And there are lots of efforts out there to fix it.

But Erik Swartz, a University of New Hampshire professor of kinesiology, studies movement and says there has been very little discussion about getting to the root of the problem: technique. Instead of clashing helmet-first, as football players often do, the better approach is to keep the head up and tackle chest to chest, never leading with your helmet — or your face, neck or shoulders.

Swartz says his idea to experiment with having players drill without helmets came from his own time playing rugby.

A tiny sensor is placed behind the ear of a University of New Hampshire football player. These sensors track the force and frequency of hits to the head during play.

Jack Rodolico/New Hampshire Public Radio

"You keep your head out of the way in a tackle in rugby," he says. "Because it's not protected, it will hurt."

Swartz's ongoing study divides the team into two 25-player groups. The control group always practices with a helmet on, while the treatment group takes helmets off during a tackling drill.

Before practice, every player has a sensor placed behind the ear to gauge and relay the force and number of impacts to the head. Swartz and his team watch to see if and how that changes over the course of the season for each player.

During full-speed tackling, the idea is to "look up when you tackle, to see what you're hitting," says Wildcats running back Donald Goodrich, who is part of the group that does the drill without helmets.

"It becomes second nature if you do it enough in practice," Goodrich says.

After that short, intense drill, the helmets go back on.

The hope is that players who think more about their skulls during a game will suffer less head trauma over time.

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Wildcats head coach Sean McDonnell says this study, or something else, has to work.

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"I'm responsible, and our coaches are responsible, for these kids' safety," McDonnell says. "If we don't take care of this, it could be the end of football."

The NFL is paying attention. The pro football league, GE and the sports clothing firm Under Armour have together funded Swartz's work with a $500,000 grant.

Nineteen of the 20 researchers given similar grants to tackle the concussion problem are making things like stronger helmets, softer turf and better concussion diagnostics. Only Swartz is trying to change basic human behavior. He thinks his approach could work.

"If you look on the sidelines, let's say, after there's a touchdown in football, oftentimes the players will head-butt themselves to celebrate," Swartz points out. "They probably wouldn't do that if they didn't have a helmet on."

The Wildcats research will continue into next year, when Swartz says he also plans to expand the study into three high schools.

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U.Va. Looks At Ways To Curb Drinking At Its Frat Houses

NPR Health Blog - Thu, 12/11/2014 - 4:30pm
U.Va. Looks At Ways To Curb Drinking At Its Frat Houses December 11, 2014 4:30 PM ET Listen to the Story 4 min 2 sec  

The University of Virginia is trying to crack down on excessive and underage drinking at fraternities.

Jay Paul/Getty Images

The University of Virginia is renegotiating its contract with fraternities, which were suspended after a Rolling Stone article described a frat house gang rape. Even though that article has been called into question, U.Va. is sticking with its vow to make changes — and that includes President Teresa Sullivan's plan to crack down on excessive and underage drinking at frat houses.

But the way to do that may not be easy.

There are dry fraternities, but that idea was quickly dismissed. Tommy Reid, head of U.Va.'s Inter-Fraternity Council, told the Board of Visitors, the school's governing body, it would simply drive drinking parties underground.

"Then they're going to happen in parking lots and random places. This is a problem that is not going to be solved by simply eliminating it. It's a problem of regulation and control," Reid says.

So how do you regulate something illegal? Sullivan suggests one place to start: those big garbage cans full of hard liquor brew.

"Even an alert and careful student who tries the sweet-tasting cocktail that has many types of liquor cannot know how much alcohol it contains," Sullivan says.

A new ad hoc group that includes parents is looking at fraternities and drinking. Group member Ashley Brown, a fourth-year student, wants to designate frat brothers to stay sober and self-police during parties.

"Having one stationed at the stairs, one up in the bedrooms, one by the bar ... because you're so much more likely to go talk to someone that looks like your peer than someone that looks like your parent," Brown says.

“ It's almost like you're playing chess. You've got to think: I make this move, the alcohol culture will respond. What's my next move?

"One of the challenges I've seen in trying to implement programs like that is, no one wants to volunteer to be the sober person," says Toben Nelson, a public health expert at the University of Minnesota. Nelson recommends fraternities use professional bar servers, even though they are costly. Professionals are more likely to ask for IDs and not serve someone who's already drunk.

Over the years, Nelson has seen a lot of schools try to curb binge drinking — usually without much success. "What they want to do is educate students about the dangers of drinking and just, if you tell them enough times with enough seriousness, that students will get the message," Nelson says.

Unfortunately, he says, they don't. What works is enforcement. But surveys show fewer than half of schools enforce their own alcohol policies.

Staige Davis, a recent U.Va. graduate, says she thinks even when the school has punished fraternities — like last year, when a string of pledges landed in the hospital for drinking too much — it wasn't harsh enough.

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"What I would like to see is a culture in which one fraternity brother says to the other, 'Dude, don't do that. One, because it's wrong. But two, because we're all going get in trouble,' " Davis says.

"Well-intentioned efforts sometimes can backfire," says Peter Lake, director of the Center for Excellence in Higher Education Law and Policy. He's seen frats be shut down only to go off campus and become wilder than ever.

"It's almost like you're playing chess. You've got to think: I make this move, the alcohol culture will respond. What's my next move," he says.

But Lake says it is possible to curb drinking if you change not just fraternities but the whole campus environment. One of the most effective policies: raising the price of a drink. No more 2-for-1 specials at local bars.

Another is to impose higher taxes on alcohol — something Virginia already has. Nelson says there's a good argument for this.

"The amount of tax revenue that's collected doesn't even come close to the social costs that those governments incur from the social problems related to alcohol — enforcement, health-related costs, transports to hospitals," Nelson says. Poor academic performance is also associated with excessive drinking, he says, which means some students are wasting a publicly funded education.

Taxpayers bear that burden, he says, which means we all have a stake in getting college students to drink less.

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Unexpected Joint Pain Seen In Test Of Experimental Ebola Vaccine

NPR Health Blog - Thu, 12/11/2014 - 3:59pm
Unexpected Joint Pain Seen In Test Of Experimental Ebola Vaccine December 11, 2014 3:59 PM ET

A shipment of experimental Ebola vaccine is opened at a hospital in Geneva.

Mathilde Missioneiro/AP

Two potential Ebola vaccines are currently being tested in people, to see if they're safe and to figure out the best dose.

Both trials have encountered some of the typical travails of vaccine research.

One vaccine, which uses a modified chimpanzee virus, was associated with some mild fevers at its highest dose. And today, the University Hospitals of Geneva said that four healthy volunteers receiving a second potential vaccine, called VSV-ZEBOV, had experienced unexpected joint pain.

The hospital has already given the vaccine to 59 people, and was about to inject another 15. But researchers there decided to hold off on those next 15 people for a week or so, while they pause to take a closer look at the people who experienced mild pain in their hands and feet. All told, the Geneva hospital plans to inoculate 115 volunteers.

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Despite this side effect, "Initial results show that the vaccination is very well tolerated," the hospital said in a statement.

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The hospital says joint pain is a common side effect of vaccines, but it had not listed this as a potential side effect for this particular study. The hospital says it will update its list of potential side effects before proceeding.

The vaccine was developed by the Canadian government and then licensed to a small U.S. biotech company called NewLink Genetics, which teamed up with pharmaceutical giant Merck for testing, manufacturing and distribution. Merck told NPR that the vaccine will continue to be tested at other sites using lower doses.

Three major manufacturers have been pursuing Ebola vaccines, and the World Health Organization says Russia has something in the works as well. In the best of circumstances, it will take many months of study to figure out whether the vaccine is safe and effective. But assuming one or more of these vaccines can protect people from Ebola, GAVI the Vaccine Alliance, says it's ready to commit $300 million to buy vaccines for Africa.

GAVI is a public-private partnership that includes U.N. agencies, the World Bank, foundations and private companies. "Up to an additional $ 90 million could be used to support countries to introduce the vaccines and to rebuild devastated health systems and restore immunisation services for all vaccines in Ebola-affected countries," Gavi said in a statement.

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Wellness At Work Often Comes With Strings Attached

NPR Health Blog - Thu, 12/11/2014 - 2:54pm
Wellness At Work Often Comes With Strings Attached December 11, 2014 2:54 PM ET

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If you get health insurance at work, chances are you have some sort of wellness plan, too. But so far there's no real evidence as to whether these plans actually improve the health of employees.

One thing we do know is that wellness is particularly popular with employers right now, as they seek ways to slow the rise of health spending. These initiatives can range from urging workers to use the stairs to requiring comprehensive health screenings.

The 2014 survey of employers by the Kaiser Family Foundation found that 98 percent of large employers and 73 percent of smaller employers offer at least one wellness program. (Kaiser Health News is an editorially independent program of the foundation.)

What makes wellness so popular with companies?

"It really is part of their strategy to help employees be healthy, productive, and engaged," says Maria Ghazal, vice president and counsel at the Business Roundtable, whose members are CEOs of large firms. "And it's really part of their strategy to be successful companies."

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And there's another reason wellness has gotten so pervasive, said health consultant Al Lewis. Workplace wellness is a big industry unto itself.

"It's somewhere between $6 [billion] and $10 billion, which creates an awful lot of people saying, 'Do more of this stuff,' " he says.

Lewis has become something of a crusader against the spread of wellness around the nation. (He's co-author of an e-book detailing its failings.) Among the many problems with wellness plans, he says, is that a lot of them aren't so innocent.

"We call them pry, poke, prod and punish programs," he says. That refers to programs that ask intrusive questions like how much alcohol a person consumes and whether a woman is planning to become pregnant. They might also require significant medical interventions or tests, such as comprehensive blood assays. The plans urge employees to participate and punish them if they don't.

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Under federal rules, wellness programs must be voluntary. But more than a third of large companies now use financial incentives, which include both rewards and penalties for those who don't participate, according to the Kaiser Family Foundation survey.

For example, at Penn State University last year, officials were forced to backtrack on a plan that would have required professors and other nonunion workers — and their spouses — to undergo comprehensive health screenings every year, including measurements of cholesterol, blood sugar and body mass.

Those who declined would be charged an extra $100 a month for insurance. Employees rebelled, and the university didn't implement the fines.

Ironically, says Lewis, for all the money some wellness plans spend to screen thousands of people, most companies don't actually have that much health spending that could be saved by wellness.

"In a company with 10,000 workers," he says, "they might have had 10 heart attacks, of which one may have been theoretically preventable with a wellness program." That's a big reason why most independent studies have found little or no cost savings.

When there have been savings, health economists Aaron Carroll and Austin Frakt wrote for The Upshot, part of The New York Times, they tend not to have come from improving workers' health. "Wellness programs can achieve cost-savings — for employers — by shifting higher costs of care to workers," they wrote. In other words, if people don't participate or don't meet the wellness goals, they pay more for health coverage.

Some programs can even do harm, says Lewis. For example, false positive results from screening low-risk people end up causing workers anxiety and their health plans still more money. Lewis is quick to add that screening tests recommended by the U.S. Preventive Services Task Force are appropriate, but their guidelines "are routinely ignored by corporate wellness programs."

But not everyone outside the wellness industry is quite so pessimistic. Harvard health economist Kate Baicker is the lead author of a 2010 study that found some potential savings. "It could be that when all the full set of evidence comes in it will have huge returns on investment, and the billions we're spending on it are completely warranted," Baicker says. But for now, "there are very few studies that have reliable data on both the costs and the benefits."

Meanwhile, the federal government is divided on how to regulate this area. The Affordable Care Act embraces the wellness concept. It lets employers link up to 30 percent of premiums to participation in wellness activities — and up to 50 percent if those activities involve quitting tobacco.

But the independent Equal Employment Opportunity Commission is suing several companies, including Honeywell, with its more than 130,000 workers. It says their programs discriminate against those with disabilities.

The idea of having to follow more than one set of rules is frustrating employers. "We want to be certain that following the Affordable Care Act is what we're supposed to be doing, and there shouldn't be additional requirements beyond the ACA," said Ghazal of the Business Roundtable.

The CEOs are so upset about the wellness lawsuits they're reportedly threatening to pull their support for the health law entirely unless things are clarified.

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Does Snoring Leave Tots More Vulnerable To Childhood Obesity?

NPR Health Blog - Thu, 12/11/2014 - 10:54am
Does Snoring Leave Tots More Vulnerable To Childhood Obesity? December 11, 201410:54 AM ET Alison Bruzek

A solid night's sleep does more than recharge a growing brain — it may also help keep a growing body lean.

Breathing problems or a chronic lack of sleep early in life may double the risk that a child will be obese by age 15, according to research published Thursday in The Journal of Pediatrics.

Childhood obesity has been linked before with the number of hours a kid sleeps each night. But other early problems with nighttime breathing — like snoring, or the more serious sleep apnea — also seem to be predictive of significant weight gain among children, according to the research.

It's the first study to look at both sleep duration and breathing problems as separate risk factors for obesity, says Karen Bonuck, professor of family and social medicine at the Albert Einstein College of Medicine of Yeshiva University and lead author.

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"Sleep problems need to be thought of as a composite," she tells Shots. "It's not just sleep duration, sleep hygiene, sleep-disordered breathing. We need to think about healthy sleep overall, and we need to think about it early."

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To examine sleep habits and how they might predict a child's body mass index, Bonuck and her colleagues used the Avon Longitudinal Study of Parents and Children, which tracked 1,900 children in England for 15 years.

The mothers surveyed were asked how long their children typically slept at ages 18 months, 2.5 years, about 5 years, 6 years and 7 years. They also reported any sleeping problems like snoring, apnea or mouth breathing between the ages of 6 months and about 7 years old. Finally, the survey collected the height and weight of the children at ages 7 years, 10 years and 15 years.

They found that children who had multiple sleeping problems were twice as likely to be obese by age 7, 10 or 15 years, compared with those who had no problems. At age 15, 9.7 percent of teens with no sleep problems were obese, compared with 18.3 percent of those with multiple sleep problems.

In addition, children who slept less than 10 hours per night at ages 5 and 6 years were more likely to be obese at age 15.

While the study could only confirm an association, not causality, it makes sense that children who don't get enough solid sleep are tired, and may eat more, sleep scientists say. "Some of this actually might be related to certain hormones that regulate appetite," says Dr. Rakesh Bhattacharjee, a pediatric sleep medicine specialist at the University of Chicago Medicine Comer Children's Hospital.

Another theory holds that poor sleep quality or short duration may cause stress on the body that leads to inflammation.

Though many questions about sleep's effects and mechanisms remain, all agree it's important, especially in growing children, Bonuck says. Newborns should get around 16 to 18 hours per day, according to the Centers for Disease Control and Prevention, and preschoolers 11 to 12 hours.

Parents should look for early signals, Bonuck says. Noisy or halted breathing at night could mean something serious is amiss. "Watch your child," she says. "Does she or he snore more than three times a week?"

The American Academy of Pediatrics recommends that all children who snore regularly be screened for sleep apnea — partly because it's easier to prevent childhood obesity than to treat it. "As Benjamin Franklin once said, 'An ounce of prevention is worth a pound of cure,' " Bonuck says. "Pun intended."

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