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Industry Payments To Doctors Are Ingrained, Federal Data Show

7 hours 39 min ago

Few days went by last year when New Hampshire nephrologist Ana Stankovic didn't receive a payment from a drug company.

All told, 29 different pharmaceutical companies paid her $594,363 in 2014, mostly for promotional speaking and consulting, but also for travel expenses and meals, according to data released Tuesday detailing payments by drug and device companies to U.S. doctors and teaching hospitals. (You can search for your doctor on ProPublica's updated Dollars for Docs interactive database.)

Stankovic's earnings were certainly high, ranking her about 250th among 606,000 doctors who received payments nationwide last year. What was more remarkable, though, was that she received payments on 242 different days —nearly every workday of last year.

Additional Information: Web Resources Check Dollars For Docs to see if you doctor received money.

Reached by telephone Tuesday, Stankovic declined to comment. On her LinkedIn page, Stankovic lists herself as vice chief of staff at Parkland Medical Center HCA Inc. in Derry, N.H., and as medical director of peritoneal dialysis at DaVita Inc., also in Derry.

That doctors receive big money from the pharmaceutical industry is no surprise. The latest data released by the Centers for Medicare and Medicaid Services shows that such interactions are widespread, with not only doctors, but thousands of dentists, optometrists, podiatrists and chiropractors receiving at least one industry payment from August 2013 to December 2014.

What is being seen for the first time now is how ingrained pharmaceutical companies and their sales reps are in the lives of those who write prescriptions for their products. A ProPublica analysis found that 768 doctors received payments on more than half of the days in 2014. More than 14,600 doctors received payments on at least 100 days in 2014.

Take Juichih Hsu, a Maryland doctor whose specialty is family medicine. She received payments on 286 days of 365, more than anyone else. Sometimes, she received meals from several drug companies on the same day. Hsu's payments totaled $5,959. She declined to comment when reached on Tuesday.

"There are physician practices which have very deep relationships with pharmaceutical representatives, where they are a very integral part of the practice," said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who has written about industry relationships with doctors. "Every day it's another drug company coming in for a lunch. Sometimes it may be some drug companies are bringing breakfast and some are bringing lunch and it's just part of the culture of the practice."

Sometimes there may be more at work than that.

The doctor with the second-highest number of interactions with drug and device reps, John Fritz, of Jersey City, N.J., logged payments on 256 days last year. His payments totaled $232,003. Fritz was indicted in June for referring patients to a medical imaging company from 2006 to 2013 in exchange for about $500,000 in kickbacks.

The drugs for which Stankovic received the most money to promote are costly. One, H.P. Acthar Gel, cost an average of nearly $39,000 a prescription, Medicare data from 2013 shows, and experts say there's little evidence it works better than less expensive drugs. Another drug, Soliris, for which Stankovic received promotional payments is among the most expensive drugs in the world but is considered highly effective in treating serious kidney disease.

ProPublica's analysis turned up big differences in the number of industry interactions among physicians in different specialties. On average, doctors who received payments interacted with drug and device companies on 14 days last year, receiving an average of $186 in total.

The nation's 3,900 rheumatologists in the data averaged 40 days of interactions with drug and device companies, more than doctors in any other large specialty. They were followed closely by endocrinologists, electrophysiologists and interventional cardiologists. On the other end of the spectrum, dentists, chiropractors, neonatologists and pathologists had among the fewest interactions with drug and device makers.

A spokeswoman for the pharmaceutical industry said in a statement that company interactions with doctors are important. "Collaboration between physicians and biopharmaceutical professionals is critical to improving the health and quality of life of patients," the statement from the Pharmaceutical Research and Manufacturers of America said.

ProPublica has been tracking industry payments to doctors since 2010. Our Dollars for Docs interactive database allowed people to search payments made by 17 companies between 2009 and 2013. Most of those companies were required to report their payments as a condition of legal settlements with the federal government.

The data released Tuesday radically expands the amount of data available to patients. ProPublica has overhauled Dollars for Docs to include these payments. The Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act, mandated that all drug and device companies publicly report payments to doctors. The transparency effort is called Open Payments.

The government initially released some data last fall, covering the period of August to December 2013, but it was significantly redacted because of data inconsistencies. The data released Tuesday covers the period of August 2013 to December 2014. The data inconsistencies have been resolved.

All told, 1,617 companies reported 15.7 million payments valued at $9.9 billion. Nearly all of those payments — 14.9 million — were classified as "general payments," covering promotional speaking, consulting, meals, travel and royalties. They totaled $3.5 billion over the 17-month period.

There were far fewer research payments, 826,000, but they were valued at $4.8 billion. The remaining payments related to ownership or investment interests that doctors had in companies. Research and ownership payments are currently not shown in Dollars for Docs.

Open Payments does not include money spent on drug samples left at doctors' offices and doesn't include the bulk of the money companies spend on independently administered continuing medical education, which they support with unrestricted grants. The government has tightened the rules for reporting such continuing education in the future.

ProPublica news application developers Mike Tigas and Lena Groeger and senior reporting fellow Annie Waldman contributed to this report.

Check Dollars for Docs to see whether your doctor has received payments from drug or medical device companies. Email us at and tell us what you find.

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How Your Brain Remembers Where You Parked The Car

7 hours 47 min ago
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If you run into an old friend at the train station, your brain will probably form a memory of the experience. And that memory will forever link the person you saw with the place where you saw them.

For the first time, researchers have been able to see that sort of link being created in people's brains, according to a study published Wednesday in the journal Neuron. The process involves neurons in one area of the brain that change their behavior as soon as someone associates a particular person with a specific place.

"This type of study helps us understand the neural code that serves memory," says Itzhak Fried, an author of the paper and head of the Cognitive Neurophysiology Laboratory at UCLA. It also could help explain how diseases like Alzheimer's make it harder for people to form new memories, Fried says.

The research is an extension of work that began more than a decade ago. That's when scientists discovered special neurons in the medial temporal lobe that respond only to a specific place, or a particular person, like the actress Jennifer Aniston.

The experiment used a fake photo of actor Clint Eastwood and Pisa's leaning tower to test how the brain links person and place.

Courtesy of Matias Ison/Neuron

More recently, researchers realized that some of these special neurons would respond to two people, but only if the people were connected somehow. For example, "a neuron that was responding to Jennifer Aniston was also responding to pictures of Lisa Kudrow," [another actress on the TV series Friends], says Matias Ison of the University of Leicester in the U.K.

The two actresses were often on screen together. So it made sense that the brain would create a link between them. And Ison thought those special neurons in the medial temporal lobe might be that link.

To find out, he and a team of researchers did an experiment involving 14 epilepsy patients who had electrodes temporarily implanted in their brains to identify the source of their seizures. The patients agreed to let researchers use the electrodes to monitor individual brain cells in the medial temporal lobe of their brains.

First, the team identified neurons that responded to pictures of a specific person, like Jennifer Aniston or Clint Eastwood. Then they identified different neurons that responded to pictures of a particular place, like the Eiffel Tower or the Leaning Tower of Pisa.

The next step was to get the patients' brains to form a new association between a person and a place. The team did that by showing them fake images of Jennifer Aniston at the Eiffel Tower or Clint Eastwood at the Leaning Tower of Pisa.

When people saw these fake images, it was like running into an old friend at the train station. The experience created a new memory linking the person and the place.

And that caused neurons in the medial temporal lobe to change their behavior, Fried says.

"When the association is created, suddenly the cell very rapidly changes its firing properties," he says. For example, a cell that had responded only to pictures of Clint Eastwood would start responding in a similar way to pictures of the Leaning Tower of Pisa.

This sort of change to individual cells could help explain how the brain creates memories of experiences, which may involve not only people and places, but emotions and sensations and lots of other information, Fried says. And when we recall an experience, these special neurons may help us re-assemble all the relevant information, he says.

Shots - Health News Bursts Of Light Create Memories, Then Take Them Away

The study may also help explain what's going wrong in the medial temporal lobe of people who have trouble forming new memories, Fried says. "We know in situations like Alzheimer's, one of the very first changes you see is in this very area," he says.

And if Alzheimer's affects the same neurons that make associations, it would explain why people with Alzheimer's can't remember things like where they parked their car, Fried says.

"I have to create an association between my car and the particular place," he says. "If an association is not created, then I will not be able to find my car."

The study also backs the idea that memories can be formed very quickly, says Michael J. Kahana, a professor of psychology at the University of Pennsylvania who was not involved in the research.

"Even a single brief exposure to any information changes the human brain," he says.

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Antipsychotics Too Often Prescribed For Aggression In Children

10 hours 17 min ago

Powerful antipsychotic medications are being used to treat children and teenagers with ADHD, aggression and behavior problems, a study finds, even though safer treatments are available and should be used first.

"There's been concern that these medications have been overused, particularly in young children," says Mark Olfson, a professor of psychiatry at Columbia University who led the study. It was published Wednesday in JAMA Psychiatry. "Guidelines and clinical wisdom suggest that you really should be using a high degree of caution and only using them when other treatments have failed, as a last resort."

Olfson and his colleagues looked at prescription data from about 60 percent of the retail pharmacies in the United States in 2006, 2008 and 2010. That included almost 852,000 children, teenagers and young adults. Teens were most likely to be prescribed antipsychotics, with 1.19 percent getting the drugs in 2010, compared to 0.11 percent in younger children. Boys were more likely to be given the medications.

Antipsychotic medications like clozapine and olanzapine are used to treat schizophrenia, bipolar disorder and some symptoms of autism. They have not been approved by the Food and Drug Administration to treat aggression and ADHD, but are prescribed off label to reduce disruptive behavior.

FDA Debates Safety Of Antipsychotic Drugs In Kids

Use of antipsychotics in children has been questioned because the drugs can have serious side effects, including tremors, weight gain, increased diabetes risk and elevated cholesterol.

This study, which may be the broadest look yet at use of antipsychotics in children, found that most children had not been diagnosed with a mental disorder before being given antipsychotics.

ADHD was the most common diagnosis, applied to 52.5 percent of young children, 60 percent of older children, and 34.9 percent of teenagers diagnosed with ADHD. Depression was the most common diagnosis in young adults, with 34.5 percent. The researchers determined that by looking at inpatient and outpatient claims for a smaller subset of patients in 2009.

"About half of the kids with ADHD have aggression and have disruptive behaviors," Olfson says. "They can be difficult to control." The medications do reduce aggression, Olfson says, but that can also be achieved with behavioral programs such as teaching problem solving skills.

"Behavior modification and family treatment is something that should always some first, but less than one quarter of children and teens are getting that," says Christof Correll, a professor of psychiatry at Hofstra North Shore-Long Island Jewish School of Medicine. He wrote an editorial accompanying the study.

Shots - Health News Risks Run High When Antipsychotics Are Prescribed For Dementia

"Physicians use these medications too fast," Correll says. There are a lot of reasons for that, he says, including a shortage of psychotherapists, the amount of time required for family therapy and lack of insurance coverage. As a result, many parents don't seek help until a child is in serious trouble, perhaps about to be expelled or land in juvenile detention.

Only a minority of children had seen a child or adolescent psychiatrist before being treated, the study found.

Earlier studies have found that giving families training on how to deal with aggression can reduce disruptive behavior. Appropriate dosing with stimulant medications like Ritalin also can help.

"It is complicated, and that's why it's hard to fault families or clinicians," Correll adds. Behavior problems can have interfere with a child's education, social interactions and development, he notes, so parents shouldn't delay seeking help. "They should try to get guidance counselor involvement at school, and not dismiss it until it's too late."

Seeking out a psychiatrist or other specialist can not only help find appropriate treatments, but can speed up referrals to therapists, Correll says.

The study, which was funded by the National Institute of Mental Health, involved researchers at Columbia University, Yale and NIMH.

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Buy A Meth House Unawares And Pay The Health Consequences

19 hours 13 min ago
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Donetta Held unloads needles and pipes confiscated from a contaminated meth home. She owns an environmental decontamination company and says meth tests are their most demanded service.

Barbara Brosher/WFIU

Jennifer Nugent and her three kids are throwing a big, blue ball around in the small living room of their rental home.

The kids are happy, but Nugent isn't. She planned to raise them in a place with much more room to play.

And she was. That is, until she learned that home was uninhabitable.

Two years ago, she and her husband bought a country home in the small central Indiana town of Mooresville.

"It was blue and it had a lot of potential for us to add on," she says. "We really, really wanted that house."

But shortly after the Nugent family moved in, their dream home became a nightmare.

Jennifer Nugent, who discovered the house she bought in Mooresville, Ind., had been used as a meth lab, wants the state to require methamphetamine tests on all houses for sale.

Barbara Brosher/WFIU

The kids were constantly sick and struggling to sleep. The Nugents puzzled over their children's health problems until a neighbor mentioned that the previous homeowner referred to the bathroom as his "smoke shop."

That's when Nugent paid $50 for a methamphetamine test. The first test revealed meth levels three times the legal limit. When meth is smoked, dangerous chemicals are released into the air that can cling to clothing, carpets and walls.

State police here have busted more than 11,000 meth labs since 2007. Indiana leads the nation in the number of meth lab seizures, causing hundreds of homes to be contaminated with dangerous chemicals each year.

Contaminated houses are listed on the state's public online database and properties are removed from the list only after they've been cleaned by a qualified inspector. The Drug Enforcement Administration keeps a national registry that logs the locations of known contaminated homes as reported by law enforcement.

Lori Endris, who heads a drug testing lab for the state of Indiana, says that doesn't mean people can still end up living in a contaminated house without realizing it.

"If you look at the numbers of properties versus the numbers that have been properly cleared by a qualified inspector, you're talking an [8,000-] to 9,000-house difference and I don't believe that all of those are sitting empty," she says.

A recently passed state law aims to protect homebuyers from unknowingly buying homes contaminated by meth.

Just like checking a box to indicate if there's lead or asbestos on a property, homeowners must disclose whether meth was manufactured there. Just over half of states have similar disclosure laws.

But, of course, they depend on the seller's honesty.

"I field a lot of calls from Realtors wanting to know if a property has been cleaned or cleared because people aren't wanting to tell the truth," Endris adds.

Indiana-based Crisis Cleaning has a special team that works solely on decontaminating meth homes.

Meth tests are the company's most in-demand service, according to Donetta Held, the firm's owner.

Additional Information: Shots - Health News Indiana's HIV Outbreak Leads To Reversal On Needle Exchanges Around the Nation Drug-Sniffing Dogs Ease Parents' Minds — Or Confirm Their Fears

"We'll do a floor, a ceiling and two walls. And we'll take a pre-wetted alcohol wipe and we'll wipe within that square, put that in the jar. We label that 'came from the kitchen' and we do that in each room and we overnight that to the lab," she says. "They analyze how much meth, if any, is in that."

It can cost tens of thousands of dollars to decontaminate a property.

That means some people just don't bother, leaving behind dozens of toxic chemicals that can contribute to lasting health problems.

Short term health risks include headache, nausea, and eye irritation. Long-term effects are unclear, but children are particularly vulnerable. That's why Nugent wants Indiana to strengthen its laws.

In her case, she says the previous homeowner didn't disclose that meth was in the home.

"You're relying on a criminal to disclose his criminal acts to a buyer and lose the sale," she says. "So I don't think that's enough."

Nugent wants the state to require homeowners or real estate agents to have methamphetamine tests performed on all listed properties.

Even after having it decontaminated, the Nugent family decided to sell their dream house. As a result, they took a significant financial loss.

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Benefits Of Sports To A Child's Mind And Heart All Part Of The Game

19 hours 15 min ago
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Ten-year-old Jake Herrera and his Los Angeles team run around the diamond as a warmup for baseball practice.

Benjamin B. Morris for NPR

Amy Roegler and her husband, Octavio Herrera, live with their young kids, Jake and Alyssa, in Los Angeles. When it comes to pro baseball, they're all Dodgers fans. And Jake loved balls even as a baby, Octavio says.

"We have a picture of him as a 3-month-old with a little Dodger jersey and a glove," Octavio says. "So he was definitely going to be introduced to sports early, and he took to it right away." Today 10-year-old Jake is on his baseball league's All-Star team.

Meanwhile his sister, 8-year-old Alyssa, has a passion for gymnastics. She, too, was a natural, her parents say — swinging on the monkey bars at age 2 and practicing splits on a balance beam today.

The parents know that the physical exercise their kids are getting is good for their health. But that's not their only motivation for encouraging the children to participate in organized athletics.

"When you do sports as a kid," Roegler says, "you learn how to win and how to lose. You learn what it's like to put in lots of work and have things not turn out terrifically. And you learn what it feels like to put in a lot of work — and then win.

Jake Herrera says he likes to get to the field early to help with the equipment and get in a little extra batting practice.

Benjamin B. Morris for NPR

"I think you can't teach those lessons," she says. "You have to experience them."

The majority of parents in NPR's recent poll on the role of sports and health in America seem to agree. The poll, done in conjunction with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, finds that the majority of adults say they played sports when they were younger.

Moreover, 76 percent of adults who have children in high school or middle school today say they encourage their children to play sports. Engaging in sports isn't just an important physical and social activity, these parents say. It also builds skills that can make a difference later.

Eight-year-old Alyssa Herrera competes in gymnastics.

Courtesy of Greeno Photography

"Parents think that the organized way you participate in sports — the leadership and fellowship — is actually preparing people not only for the next game but for much broader roles in life," says Harvard professor and health policy analyst Robert Blendon, who co-directed our poll.

Like the Herreras, the parents in our poll talk about sports teaching their children about discipline, dedication and how to get along with others — all skills to help in future schooling and beyond.

Octavio Herrera also played baseball when he was Jake's age, and well remembers how it felt.

"Nerves in your stomach, right?" he says. "Butterflies. I remember that as a kid, pitching in a game — 10 years old — so nervous and so scared."

It may be uncomfortable at the time, he says, but "that's great to have in a situation where the stakes are really low — where, if you fail you're still going to get pizza and ice cream, and your parents are still going to tell you they love you."

If kids can learn to fight their fear and work through it, he says, that steadiness comes in handy later in life — when the stakes are much higher. It's an ability Octavio says he relies on routinely, as a software entrepreneur who has created, bought and sold a number of companies.

Shots - Health News Take A Swing At This: Golf Is Exercise, Cart Or No Cart

Octavio also stresses the value of learning to be part of a team — both in childhood and now, at the office.

"It's just like that baseball team when we were little kids," he says. "Not all the kids were great hitters, or could pitch. But everyone could contribute." His business works the same way, he says.

"I can't do everything. My partner can't do everything. We hire people who are good at what they do — we put together a team, come up with an idea, execute. It takes teamwork — just as winning a baseball game does."

Amy Roegler played soccer in high school and college and says team sports aren't just about winning, but also about developing a solid work ethic, and learning why that's important.

"I was the captain in high school," she explains, "and then my first year playing college soccer, I was on the bench."

No problem," she says. "I belonged on the bench — many teammates were incredible." It motivated her to want to earn a starting position, she says.

Jake's very proud of his All-Star jacket, says his mom, Amy Roegler. She played soccer in high school and college, and says team sports aren't just about winning. Players also develop a strong work ethic, she says, and learn why that's important.

Benjamin B. Morris for NPR

Andy Driska is a Michigan State University researcher with the Institute for the Study of Youth Sports. He says parents are right when they cite life skills — like discipline, commitment and physical confidence — that can develop naturally when kids play sports.

In a recent study that's not yet published, Driska and his colleagues looked at an intense two-week wrestling camp, measuring feelings and attitudes of 89 teens before the camp experience and after.

As expected, the players' confidence increased — it was a tough camp to get through, Driska says. But what surprised him, he says, was how much feelings of hopefulness among the young people also increased.

Profoundly so, he says. One teenage boy, for example, told Driska the camp changed the way he interacted with his mom, helping to quell the bitter arguments they always seemed to fall into.

"He said that he sat down — talked it out, resolved the situation," Driska says. The teen told Driska that "before camp he would not have done that — been pro-active in seeking a solution. He simply would have walked away and just been bitter or complained about it."

Playing catcher, Jake makes a play at home base during a practice at the Bad News Bears Field in Los Angeles.

Benjamin B. Morris for NPR

In just a brief sports experience at camp, that teen and many of the others developed a "can do" life strategy that seemed to translate to other aspects of their lives, Driska says.

And that change persisted. Nine months after the camp ended, Driska notes, the teens in his study maintained their bolstered sense of confidence — and hope.

Our Sports and Health series continues over the summer, based on the results of our poll with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

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Caveats About Favored Access Method For Dialysis

Tue, 06/30/2015 - 3:34pm

What's the best way to connect patients to dialysis machines?


When it comes to dialysis, one method of accessing the blood to clean it gets championed above the rest. But quite a few specialists say there's not enough evidence to universally support the treatment's superiority or to run down the other options.

"When we talk to [dialysis] patients in the clinic, we cannot address their profound question: 'Which access is better for me?' " says Dr. Pietro Ravani, an epidemiologist at the University of Calgary in Canada. "We just don't know, yet we are selling patients on a certain one."

Ravani is talking about guidelines that encourage doctors to pursue connections for dialysis known as arteriovenous fistulas. Research says hemodialysis patients with fistulas have a reduced risk of death, blood clots and infections compared with other access methods.

Shots - Health News Most Dialysis Patients Aren't Receiving The Best Treatment

The connections require surgeons to stitch together an artery and vein, usually in the arm, to create a sturdier vein with greater blood flow. Patients are then pricked at the site of the fistula during each visit to connect to the blood-cleaning hemodialysis machine.

About 450,000 people in the U.S. are on dialysis.

Studies, like this one that was published in May, have shown patients with the fistulas had a lower risk of death (about a third less) when they start dialysis with fistulas rather than catheter connections.

But Ravani says not so fast. "The literature that is available and used to promote fistulas is biased," he says, adding there is no way catheters, an alternative to fistulas, are as deadly as some others have concluded.

Catheters are small plastic tubes, usually placed in a vein along the neck, chest, leg or groin, that can also be conduits for infection. Catheters are the go-to method for access to the blood when the kidneys suddenly fail and patients crash into dialysis, requiring emergency hospitalization and treatment. Fistulas can't be used for one to three months after an operation. Catheters can be used immediately.

Studies comparing these two access types and their mortality rates have only been observational, Ravani argues. That means researchers have looked at what happens to patients after doctors decided on their own how to treat patients. A randomized controlled trial that assigns patients to one treatment or the other and then collects information on what happens to them is necessary to ultimately prove the superiority of one method over another, Ravani says.

Patients with catheters, he explains, are usually pretty sick. But because it takes fistulas several months to develop before use, they are typically given to healthier patients who aren't in immediate need of dialysis.

"The very strong association between catheters and mortality could be related to how sick the patients were, not to the access type," Ravani says. "When you need to start dialysis urgently, it's because you're very sick so you use catheters, not fistulas. This makes it hard to determine if the poorer outcomes observed in patients with catheters are because of catheter or because they are already very sick."

For this same reason — serious illness — Ravani argues that patients with catheters succumb to infection more often than healthy patients with fistulas. If a healthy patient used a catheter, they wouldn't be as likely to contract an infection.

Nephrologist Swapnil Hiremath, at Ottawa Hospital in Canada, agrees that more research is needed to fully assess the value of fistulas. "The portrayal that fistulas are the ultimate access [for dialysis] and that if everyone has one, mortality rates will go down, is an exaggeration," Hiremath says. "You cannot go around blaming catheters; it's the nature of things that these patients are sicker and have a higher risk of death."

Hiremath adds that despite initiatives to increase the number of dialysis patients with fistulas, the treatment method is extremely difficult to provide to patients in the first place.

Roughly half of fistulas fail to mature, particularly in older individuals, and don't end up being used to access the blood, he says. Doctors then resort to catheters or another method to connect patients to dialysis machines. What's more, some 30 percent of patients completely reject the proposal of a fistula, despite explanations of their benefits.

And patients with fistulas can develop complications, such as heart failure, blood clots and swelling.

"To say that everyone who has a catheter should have a fistula, that's not easy," Hiremath says. "Doctors need to have an open mind, but unfortunately many people have already decided that fistulas are the best option."

Johns Hopkins University surgeon Dr. Mahmoud Malas, lead author of the recent paper on the advantages of fistulas, says Ravani's and Hiremath's criticism doesn't make sense to him.

Malas and his colleagues were behind an observational study showing patients starting dialysis with fistulas had lower risks of death. Despite the fact that he and his colleagues only reviewed existing numbers in the U.S. Renal Data System, Malas says they were able to minimize bias by matching the characteristics of patients with fistulas and catheters.

"If we saw a male patient with a catheter that was 40 years old who had diabetes and hypertension, we would find his exact match in a patient using a fistula," Malas explains. "Even with this matching analysis, you still see a much higher mortality rate for those on catheters."

"And our finding is not new, hundreds of prior studies have shown this difference," he adds.

Either way, Malas doubts a randomized trial could ever be carried out to truly compare those on fistulas and catheters. "Nobody would approve that trial," he says. "People will think it's unethical."

Ravani and Hiremath think differently. They are currently pursuing a randomized trial in Canada to tease out the differences between the two methods once and for all.

"For 40 years we have ignored this question with a randomized trial," Ravani says. "And until we have this answer, we cannot say fistulas are better."

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Branding Teen Drivers As Newbies Doesn't Prevent Crashes

Tue, 06/30/2015 - 12:31pm

Marking novice drivers' cars doesn't help reduce crash rates when it comes to learner's permit holders, study finds.


Nothing says "I'm a new driver" more than a fire-red label stuck to your license plate for all to see. That's what happens in New Jersey to anyone with a learner's permit under age 21. But identifying these newest drivers doesn't necessarily help reduce crash rates, research finds.

For young drivers holding a learner's permit, putting up the decal has no significant effect, a study published this week in the journal Injury Prevention suggests. On the other hand, the same researchers have found a substantial reduction in crashes when warning labels are required in the first months after a young person exchanges that beginner's permit for an actual driver's license.

Shots - Health News Teens Say They Change Clothes And Do Homework While Driving

New Jersey rolled out its decal mandate in May 2010 as part of the state's graduated driver licensing laws. These GDL laws, which are now in use in various ways in all 50 states and the District of Columbia, are designed to only gradually ramp up the rights and independence of teen drivers.

Here's how they work: New drivers have to be at least 16 to get a driving permit. Then they can only drive under adult supervision, typically for at least 50 hours. After earning an intermediate license when they can drive alone, teens face restrictions on nighttime driving, cellphone use and the number of peer passengers allowed in the car. These restrictions disappear with full-fledged licensure, usually 12 months after the intermediate stage or when the driver reaches the age of 18. And they are still required to follow state laws.

"GDL has been the cornerstone of public policy in reducing crashes [involving teen drivers]," Allison Curry, main author of the study, says. "One of the challenges with GDL is it's difficult for the police to identify learner drivers and intermediate drivers," Curry says.

­New Jersey's decal mandate is the first of its kind in the nation. The reasoning behind it is simple: The police can now easily identify teen drivers who are violating GDL restrictions, such as driving at night. And the hope is that the chance of being caught will make teens less likely to engage in wrongdoing.

Shots - Health News When Teen Drivers Multitask, They're Even Worse Than Adults

Curry, director of epidemiology and biostatistics at the Center for Injury Research and Prevention, Children's Hospital of Philadelphia, and her team looked at New Jersey's crash rates and GDL citations among drivers younger than 21 in the four years pre-decal and two years post-decal.

For drivers still in the baby stage of holding a learner's permit, the study showed decals didn't seem to be of much use. Curry attributes this lack of impact to parents and supervisors sitting in the car. Studies that observed what drivers were doing in their cars found that virtually all of the time, an adult sat next to the new driver, as they're supposed to. This is probably why the crash rate for newbie drivers is already very low, Curry says, and it leaves little room for the decals to make an impact.

But that's not the case for intermediate drivers on the road. For them, decals are saving lives. In a study published earlier this year, Curry's team found a significant 9.5 percent decrease in crash rates for that group two years after the mandate was enforced. That's an estimated 3,197 intermediate drivers prevented from crashing in two years, she says.

This all sounds promising, but could singling out teen drivers to all drivers sharing the road make them more rebellious and rash behind the wheels?

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"Fortunately, the research did not reveal an increase in citations, which is a potential side effect of concern from the perspective that teenage drivers should not necessarily be singled out," Bruce Simons-Morton, a behavioral scientist with the National Institutes of Health who researches adolescent driving, wrote to Shots in an email. He did not participate in the study.

One of the notions underlying GDL rules, Simons-Morton says, is that teens are best managed by their parents rather than police. Novice drivers are seldom stopped or cited for violation of GDL rules, he says, and decals appear not to increase citations.

No word yet whether other states are thinking of deploying this sort of decal system with learners' permits, but Curry notes there may be long-range benefits that didn't show up in their data.

Remember that the goal is to establish good driving habits early on, she says. "Today's learner drivers are tomorrow's intermediate drivers."

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Supreme Court Reprieve Lets 10 Texas Abortion Clinics Stay Open For Now

Tue, 06/30/2015 - 4:58am
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The U.S. Supreme Court gave a reprieve to Texas clinics that provide abortion services.

Mark Wilson/Getty Images

Tuesday would have been the last day of operation for 10 clinics in Texas that provide abortion services. But on Monday the U.S. Supreme Court, in one of its final actions of this session, said the clinics can remain open while clinic lawyers ask the court for a full review of a strict abortion law.

Two dozen states have passed regulations similar to the ones being fought over in Texas.

Shots - Health News Texas Abortion Case May Hinge On Definition Of 'Undue Burden'

Two years ago, when Texas passed one of the toughest laws in the country regarding abortion services, the number of clinics offering the procedure dropped from 41 to 19.

Amy Hagstrom Miller, chief executive of Whole Woman's Health, already had to close two clinics in Texas because of the law and was about to close two more. "Honestly, I just can't stop smiling," Hagstrom Miller says. "It's been so much up and down, so much uncertainty for my team and the women that we serve."

The Texas law says doctors who perform abortions must have admitting privileges at a nearby hospital. But some hospitals are reluctant to grant them because of religious reasons, or because abortion is so controversial.

The law also requires the clinics to meet the same standards as outpatient surgery centers. Those upgrades can cost $1 million or more.

"It's an example of the rash of laws that have passed throughout the country the past couple of years that have taken a sneaky approach by enacting regulations that pretend to be about health and safety but are actually designed to close down clinics," says Nancy Northrup, chief executive of the Center for Reproductive Rights, which is representing clinics in their fight to overturn the Texas law.

Supporters of the law say every woman deserves good medical care whatever the procedure.

Shots - Health News Court Decision On Texas Abortion Law Could Hasten Clinic Closures

"While we hope that she would not be compelled to choose abortion we hope that her life would of course not be at risk should she choose to do that," says Emily Horne of Texas Right to Life. "Pro-life does not just mean care for the life of the unborn child, it's care for the life of the woman undergoing the abortion as well."

The law has had a drastic effect in Texas, the country's second most populous state, leaving most of the remaining clinics in major cities.

There's just one clinic left along the Mexican border and one in far west El Paso. There were among the nine expected to shut down.

If they had closed, the women there faced round trips of 300 miles or more within Texas to get an abortion.

Hagstrom Miller says all these clinic rules and the doctor restrictions are a deliberate strategy waged by anti-abortion groups. "They're going state by state by state by state," she says. "They can't make it illegal so they're basically making it completely inaccessible."

Other states that have passed similar laws are also facing legal challenges.

Emily Horne, of Texas Right to Life, says her group would welcome a legal review by the Supreme Court. "With this case, issuing some more guidance on that could be very helpful for the pro-life movement in determining what courses to pursue, which laws they might pass in other states in the future," she says.

The clinics in Texas can stay open at least until the fall. If the court decides to take the case, it would hear arguments in its next term that starts in October.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

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Medical School Hopefuls Grapple With Overhauled Entrance Exam

Mon, 06/29/2015 - 3:50pm
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Travis Driscoll, a medical school applicant from Berkeley, Calif., studies for the revamped MCAT.

April Dembosky/KQED

It's T minus four days until exam day, and Travis Driscoll is practically living at his desk.

"Each day, I'm easily here for five hours," he says. "I haven't done much of anything else but studying for the last two months."

Driscoll is one of 13,000 medical school applicants across the U.S. taking the new Medical College Admissions Test, or MCAT. He's got stacks of science books on his desk to help him prepare and a rainbow of biochemistry charts pasted to the walls: glycolysis, citric acid cycle, electron transport chain, mitosis, meiosis and DNA replication.

He also has a thick prep book on psychology and sociology — new ground for this year's MCAT takers.

The test has been thoroughly revamped and is now three hours longer. It takes 7 1/2 hours to complete, including breaks, and covers four new subjects, including a combined section on psychology and sociology that account for a quarter of the overall score.

Shots - Health News A Top Medical School Revamps Requirements To Lure English Majors

Test takers will now have to define terms like "institutional racism" and "social constructionism," and answer applied questions about how race and class affect health.

Driscoll, who works in a San Francisco theater, focused on biomedical engineering in college. So for him, the new psychology/sociology section is the one he's most nervous about.

"It's at the end of the test, which makes it more difficult because you're pretty tired by then," he says. "And it's the thing I had the least experience with."

Bringing Test Up To Date

The Association of American Medical Colleges, which administers the MCAT, wants to make sure the doctors of tomorrow are better prepared to care for an increasingly diverse patient population in a rapidly changing health care system. Administrators say the exam changes are necessary to bring it up to date with how medicine is practiced, and with all the scientific discoveries that have been made since the test was last revised, more than 20 years ago.

Research on genetics and the social factors that affect health, in particular, have advanced significantly.

"Whether or not someone becomes ill has a lot to do with the society in which they live," says Catherine Lucey, vice dean of education at University of California, San Francisco School of Medicine and a member of the committee that will assess the new MCAT.

For example, she says, we now know a lot more about what happens to children who are exposed to violence before they turn 5.

"If they live in a violent neighborhood, if they hear gunshots all the time, if they themselves are the victims of interpersonal violence or child abuse," Lucey says, "they are much more likely to develop diabetes, high blood pressure, obesity, and many other chronic conditions, because of their social environment."

How those conditions are treated has also evolved. Doctors know how to treat acute infection now. But managing chronic disease has become a much bigger part of medical care, and doctors need to develop different skills and a different kind of relationship with the patient. Doctors need to build trust, Lucey says, to understand how patients think and make decisions, in order to convince them to exercise more and change their diet.

"My ability as a physician to affect that patient's health is not only dependent on medical knowledge, in terms of what drug should I give this individual, but on my ability to support this patient in the decisions they're making on a daily basis," she says.

Attracting A New Type Of Students

While the test prep industry adapted quickly to the new MCAT, enrollment in prep courses at the Princeton Review and Kaplan is only starting to pick up.

The real rush was last fall, when students flocked to take the old test, says Krissi Taylor Leslie, tutoring director at the Princeton Review in Northern California.

There was a recognition among students "that was my chance at the 'easier' test and now I'm up against this beast," Leslie says.

She says the new social sciences section is already attracting a different kind of student to consider med school.

"It entices certain students to come in and consider this test when they might not have otherwise," she says. "For instance, an increase in the number of English majors, of psychology majors."

And philosophy majors, like Ari Fischer. He started thinking about a career in medicine the summer after his junior year, when his grandfather was diagnosed with cancer.

"And that's when I was first shown, hands on, what physicians do every day," he says.

He started taking medical ethics classes — one was called "Life and Death" — where he read works about immortality, the meaning of death and the meaning of life in the face of death.

Fischer says he can imagine drawing on this knowledge one day if he has a patient facing tough end-of-life decisions.

"There's always a scientific view, then there's the theological views, or philosophical views. Knowing what other disciplines believe is going on at the same time, I think that could really help me in a daily practice of medicine," Fischer says. "What a cool way to take my degree in philosophy and turn it into a helpful, practical skill."

Fischer took the MCAT on the first testing date for the new exam in April, and just got his full score back on Tuesday. He did best on the social sciences section and the verbal, analytic reasoning. Overall, he landed in the 87th percentile.

"Perhaps Harvard will think I'm lacking in my MCAT score," he says. "For myself, I did well enough."

Altogether, he's applying to 38 schools. He says he's willing to go anywhere that will take a humanities major like him.

"All I've ever wanted out of the MCAT really is a score that's good enough to not get me kicked out of the pile when it comes to admissions decisions," he says. "Any school that gives me a shot, I'm going to be thrilled."

Copyright 2015 KQED Public Media. To see more, visit
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Supreme Court's Decision On Same-Sex Marriage Expected To Boost Health Coverage

Mon, 06/29/2015 - 11:16am

The crowd reacts as the ruling on same-sex marriage was announced outside of the Supreme Court in Washington, D.C., Friday.

Jacquelyn Martin/AP

The right to marry in any state won't be the only gain for gay couples from last week's Supreme Court ruling. The decision will likely boost health insurance among gay couples as same-sex spouses get access to employer plans.

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren't married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week's ruling, up from nine in 2012.

New York legalized gay marriage in 2011. The next year, there was a big increase in same-sex couples covered by employer-sponsored health insurance, according to a study published Friday by JAMA, a journal of the American Medical Association.

Although the court found a constitutional right to same-sex marriage, lawyers gave mixed messages on whether employers must now offer health insurance to same-sex spouses if they offer it to opposite-sex spouses.

Edward Fensholt, a benefits lawyer with brokers Lockton Companies, expects most companies to cover same-sex spouses if they already offer benefits to opposite-sex spouses. But the decision doesn't require them to, he said.

"Employers get confused about this," he said. "They'll see that ruling and they'll start to think they have to offer coverage to same-sex spouses."

But Lambda Legal, which advocates for gay rights, said employers refusing to offer health insurance to all married couples would violate federal law prohibiting sex discrimination.

"You should be able to add your [same-sex] spouse to your health insurance," Lamba Legal and other civil rights groups wrote in an online FAQ.

Also, state laws may require equal benefits for same-sex spouses.

Big companies also like the simplification the ruling brings to their human resources departments.

"We're relieved because this basically means you won't have to do a state-by-state analysis" of how the law applies to same-sex couples, said Gretchen Young, senior vice president of health policy at the ERISA Industry Committee, which represents very large employers. "We always want uniform treatment."

Weirdly, a constitutional right to same-sex marriage may harm some same-sex couples: those with domestic-partner benefits who don't want to get married.

Last year Verizon told same-sex partners in states where gay marriage is legal they had to wed if they wanted to qualify for benefits. Now that the high court has placed same-sex and opposite-sex marriage on the same level, other companies are likely to follow, say benefits specialists.

"We would certainly expect to see a falloff in domestic partner benefits," said J.D. Piro, a health benefits lawyer with Aon Hewitt, a consulting firm. "Given the decision, employers might want to be asking, do we still need to do that?"

Copyright 2015 Kaiser Health News. To see more, visit
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Can Technology Ease The Burden Of Caring For People With Dementia?

Mon, 06/29/2015 - 4:15am
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Arturo Martinez watches his wife, Aurora Martinez, put on makeup in their San Rafael, Calif., home. She has Alzheimer's.

Lynne Shallcross for NPR

A doctor I interviewed for this story told me something that stuck with me. He said for every person with dementia he treats, he finds himself caring for two patients. That's how hard it can be to be a caregiver for someone with dementia.

The doctor is Bruce Miller. He directs the Memory and Aging Center at the University of California, San Francisco. According to Miller, 50 percent of caregivers develop a major depressive illness because of the caregiving. "The caregiver is so overburdened that they don't know what to do next," he says. "This adds a huge burden to the medical system."

This burden is going increase dramatically in the coming decade. By 2025, 7 million Americans will have Alzheimer's disease, according to one recent estimate. Millions more will suffer from other types of dementia.

Together these diseases may become the most expensive segment of the so-called "silver tsunami" — 80 million baby boomers who are getting older and needing more medical care. The cost of caring for Alzheimer's patients alone is expected to triple by 2050, to more than $1 trillion a year.

So UCSF, along with the University of Nebraska Medical Center, is beginning a $10 million study funded by the federal Centers for Medicare & Medicaid Innovation. Researchers plan to develop a dementia "ecosystem," which aims to reduce the cost of caring for the growing number of dementia patients and to ease the strain on caregivers.

That includes caregivers like Maria Martinez, 42, who visits her parents' small apartment in San Rafael, Calif., almost daily to help care for her mom, Aurora Martinez, who has Alzheimer's.

Maria Martinez is an only child with a partner and a full-time job as an occupational therapist. But nearly every day she spends at least a couple of hours with her parents, managing a long list of responsibilities that are critical to their ability to live independently.

"Does she have a doctor's appointment?" Martinez says. "Are there enough diapers? Clothing? Laundry. Financial stuff, I manage that too."

She bathes her mother, who is 78, manages upkeep on the apartment, does much of the shopping and fills prescriptions for both of her parents.

Especially in the early stages of Aurora's illness, practical concerns loomed large. Sometimes she would wander in the middle of night. Her husband, Arturo Martinez, 75, took to sleeping on the floor in front of the door, worried Aurora might end up falling in the street and being hit by a car.

Eventually, Martinez installed a lock at the top of the door where Aurora couldn't reach it, and a wind chime to serve as an alarm.

Though the Martinezes are not part of the study, they are the kind of family that the dementia ecosystem study is designed to help.

The study will enroll 2,100 patients at the two sites. Each patient will have a navigator, a nonmedical staff person who will coordinate care and triage calls, so minor issues don't land patients in the ER.

Some patients will also receive activity trackers and sensors, which will be placed around the house or worn on the patient's wrist. Much like Martinez's wind chimes, the idea is to see whether sensors can detect when a patient is wandering off or if they've been inactive for too long.

A few weeks ago, in a sunny conference room at UCSF, techies and doctors, almost all of whom have had family members with dementia, sat around a table, brainstorming other ways technology might be applied to dementia care.

"There are safety issues like leaving the stove on," suggests Katrin Schenk, who teaches physics at Randolph College in Virginia.

"You could easily put in a temperature sensor that knows they went in there and turned on that burner," Schenk says. "It's been on for two hours — someone needs to do something."

Or, she continues, what about the roughly one third of dementia patients who also have diabetes? Could Bluetooth-enabled blood-sugar monitors allow family members and medical staff to check up on them remotely?

If this all sounds intrusive, says Kate Possin, a neuropsychologist at UCSF, consider the alternative: anxious adult children, and parents who end up in nursing homes sooner than they want to.

"This may be a compromise for them," Possin says. "'If I use this system, then my son who lives three hours away feels comfortable and safe with me living at home a little bit longer.'"

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A handful of tech start-ups are making the same case. In San Francisco, Lively markets a system of networked sensors and a watch that can pick up on activity around the house and let family members or care providers know if there's a worrisome change.

These kinds of products, which let doctors and caregivers check up on patients remotely, make sense for some cases, Schenk says.

But do they help in the long run?

That's one question researchers want to answer.

"I know for sure no one's gotten the data and proven that [this technology] works," Schenk says. "Proven that it improves peoples' health, improves caregiver burden."

"Reduces hospitalizations," adds Possin.

"Delays the entrance into a nursing home," finishes Schenk.

Researchers will also want to see whether sensors and other technologies are helpful for people in later stages of dementia like Aurora Martinez or whether they just create more hassle.

Possin says they hope to have some preliminary results next January.

Copyright 2015 KQED Public Media. To see more, visit
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Vaccine Against Meningitis B Gets A Boost From CDC

Mon, 06/29/2015 - 3:28am
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Stuart Kinlough/Getty Images/Ikon Images

Parents, take note! The Centers for Disease Control and Prevention's vaccine committee has expanded its recommendation for immunization against meningitis B, a rare but potentially deadly strain of meningitis.

The committee's revised guidance, issued late last week, broadens the group of young people that the CDC thinks should consider getting the shot, and increases the likelihood that health insurance policies will pay for the injection.

The previous recommendation was limited to people at high risk of getting the disease — such as lab workers and students at colleges with outbreaks of three or more cases. Now the advisory committee on immunization urges all young people between the ages of 16 and 23 to talk to their doctor about whether the shot is a good idea for them, too.

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Meningitis B has been to blame for a number of outbreaks on college campuses over the past few years. That's because college students who live in dorms and who frequent crowded areas seem to be at particular risk. Close contact spreads the disease.

Since 2005, there has been an effective vaccine to help protect against four other strains of bacterial meningitis: serogroups A, C, W and Y . The CDC recommends routine vaccination with this four-strain shot, starting at age 11 or 12, with a booster at about age 16. But coming up with an effective vaccine against Meningitis B has been trickier.

The bacteria that cause the illness are common in the environment and can also be found in the nose and respiratory system. They are spread in saliva and mucous, during close contact like kissing, coughing, or even just sharing a water bottle.

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Symptoms of bacterial meningitis can be deceptive at first, appearing as a severe cold or flu, with headaches, nausea, and high fever. But the microbes go on to invade the brain and spinal cord, causing inflammation and swelling of protective membranes. These symptoms can escalate very quickly, within days, or even hours, and result in brain damage. And, despite treatment with antibiotics, 10 to 15 percent of patients with the disease die.

Last fall, the Food and Drug Administration approved two new vaccines against the fifth strain of bacterial meningitis, and recommended its rather narrow use by people at high risk of contracting the illness. The new guidelines say that if doctors and any patients agree the vaccine is appropriate, it should be given.

Infectious disease specialist Dr. William Schaffner, of Vanderbilt University, is a member of the CDC committee that advises federal health officials on vaccine recommendations.

Schaffner calls this revised recommendation, "a signal to all private insurers that this vaccine should be covered." It also means that the Vaccines for Children Program, a federally funded immunization program for lower income families, will likely cover the cost of the vaccine.

And, Schaffner says, it gives colleges and universities the option of requiring vaccination against meningitis B for all incoming freshman.

The CDC committee stopped short of firmly recommending that all people aged 16 to 23 get the shot; rather it urges these patients to consult their doctor about whether the shot makes sense for them — a subtle but important difference. And, so far, the committee has been silent about younger adolescents; some unanswered questions remain about the vaccine's complete effectiveness and how long it lasts. Once those questions are answered, committee members say, they'll likely revisit the recommendation, and perhaps suggest expanding it further.

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Texas Defends A Woman's Right To Take Her Placenta Home

Sun, 06/28/2015 - 2:25pm
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Melissa Mathis holds a container of freeze-dried placenta capsules.

Carrie Feibel/Houston Public Media

After giving birth, some women save the placenta in order to consume it in the following weeks. In fact, Texas just passed a law giving women the right to take the placenta home from the hospital, the third state to do so.

Science doesn't support a lot of the claims of its purported benefits. But for Melissa Mathis, it's about her rights. Last year she had her baby, Betsy, in a Dallas hospital. When Mathis took Betsy home, she wanted to take the placenta home, too.

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"As far as I was concerned it was a part of my body that was in my body. So it wasn't like something, it didn't really feel that strange to me," Mathis says.

Like many women, Mathis had heard through friends about eating a little placenta every day in the weeks after giving birth.

The placenta, sometimes called the afterbirth, is typically dehydrated, ground up and put into edible capsules. Many midwives and doulas believe that because the placenta grows along with the fetus, it contains hormones and nutrients that can help a woman recover from childbirth.

Some say it helps women breastfeed or can prevent postpartum depression.

Mathis took the capsules for six weeks.

"It's hard for me to know what the effects were because I don't have anything to compare it to," she says, "But I had great success breastfeeding, I had no problems with emotional instability. I definitely feel that it helped me."

Mathis says the hardest part was just getting her placenta in the first place.

Texas classifies placentas as medical waste. And hospitals have liability concerns because placentas could carry infectious disease. Mathis says she spent months during her pregnancy communicating with hospital administrators about arranging custody of her placenta when the time came, but she says the answers she got were too vague.

Melissa Mathis holding the cooler she used to smuggle her placenta out of the hospital.

Carrie Feibel/Houston Public Media

So when Betsy arrived, Mathis and her husband waited until nobody was looking.

"And we were able to grab it, and we got it and put it in a cooler and threw it in a backpack and my husband handed it off to the placenta handler in the lobby of the hospital and that's not ideal. And, in my opinion, that's not acceptable."

Mathis talked about it with her state representative, Dallas Republican Kenneth Sheets.

"It seemed like an issue that involves freedom and liberty and just a basic right and we just decided we'd take it on," he says.

Sheets wrote the new law that allows women to keep placentas, if they sign a waiver and don't test positive for infectious disease.

Texas is the third state in less than a decade to put a placenta law on the books. The first were Hawaii and then Oregon.

And yet doctors say there's no scientific evidence behind all the health claims. Some women say the placenta helped them, but researchers say it's probably just a placebo effect.

"We don't have any studies on this," says Dr. Catherine Spong, deputy director of the National Institute of Child Health and Human Development.

Spong is much more interested in how the placenta functions during pregnancy, not after.

"The placenta is really the lifeline. It serves as the baby's lungs, the baby's kidney, it has functions of the liver, of the GI tract," Spong says. "Interestingly, it also has immune functions and endocrine functions."

Spong says her institute will spend $44 million on placenta research over the next few years. She says she doesn't feel comfortable offering an opinion on moms who eat placenta, simply reiterating that science doesn't support it.

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But Mark Kristal does have an opinion.

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Kristal is a behavioral neuroscientist with the State University of New York at Buffalo. He's been studying placenta eating in mammals for 43 years.

"The overwhelming majority of mammalian placental mothers ingest afterbirth," he says.

In fact, many women point to this fact as evidence that humans should do it too.

But Kristal says not so fast. The reason many mammals do it is because there's a chemical he discovered in amniotic fluid and placenta that provides pain relief during birth.

"It boosts the effectiveness specifically of opioid or opiate painkillers," he says.

So wouldn't this work in humans?

Kristal says the chemical is also in human the placenta but it's fragile. Cooking and encapsulating the placenta would actually destroy it.

Kristal says eating it raw isn't a good idea either. Since placentas are also filters, there may be waste products in our placenta that are harmful or toxic.

In fact, he believes humans have evolved away from eating placenta.

"It's not a routine human behavior. On the contrary, there are a lot of cultures that have developed taboos against doing it," he says.

Kristal speculates evolution has provided women with something else to deal with the pain of childbirth. And that's the company of other people.

Most mammals that eat placenta give birth unassisted. But humans don't.

"The advantage of socially assisted birth is not only to help the mother but also to pass information about childbirth from older more experienced women to younger less experienced women who might be helping," Kristal says. "The human data bank grows by this social experience."

Dallas mom Melissa Mathis says she's open to hearing more science about the placenta. But until then, she wants to decide for herself.

"I feel like it's a personal liberty issue. It's our freedom to choose what we're going to do with our own bodies," she says.

Texas hospitals will start releasing placentas in 2016.

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In Bid For Stricter Vaccine Rules, Officials Grapple With Decades-Old Distrust

Sat, 06/27/2015 - 5:06pm
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Parents rally against SB 277, a California measure requiring schoolchildren to get vaccinated, outside the Capitol in Sacramento, Calif.

Rich Pedroncelli/AP

California is on the brink of passing a law that would require nearly all children to be vaccinated in order to attend school. The bill has cleared most major hurdles, but public health officials have grappled with a strong, vocal opposition along the way.

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There's actually a long history to the anti-vaccination movement.

"From the moment the very first vaccine came on the scene, which was the smallpox vaccine, there has been resistance to vaccines and vaccination," says Elena Conis, a history professor at Emory University and author of Vaccine Nation: America's Changing Relationship with Immunization.

She says that the modern-day resistance movement shares its roots and rhetoric with the social movements of the 1960s and '70s, including feminism, environmentalism and consumer rights.

"They encouraged people to question sources of authority, including doctors," she says.

For example, women's advocates started to question medical advice on reproductive health and childbirth.

"Women also start opting to increasingly use midwives, have births outside the hospital," she says, "And also reject professional advice about formula feeding over breastfeeding."

Environmental activists were also encouraging people to think about chemical exposures, even in small amounts, at the same time that drug manufacturers started including package inserts listing drug ingredients.

Conis says that this is the context for the list of vaccine recommendations, which has grown longer over the last generation. It can be overwhelming for today's parents to watch their babies cry through one shot after another.

"We started looking at the vaccine schedule and how intense and frequent these vaccines seem to come up," says George McCann, a general contractor and father of two daughters, who lives north of San Francisco. "So we started talking about whether or not this seemed to be the best approach for our children."

He and his wife decided to have their girls get some vaccines, but not all. They skipped vaccines for pneumonia and chicken pox and waited on polio until the girls were older.

"The whole issue for me comes down to the idea that somehow the state would get to mandate that all of us have to do something, as if we don't have the ability to look into this with compassion and intelligence and critical thinking on behalf of our children," he explains.

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But Carl Krawitt asks that those who don't vaccinate or delay think about other peoples' children. His son couldn't get vaccinated for five years while he was being treated for leukemia. He depended on others to be immunized so they couldn't spread potentially deadly diseases.

"People often don't understand that their choices have an impact on others," he says. "People take personal freedoms to such an extreme that they forget about the community."

These are the types of parental debates Dr. Matt Willis is navigating. He's the public health officer for Marin County. In some communities there, only half the kids are fully vaccinated.

His office is trying to figure out why. It did a survey and found a few common characteristics of today's parents who don't vaccinate.

"A higher proportion are getting information from the internet, and a higher number of the parents were seeing alternative medical providers," he says.

Willis has developed a list of talking points for each vaccine. He tells parents that there's no link between the measles vaccine and autism.

He says that polio is probably his toughest sell. The disease was eradicated from the United States in the late 1970s, so American parents today have no memory of how horrible the disease was. While the polio virus is not endemic to the U.S., he reminds parents that it still is in other parts of the world.

Shots - Health News Once A Vaccine Skeptic, This Mom Changed Her Mind

"It's really just one plane ride away," he says.

Willis tell parents who want to delay some vaccines to think of them like a seat belt.

"You could choose to put them in their safety belt as you leave your driveway and start driving, or you could choose to pull over 10 miles later and put it on," he says.

Willis is hoping California Gov. Jerry Brown will sign the bill prohibiting parents from opting out of vaccines for religious or personal beliefs. If passed, the law would take effect on Jan. 1, 2016.

"It will certainly make my job a lot easier," he says, because controlling a disease outbreak is like fighting a fire. "It's much easier to prevent a fire from happening in the first place than it is to try and extinguish it once it's spreading."

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

Copyright 2015 KQED Public Media. To see more, visit
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San Francisco Doctors Tap App For Nationwide LGBT Health Study

Fri, 06/26/2015 - 2:01pm

Nephrologist Mitchell Lunn (left) and OB-GYN Juno Obedin-Maliver want to hear about the health issues on the minds of members the LGBTQ community.

Susan Merrell/Courtesy of UCSF

Drs. Mitchell Lunn and Juno Obedin-Maliver, both clinical fellows at the University of California, San Francisco, have spent the past decade studying the health problems of people who identify as lesbian, gay, bisexual, transgender and queer.

Their biggest challenge is the lack of population health data about LGBTQ people. The researchers hope that an iPhone app can change that.

The new app, called PRIDE, will ask LQBTQ participants about their health history and concerns. Their answers will inform a longer-term study, which kicks off in January 2016.

After downloading the app, participants are prompted to answer some basic demographic questions and post a topic they would like a researcher to study in the future. They can also see questions or topics that others have posed, which are tagged by category, such as "behavioral health" or "sexual health."

Lunn said he views the first year of the project as a "community listening phase." Next year, the researchers intend to kick off a more rigorous and in-depth study, which will include some of the questions posed by the community.

The app debuted in the App Store Thursday, just ahead of the much anticipated Supreme Court ruling that made same-sex marriage the law of the land.

"We know that there are health disparities, but we don't have the data to drive clinical practice and public health priorities," said Obedin-Maliver, who also practices as a resident physician in obstetrics and gynecology.

For example, about 1 in 3 people from the LGBTQ community smokes, which is a far higher rate than the average U.S. adult population. Therefore, scientists assume that a higher number of LGBTQ people die from cancer and other diseases that are linked to smoking — but they don't have a way to prove it.

Progress has been slow on that front. The Institute of Medicine in 2011 issued a report finding that LGBT people "have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are." It wasn't until 2013 that the Centers for Disease Control and Prevention's annual National Health Interview Survey included a question about sexual orientation.

Privacy and Security Concerns

The researchers found support for their app from Apple employees, who helped connect the team with a mobile design firm.

Apple CEO Tim Cook has emerged as an outspoken advocate of LGBTQ rights. In a Bloomberg BusinessWeek op-ed published last October, Cook said he doesn't consider himself an activist but is "proud to be gay."

The PRIDE app connects with Apple's ResearchKit service, which makes it easier for clinical researchers and developers to develop mobile apps that gather data from participants — with their consent.

The first five ResearchKit apps focused on Parkinson's disease, breast cancer, diabetes, asthma and heart disease. This is the first ResearchKit-powered app that aims to gathering data about population health, rather than a specific disease.

"When Apple launched ResearchKit [last month], we reached out to the team at Apple to ask whether we could think about modifying it to make it more of a tool to engage the community," Lunn explained. "They were very excited."

Some potential participants may be concerned about sharing their sexual orientation and gender identity with an app. Lunn said they built the app with security and privacy in mind — it is HIPAA-compliant and includes "military-grade encryption," he said.

The data will only be available to researchers from UCSF for now. But it may later be shared with researchers in an "aggregate and de-identified way," meaning first name, Social Security number and contact information won't be visible.

Thrive, Not Just Survive

Lunn and Obedin-Maliver say this is the first national public health study focused on LGBTQ people.

Other researchers say this kind of data would help fill a void. National cancer registries, such as one called "SEER" for short, don't include questions about sexual orientation and gender identity.

"I really need this data," said Liz Margolies, founder and executive director of the National LGBT Cancer Network. "The federal government should be making sure this data is collected, but it takes years. In the meantime, it is very difficult to get funding."

The UCSF study will also investigate some of the discrimination that LGBTQ people face during their treatment. Recent research found that 55 percent of lesbian and gay patients and 70 percent of transgender patients felt they had experienced discrimination or substandard care.

"In order for the community to thrive — not just survive — we need to incorporate LGBTQ people into all facets of life, including health and research," said Obedin-Maliver. "We need to understand their needs in their own words and voices."

Christina Farr is the editor and host of KQED's Future of You blog, which explores the intersection of emerging technologies, medicine and health care. She's on Twitter: @chrissyfarr

Copyright 2015 KQED Public Media. To see more, visit
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5 Challenges Still Facing Obamacare

Fri, 06/26/2015 - 11:37am

President Obama and Vice President Biden shake hands after the president spoke in the White House's Rose Garden Thursday about the Supreme Court decision in favor of Obamacare.

Carolyn Kaster/AP

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges — including one resolved Thursday — and dozens of repeal efforts in Congress. But its long-term future still isn't ensured.

Here are five of the biggest hurdles that remain.

Medicaid Expansion

About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. So far, 21 states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington's long-term commitment to pay for most of the costs.

Anemic Enrollment

Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven't purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance. Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven't figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.

Market Stability

Nationally, premiums haven't gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they're not, expect increases.


People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The "Cadillac tax," created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes' cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.

Political Resistance

Thursday's ruling did little to diminish the GOP's zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.

Kaiser Health News writers Julie Appleby, Mary Agnes Carey, Phil Galewitz and Jordan Rau contributed to this report.

Copyright 2015 Kaiser Health News. To see more, visit
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To Master Stage Fright, Practice Makes Imperfect OK

Fri, 06/26/2015 - 9:34am

Sara Solovitch plays the piano in the Terminal B baggage claim area at San Jose International Airport.

Chloe Veltman/KQED

In the past, if Sara Solovitch tripped up while playing the piano she would get flustered and stop. Especially in front of an audience.

"I felt like I had to correct everything and each note had to be perfect," the Santa Cruz, Calif.-based author and pianist. But now, she can breeze through a few bum notes while playing Claude Debussy's lyrical piano piece Reflections on the Water as if no one were listening.

"One of the things I've really worked on has been continuing to play," Solovitch says.

For the past three years, Solovitch has been coming regularly to San Jose International airport to play the beat-up Hamilton baby grand located in the Terminal B baggage claim area.

"Here, I'm not worried about people's judgment and evaluation," Solovitch said. "People aren't listening and that's kind of a godsend to me."

Solovitch's impromptu airport recitals are part of her push to overcome stage fright — a phobia that has plagued the musician since she was a little girl.

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And now she's written a book on the subject — Playing Scared: A History and Memoir of Stage Fright.

Solovitch loves the piano. But she's so scared of playing the instrument in public that even practicing at home when her family is around regularly unsettles her.

"My hands turn wet with sweat and they'll slip and slide," Solovitch said. "My feet tremble so that I have a hard time controlling the pedal. I feel my heart beating really uncontrollably. And then there's just this kind of like pounding in my head."

As a teen, stage fright drove Solovitch to give up her dream of becoming a professional musician. But even the most seasoned performers struggle with the anxiety.

Berkeley standup comedian W. Kamau Bell has hosted his own cable TV series and has appeared on popular podcasts like WTF with Marc Maron.

Yet despite Bell's impressive chops, the comic still suffers from performance anxiety on a regular basis. And it makes no difference if he's in front of a national television audience or a small crowd at a bar; he says his mind scrambles and his mouth goes dry.

"I've often said that if there's a way to email the crowd the jokes and still get the same feeling from performing live I would just as soon do that," Bell said.

Comedian W. Kamau Bell at home in Berkeley, Calif.

Chloe Veltman/KQED

It's not just performers who deal with this issue. John Beebe, a Jungian psychiatrist in San Francisco, has dealt with performance anxiety in his own career and treats people who suffer from it. He thinks stage fright is universal.

"When we can't live up to the image we'd like to project we just feel within ourselves that we fail terribly," Beebe said.

But Beebe believes people can overcome stage fright if they face it head on. Repetition is key.

"I think some of us have learned that the only way to master anything is to practice and do it," Beebe said.

A steady diet of playing to passersby at the airport has helped Sara Solovitch vanquish her stage fright. Yoga and anti-anxiety medication has helped, too.

"You have to practice performing as much as you practice practice," Solovitch said.

Practice seems to have paid off: Solovitch is actually looking forward to her next gig. She'll be performing at the public library in Santa Cruz in August.

"I used to talk to myself the way one doesn't talk to their dog: You know, 'You're stupid, you're an idiot, how could you make that mistake?' " Solovitch said. "And now as I approach a performance, instead of saying 'I'm nervous,' I say to myself 'I'm excited.' "

This story was produced by KQED Arts.

Copyright 2015 KQED Public Media. To see more, visit
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California Law To Curtail Vaccine Exemptions Clears Hurdle

Thu, 06/25/2015 - 3:33pm

A box of vaccine vials sits on a table during a Solano County health fair in 2010 in Vallejo, Calif.

Justin Sullivan/Getty Images

The controversial bill that would require almost all children entering day care or school in California to be vaccinated crossed another key hurdle Thursday, as the state Assembly approved it by a vote of 46-30.

The bill, SB 277, now returns to the state Senate, where lawmakers will be asked to concur with amendments made in the Assembly.

If it passes out of the Legislature, the bill would then move to the desk of Gov. Jerry Brown. The governor hasn't indicated whether he'll sign the bill, but a spokesman said via email that Brown "believes that vaccinations are profoundly important and a major public health benefit and any bill that reaches his desk will be closely considered."

Sens. Richard Pan (D-Sacramento), a pediatrician, and Ben Allen (D-Santa Monica), the son of a polio survivor, introduced the legislation in the midst of the measles outbreak that began at the Disney theme parks in Anaheim last December.

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By the time the state Department of Public Health declared the outbreak over in April, more than 130 people in California had contracted the highly contagious disease. Health experts say the disease was able to spread due to low vaccination rates in some communities.

SB 277 strives to boost childhood immunization rates by eliminating the personal belief and religious vaccine exemptions. The bill would maintain the medical exemption; it was amended in the Assembly health committee to clarify that physicians can determine when vaccination isn't medically appropriate.

As the bill has moved through the Legislature, thousands of people have flooded the state Capitol to oppose the bill, saying it infringes on their parental rights. Some oppose vaccination outright, while others don't want to follow the vaccination schedule laid out by the Centers for Disease Control and Prevention.

If passed, the bill would take effect on Jan. 1, 2016. Under the law, students who weren't fully vaccinated due to philosophical or religious beliefs before this date wouldn't need to get vaccinated until they entered preschool, kindergarten or seventh grade.

Beginning July 1, 2016, students would not be admitted for the first time to any public or private day care, elementary or secondary school, and wouldn't be allowed to advance to seventh grade, if they didn't have all the vaccinations required for their age.

Under the law, parents who choose to not vaccinate their children would be able to participate in a multiple-family private home school, or home-school their kids using a public school independent study program.

During debate on the Assembly floor, some lawmakers said they support the bill because it protects public health.

"We live in a society where we have a social responsibility to act in a manner that protects not only ourselves but others as well," said Assembly member Marc Levine (D-Marin and Sonoma).

Several Assembly members said they support vaccines, but argued the bill violates parents' rights to choose which medical care their children receive. They also said the bill would encroach on children's right to an education.

"I'm interested in protecting the rights of our parents," said Assembly member Shannon Grove (R-Bakersfield). Parents, she added, should be "in the driver's seat" when it comes to their children's health.

If SB 277 becomes law, California would become the 32nd state to ban the philosophical exemption and just the third — West Virginia and Mississippi — to not offer a religious exemption, according to the National Conference of State Legislatures.

For more health coverage from KPCC, check out its Impatient health blog.

Copyright 2015 Southern California Public Radio. To see more, visit
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With More People Quitting Smoking, Do We Need E-Cigarettes?

Thu, 06/25/2015 - 1:31pm

E-cigarettes are marketed as a safer way to inhale nicotine, but the evidence remains unclear on benefits and harms.

Nam Y. Huh/AP

Once a smoker always a smoker, right? Not quite.

As the number of smokers drops, the remaining smokers actually smoke less and are more likely to quit, according to a study published Wednesday in the journal Tobacco Control.

It supports the idea that smoking in the United States is heading down a "softening" curve. That means more people are trying to quit, and the number of people quitting compared to smokers is increasing as the number of total smokers declines.

Over in Europe, the researchers found, things are slightly different. The percentage of smokers who have quit remained constant even as fewer people smoked, while the number of cigarettes smoked per day dropped, as it has in U.S.

The study is based on population data collected by the Census Bureau in the U.S. over 18 years, while six years' worth of public opinion surveys conducted by the European Commission were used for EU counterpart.

The researchers say their results bring into question the practice of harm reduction, a public health approach for tobacco control in use since the 1970s. Harm reduction was proposed as a way to minimize the exposure of smokers unable or unwilling to quit. More recently, e-cigarettes have been promoted as a replacement for the traditional cigarette.

"The fundamental thing is that harm reduction is wrong," says Dr. Stanton Glantz, senior author of the study and director of the Center of Tobacco Control Research and Education at the University of California, San Francisco. "It's not an irrational idea, but it's just not happening."

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While Joanna Cohen, director of the Institute for Global Tobacco Control at Johns Hopkins Bloomberg School of Public Health, agrees that there's a 'softening' trend, she thinks that e-cigarettes and harm reduction policies are not a black-and-white issue.

"In tobacco control, those words carry a log of baggage right now," Cohen says. "Different experts have different opinions." There's no formal policy at the Centers for Disease Control and Prevention or other agencies that specifically has a harm reduction approach, she notees.

"Some people think that [e-cigarettes] are going to be the solution to the problem," she continues, "Other people are more concerned that either they won't make a difference or cause harm."

Potential problems include e-cigarettes preventing people from quitting smoking altogether and tempting new users, since they are marketed as not as harmful as the traditional cigarette. Evidence isn't clear either way at this point.

One reason for the shifting debate is that our attitudes and understanding have changed about nicotine, Glantz says.

People used to believe that nicotine kept people addicted to cigarettes but that it wasn't dangerous itself. The smoke was thought to be the source of harmful toxins. So the idea was to introduce new ways to deliver nicotine such as e-cigarettes that could give people the nicotine they desired but didn't involve burning tobacco.

Now we know better. The 2014 U.S. Surgeon General's report concluded that nicotine is addictive, that a high-enough dosage can be very toxic in a short amount of time, and that exposure to nicotine during pregnancy and childhood can have serious adverse consequences. E-cigarettes deliver nicotine and other chemicals to users, but in vapor instead of smoke.

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The study results suggest that current tobacco control policies already in place are working. Glantz says. He and first author Margarete Kulik, a postdoctoral fellow at UCSF, attribute the general decline in smokers to this success, which includes the debut of clean indoor air laws that ban smoking inside workplaces, restaurants and other facilities. National media campaigns that aimed to de-normalize smoking and raised cigarette taxes also helped.

"It certainly suggests that we need to keep doing what we're doing," says Dr, Vaughan Rees, director of the Center for Global Tobacco Control at the Harvard T.H. Chan School of Public Health, who was not involved in this study.

Since current policies work and data suggests that remaining smokers are more likely to quit and smoke less, then there really is no need to promote new recreational nicotine products like e-cigarettes under the name of harm reduction, Glantz says.

Cohen also points out that there are challenges when you look at population-level data and think about what that means for policy.

A governmental institution such as the CDC might make use of the same data in a different way than the average physician will. If you have a hard-core smoker sitting in front of you, you as a health care provider want to help that person as best as you can. Maybe an e-cigarette is the best choice for that particular patient.

"In the end, everyone's heart is in the same place. Everybody wants to reduce death and disease from tobacco products," Cohen says.

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Statehouse Fights Over Obamacare To Rage On Despite Supreme Court Decision

Thu, 06/25/2015 - 12:20pm

The Oklahoma State Capitol is one of many legal battlegrounds that remain for the Affordable Care Act.

Sue Ogrocki/AP

The Supreme Court ruling in favor of the Obama administration means 6.4 million people won't lose subsidies that helped them afford health insurance.

But the historic ruling in King v. Burwell may be far from the last word on health overhaul.

Bills to advance or cripple the law in statehouses didn't come to a halt in the months that lawmakers awaited the Supreme Court decision. They may well smolder for months or years.

"I think we should continue to do everything we can to opt out of Obamacare," said Mike Ritze, a Republican member of the Oklahoma House of Representatives and staunch foe of the law.

The court's decision in King v. Burwell was anxiously awaited by both backers and supporters of the Affordable Care Act, who agreed that a decision invalidating the subsidies would have created chaos for Obamacare.

Shots - Health News State Lawmakers Keep Busy While Supreme Court Weighs Obamacare

Plaintiffs in the case, four residents of Virginia, argued that they should not be forced to buy health insurance and shouldn't receive tax credits under the law. Their argument rested on wording in the law that was vague on whether the tax credits applied to residents of states using a federal insurance marketplace, or "exchange," rather than an exchange established specifically by a state; 34 states are using the federal exchange. But the justices ruled in a 6-3 decision that siding with the plaintiffs might well destroy insurance markets.

"The combination of no tax credits and an ineffective coverage re­quirement could well push a State's individual insurance market into a death spiral. It is implausible that Congress meant the [Affordable Care] Act to op­erate in this manner," Chief Justice John Roberts wrote for the majority.

But in statehouses around the country, fighting over the act will likely continue. The Center for Public Integrity reported on the heated war over Obamacare in state legislatures earlier this year, finding more than 700 health overhaul-related bills introduced during 2014 or carried over from 2013 in states where legislatures allow that.

Five states — California, Hawaii, Illinois, New York and Washington — saw 50 or more health bills each, according to data from the National Conference of State Legislatures.

The NCSL has tracked more than 170 new state bills filed in 2015 relating to health issues, including some direct assaults on the Affordable Care Act. A list is here.

Whether some diehard opponents will stand down amid greater public acceptance of the law isn't clear. One who says he won't is Ritze, an osteopathic physician who chairs the Oklahoma House Public Health Committee.

"We'll continue to introduce bills and legislation to take bites out of the ACA," said Ritze.

The National Academy for State Health Policy, an independent group, has taken notice of bills to create exchanges or to junk them.

As of June, 11 states are considering bills to now establish their own exchanges or designate the federal exchange as the state's own. On the flip side, lawmakers in 10 states introduced bills this year to block creation of an exchange or to scrap one that's in place, according to the academy. Here's a state-by-state list tracking the bills. How states might link up to the federal site isn't entirely clear at this point.

Not-so-hidden agendas

Some bills are the handiwork of political groups that push agendas on a range of hot-button topics across the country.

The conservative American Legislative Exchange Council, works to "advance limited government, free markets and federalism at the state level." It has long championed "model" bills that gum up enforcement of the health reform law.

It's liberal foil is the State Innovation Exchange, that sees itself as the "legislative wing of the progressive movement."

The Tenth Amendment Center, which considers Obamacare unconstitutional, wants to see legislators pull levers of state government in ways that will obstruct the law. One such step is to threaten to revoke the licenses of insurance agents who agree to sell Obamacare policies. Another tactic is to enact laws that tie the hands of state insurance department officials, who are largely responsible for regulating health coverage.

"The federal government needs states to be complicit to pull this off," the group says on its website.

The ACA's backers tend to dismiss these sorts of bills as fringe politics or gimmicks that will ultimately be struck into oblivion by the courts. But the impact of multiple legal tussles over Obamacare isn't known. Some states have recently taken the first steps down that trail.

In April, Arizona Gov. Doug Ducey, a Republican, signed HB2643, which prevents the state "from using any personnel or financial resources to enforce, administer or cooperate with the Affordable Care Act."

Ritze, the Oklahoma lawmaker, cited a recent bill in his state that tightens oversight of Obamacare "navigators," who help walk uninsured people through the complexity of picking a plan and signing up. ACA supporters have attacked these bills as thinly veiled ploys by insurance agents to scare off competition.

The Oklahoma bill, SB 236, for instance would require criminal background checks for navigators and require them to register with the state. It was signed into law in April.

According to Ritze, navigators "were not giving consistent answers" when people had questions about insurance policies. "We felt they should be certified or have some oversight," he said.

In Montana, SB 350 became law in April and will also require licensing of navigators.

The great unknown

Tracking how much is being spent in the states to lobby lawmakers to pass these sorts of bills can't be done with any certainty, said Denise Roth Barber, managing director of the National Institute on Money in State Politics in Helena, Montana.

Barber said half the states don't require companies and lobbyists to report money that is paid to lobbyists.

"If you don't have that piece of the puzzle you are missing a significant chunk," she said. "It's an amazingly important question that can't be answered."

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter.

Copyright 2015 The Center for Public Integrity. To see more, visit .
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