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Feds Act To Help More Ex-Inmates Get Medicaid

10 hours 54 min ago

Administration officials moved Thursday to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expanding eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates "is critical to our goal of reducing recidivism and promoting the public health," said Richard Frank, assistant secretary for planning for the Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

"It's highly variable. Some states and jurisdictions are having a lot of success" enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. "Others of them have initiatives in place that aren't reaching the kinds of numbers that are making a dent."

The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 up to January 2015.

Shots - Health News Thousands Leave Maryland Prisons With Health Problems And No Coverage

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS' guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners' names in the Medicaid computers while they're locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is "providing encouragement and a nudge" to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. "They understand that this is a technology issue."

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they're fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, "if you have a fair amount of freedom of movement" in a halfway house, "you're not considered an inmate" for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. "That will be very helpful for a lot of people who are trying to transition out of incarceration."

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland's Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

"That helps a lot" if people like him could get on Medicaid after they first leave prison, he said. "People can get the health care they need sooner. I've been out a week now and I still haven't been able to see a doctor because I don't have my card."

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage "can mean the difference between life in the community and recidivism and even life and death," Michael Botticelli, the White House's director of national drug control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act's Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far 31 states and the District of Columbia have expanded Medicaid under the law.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Jay Hancock is on Twitter: @jayhancock1.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

In Houston, Pregnant Women And Their Doctors Weigh Risks Of Zika

Thu, 04/28/2016 - 3:00pm
In Houston, Pregnant Women And Their Doctors Weigh Risks Of Zika Listen· 4:04 4:04
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April 28, 20163:00 PM ET Heard on All Things Considered Carrie Feibel

From

Tracy Smith, 38, and her children Hazel, 8, and Finley, 5, at their home in Houston. Smith is pregnant with twins and says she's a little more worried than usual about the approach of mosquito season.

Carrie Feibel/Houston Public Media

As summer approaches, anxiety about Zika is growing in Gulf Coast states like Florida and Texas. The virus hasn't spread to mosquitoes in the region, and it may not, but experts are preparing nonetheless.

And because Zika can cause birth defects in newborns, many women — and their doctors — are nervous. In the waiting room of the fertility clinic Houston IVF, patients are handed a map of Zika-affected countries, and asked to fill out a questionnaire.

"The first thing I'm discussing now is Zika," says Dr. Jamie Nodler.

He says at least a few couples he's spoken with at the clinic have had to delay starting fertility treatment because the woman or her partner may have already been exposed to the virus while traveling to Central or South America.

"Especially in Houston, a lot of our patients and families are in the oil and gas industry," Nodler says. "These aren't people who are traveling to Mexico and Puerto Rico for fun or vacation. These are people who have to work in some of these offshore drilling areas."

This map shows the predicted distribution of Aedis aegypti, the mosquito that can carry the Zika virus. The redder the area, the likelier you are to find A. aegypti there.

Kraemer et al., eLife

Nodler is even advising patients who haven't been to regions where Zika is prevalent to slather on repellent — just in case the virus is already in some mosquitoes along the Gulf Coast but we don't know it yet.

"No one wants to see an affected child," he says.

Nodler says couples will need to work together to manage their Zika risk. If his partner is already pregnant, a man should use condoms to avoid sexually transmitting the virus.

All over the city, parents and would-be parents have been absorbing the international news about Zika.

"They've been saying Zika is coming to Houston; they don't know when," says Annie Tursi. She's 35 and owns four hair salons. Her husband is a consultant. Tursi says they were going to try for a third baby in 2016, but have decided to watch and wait, instead, to see whether Houston has a Zika outbreak.

"I think we're really blessed to have two healthy boys," she says. "And if it does come this summer and it is a risk, then I probably just won't even try for another one."

Between their jobs and the toddler and the baby, there's no way she can simply hunker inside all summer to avoid mosquitoes, Tursi says.

"Right now there are just so many unknowns. And I think by the time they have a vaccine and know more, we'll be done" with having children, she says, chuckling. "We'll be out of diapers and we'll be done."

Another Houston mom, Tracy Smith, couldn't make that choice. She was already pregnant with twins when she heard about Zika. At a recent checkup, Smith's doctor told her she should still take some precautions, even though she's now into her second trimester.

"She said it's something to be concerned about your whole pregnancy," recalls Smith. "You need to be in long sleeves, and long pants — wearing DEET." Smith was shocked to be advised to use the powerful insect-repellent.

"My first thought was, 'I'm pregnant! I'm not going to put DEET all over myself!' " Smith says. "But I guess that's what we do this summer."

She's now wondering if she and her two other kids should move to her parents' house for the summer — over in a less buggy part of Houston.

"The probability is low" that she'll contract Zika, Smith figures. "But the potential impact is so great — and those are the kinds of threats that can be scary and are, disproportionately, sort of taking up space in my brain."

Health officials say because U.S. cities have a lot of enclosed public spaces and residences with air conditioning or screens, most people are generally better shielded from mosquitoes than in some other countries. And Houston officials are already stepping up mosquito abatement efforts to further reduce the risk of mosquito-borne illnesses.

These are the same mosquitoes that can carry chikungunya and dengue viruses, federal health officials point out. And recent outbreaks of those illnesses on the U.S. mainland have been very small.

Nonetheless, doctors in Houston have already opened a special clinic where women who have traveled to countries where the Zika virus is actively spreading can get blood tests and counseling. A second clinic will open this summer.

Dr. Kjersti Aagaard, an ob-gyn and professor at Baylor College of Medicine, says doctors are offering those clinic patients an ultrasound exam 15 weeks into their pregnancy.

"We've actually developed a protocol around looking for very special views of the fetal brain and the eyes to look at for any evidence of fetal malformation with Zika," she says.

Aagaard says she reminds her patients that Zika is just one of many possible risks during pregnancy — and risks can be managed, whether that's through prenatal vitamins, genetic screening, or, in the case of Zika, window screens and bug spray.

Still, Zika is tough to talk about, she says, because research on the virus's effects on a pregnancy is still limited.

"As much as we wish we could give them a set of very clear facts around, 'This is your risk; this is the time in pregnancy you're at highest risk' or 'This is the time prior to planning a pregnancy you're at highest risk,' we simply don't have that information," Aagaard says. "We don't know."

Despite the unknowns, doctors in Houston aren't advising people to avoid pregnancy.

What they are telling them is that they need to add mosquito bites to the list of cares and calculations that surround any pregnancy.

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

Copyright 2016 KUHF-FM. To see more, visit KUHF-FM.
Categories: NPR Blogs

Teen Birth Rates Plummet For Hispanic And Black Girls

Thu, 04/28/2016 - 1:08pm

The nation's falling teen birth rate saw an even bigger drop over the past decade, with dramatic declines among Hispanic and black teens.

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Birth rates are down a whopping 51 percent among Hispanics age 15 to 19 since 2006, and down 44 percent among black teens, according to a survey of census data by the Centers for Disease Control and Prevention. Teen pregnancy rates among whites also fell by a third.

"It's really a one-two punch," says study co-author Shanna Cox, associate director for science for the CDC's Division of Reproductive Health. "Teens are having less sex, and among the teens who are having sex, they're using more effective methods of birth control."

The study finds the use of long-acting contraceptives like IUDs and implants jumped from 1 percent of teens a decade ago to 7 percent in 2014. While teen birth rates for minorities are still nearly double that for whites, the CDC finds that disparity has shrunk in many areas.

Still, Cox says the study also shows that teen birth rates can vary widely by place, even by county within the same state, and that there's a strong connection with socioeconomic factors.

Regardless of race, teen birth rates are higher where unemployment is higher and education and income rates are lower. The CDC and the Department of Health and Human Services have been working with nine communities with some of the highest teen birth rates in the country to develop broad efforts to address all of this.

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"So for example, we can work with job skills training," Cox says. "We can work with sports, community service." The goal, she says, is "really thinking about ways we can promote teens finishing school, planning for their future and being engaged in their communities."

The report names other efforts that have been effective in reducing teen birth rates:

Examples of activities included presenting community-specific teen birth data to civic leaders; encouraging health care providers to offer evening and weekend hours and low-cost services to increase access; having teen-focused, culturally appropriate materials available dur­ing health care visits; and implementing evidence-based teen pregnancy prevention programs to reach teens of both sexes both inside and outside of schools (e.g., through Job Corps, alternative schools, churches and community colleges.)

Last year the federal government expanded these kinds of efforts to 84 communities.

The recent decline is part of a longer downward trend in teen birth rates since 1991. But teen pregnancy in the U.S. remains higher than in many other developed countries.

Copyright 2016 NPR. To see more, visit NPR.
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Genetic Variations Help Make Fraternal Twins More Likely

Thu, 04/28/2016 - 12:05pm

Fraternal twins tend to run in families, and scientists think they've identified genetic variations at play. Understanding that might someday help predict who is more likely to have a risky pregnancy, and might also help treat fertility problems.

A team led by Dorret Boomsma at Vrije University in Amsterdam studied the DNA of 1,980 mothers who had given birth to fraternal twins, as well as 12,953 people who had no history of twins in their families. They found that the mothers who had variations in two genes, FSHB and SMAD3, were 29 percent more likely to give birth to twins than mothers without those changes.

This study, which was published Thursday in American Journal of Human Genetics, is the first twin study to rapidly scan the DNA of people looking for key markers, using a technique called genome-wide association study. The researchers were looking for common genetic variations that are associated with giving birth to twins.

One prime target was FSHB. It's a gene that prompts production of follicle-stimulating hormone, which helps ovaries produce eggs and is tested to evaluate fertility. The researchers found that women who had altered regulation of the FSHB gene had higher levels of follicle-stimulating hormone in their blood. Those women would be more likely to produce two separate eggs at once, resulting in fraternal twins.

The other gene, SMAD3, plays a smaller role in twinning, but does help the body respond to follicle-stimulating hormone.

The scientists think knowing about the genetic influences could have applications in reproductive health. Multiple births are riskier for both the mother and children. Developing genetic tests based on these variations could give a better idea of which women may be more likely to have multiple births.

And it also might someday help improve fertility treatment. Women who undergo fertility treatment often use hormones to stimulate the ovaries and produce more eggs at once. As it stands now, there is no good way to gauge how much medication a particular woman may need. This can occasionally lead to ovarian hyperstimulation syndrome. The authors hope that they can someday use their findings to design a genetic test that could identify women who are at risk for severe responses to hormone therapy. This tool might be used to help doctors determine appropriate dosage of hormone treatment.

Copyright 2016 NPR. To see more, visit NPR.
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That Surgery Might Cost You A Lot Less In Another Town

Wed, 04/27/2016 - 4:20pm
That Surgery Might Cost You A Lot Less In Another Town Listen· 3:04 3:04
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April 27, 20164:20 PM ET Heard on All Things Considered // Require.js is on the page (new Seamus) if (typeof requirejs !== 'undefined') { // Create a local require.js namespace var require_health_prices_map_20160427 = requirejs.config({ context: 'health-prices-map-20160427', paths: { 'pym': 'http://apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/js/lib/pym', 'CarebotTracker': '//apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/js/lib/carebot-tracker' }, shim: { 'pym': { exports: 'pym' } } }); // Load pym into locale namespace require_health_prices_map_20160427(['require', 'pym', 'CarebotTracker'], function (require, Pym, CarebotTracker) { // Create pym parent var pymParent = new Pym.Parent( 'responsive-embed-health-prices-map-20160427', 'http://apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/child.html', {} ); // Unbind events when the page changes document.addEventListener('npr:pageUnload', function (e) { // Unbind *this* event once its run once e.target.removeEventListener(e.type, arguments.callee); // Pym versions with "remove" if (typeof pymParent.remove == 'function') { pymParent.remove(); // Pym version without "remove" } else { // Unbind pym events window.removeEventListener('message', pymParent._processMessage); window.removeEventListener('resize', pymParent._onResize); } // Explicitly unload pym library require_health_prices_map_20160427.undef('pym'); require_health_prices_map_20160427 = null; }) // Add Carebot linger time tracker var lingerTracker = new CarebotTracker.VisibilityTracker('responsive-embed-health-prices-map-20160427', function(result) { pymParent.sendMessage('on-screen', result.bucket); }); // Add Carebot scroll depth tracker var scrollTracker = new CarebotTracker.ScrollTracker('storytext', function(percent, seconds) { pymParent.sendMessage('scroll-depth', { percent: percent, seconds: seconds }); }); }); // Require.js is not on the page, but jQuery is (old Seamus) } else if (typeof $ !== 'undefined' && typeof $.getScript === 'function') { // Load pym $.getScript('http://apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/js/lib/pym.js').done(function () { // Wait for page load $(function () { // Create pym parent var pymParent = new pym.Parent( 'responsive-embed-health-prices-map-20160427', 'http://apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/child.html', {} ); // Load carebot and add tracker // Separate from pym so that any failures do not affect loading // the actual graphic. $.getScript('http://apps.npr.org/dailygraphics/graphics/health-prices-map-20160427/js/lib/carebot-tracker.js').done(function () { // Add Carebot tracker var tracker = new CarebotTracker.VisibilityTracker('responsive-embed-health-prices-map-20160427', function(result) { pymParent.sendMessage('on-screen', result.bucket); }); // Add Carebot scroll depth tracker // Uncomment on one graphic per story var scrollTracker = new CarebotTracker.ScrollTracker('storytext', function(percent, seconds) { pymParent.sendMessage('scroll-depth', { percent: percent, seconds: seconds }); }); }); }); }); // Neither require.js nor jQuery are on the page } else { console.error('Could not load health-prices-map-20160427! Neither require.js nor jQuery are on the page.'); }

Need knee replacement surgery? It may be worthwhile to head for Tucson.

That's because the average price for a knee replacement in the Arizona city is $21,976, about $38,000 less than it would in Sacramento, Calif. That's according to a report issued Wednesday by the Health Care Cost Institute.

The report, called the National Chartbook on Health Care Prices, uses claims and payment data from three of the largest insurance companies in the U.S. to analyze how prices for procedures vary from state to state, and city to city.

The takeaway?

Health care prices are crazy.

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"There doesn't seem to be a systematic pattern with respect to what's high and what's low," says David Newman, HCCI's executive director. Newman is lead author of an article published Wednesday online in the journal Health Affairs that accompanied the release of the Chartbook.

The reports compare average state prices for 242 medical services — from primary doctor visits to coronary angioplasty to a foot x-ray — to the national average price for those services. It shows that states such as Minnesota and Wisconsin have higher than average prices while others, such as Florida and Maryland, were cheaper overall.

Arizona's health care prices were generally cheaper, about 82 percent of the national average, while next door in New Mexico, care was more expensive, about 25 percent above average.

And prices vary within states, too.

If a Sacramento knee replacement patient doesn't want to drive the 871 miles to Tucson, he or she could drive south to Riverside, Calif., and pay $27,000 less. In Florida, the surgery costs $17,000 less in Miami than it does 180 miles north in Palm Bay.

"For every mile that a consumer drives south on I-95, they will save $100," Newman says.

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The HCCI data is some of the most detailed and complete information available on health care prices paid by private insurance companies. It includes payment data from Aetna, Humana, UnitedHealthCare. It doesn't include claims information from The Blue Cross and Blue Shield Association, which is the largest health insurer in the country.

The price variations revealed by HCCI show that the health care market is not following traditional economic and market rules.

"The market just isn't working," says Zack Cooper, a professor of health policy and economics at Yale University.

Cooper says in the past, analysts believed that health care costs were rising because people were using too much health care. That analysis was based on Medicare data. However, Medicare pays the same across the country.

The data show that private-insurance payments vary widely and states that have low Medicare spending, like Minnesota, often have higher prices in the private insurance market.

He says one major factor is the consolidation of hospitals, leading to a lack of competition.

"Where one large hospital dominates the markets, that hospital is able to get higher prices," he says. "Hospitals have gotten increasingly powerful over time."

The new data may give insurers and consumers better ammunition to shop around for lower prices or to negotiate better deals.

But that will require people taking a different approach to choosing health care.

People should be willing to travel farther for services, Cooper says. That would put powerful hospital systems in different cities in competition with one another, perhaps putting pressure on prices.

And there are limits on where competition can bloom in health care, says
Sarah Dash, president and co-CEO of the Alliance for Health Reform.

"A woman is going to go to the one OB-GYN that she goes to. She's not going to run all over town trying to find the cheapest one necessarily," Dash says.

"Where it's shoppable, where it's elective, where it's not an emergency and where the price is knowable, then there are things that can be done," she says.

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A Concussion Can Lead To Sleep Problems That Last For Years

Wed, 04/27/2016 - 4:14pm
A Concussion Can Lead To Sleep Problems That Last For Years Listen· 3:27 3:27
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April 27, 20164:14 PM ET Heard on All Things Considered

Months after a concussion or other traumatic brain injury, you may sleep more hours, but the sleep isn't restorative, a study suggests.

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People who sustain a concussion or a more severe traumatic brain injury are likely to have sleep problems that continue for at least a year and a half.

A study of 31 patients with this sort of brain injury found that 18 months afterward, they were still getting, on average, an hour more sleep each night than similar healthy people were getting. And despite the extra sleep, 67 percent showed signs of excessive daytime sleepiness. Only 19 percent of healthy people had that problem.

Surprisingly, most of these concussed patients had no idea that their sleep patterns had changed.

"If you ask them, they say they are fine," says Dr. Lukas Imbach, the study's first author and a senior physician at the University Hospital Zurich in Zurich. When Imbach confronts patients with their test results, "they are surprised," he says.

The results, published Thursday in the online edition of the journal Neurology, suggest there could be a quiet epidemic of sleep disorders among people with traumatic brain injuries. The injuries are diagnosed in more than 2 million people a year in the United States. Common causes include falls, motor vehicle incidents and assaults.

Previous studies have found that about half of all people who sustain sudden trauma to the brain experience sleep problems. But it has been unclear how long those problems persist. "Nobody actually had looked into that in detail," Imbach says. A sleep disorder detected 18 months after an injury will linger for at least two years, and probably much longer, the researchers say.

The results suggest that doctors who treat traumatic brain injuries can't rely on their patients alone to report sleep problems, says Dr. Brian Edlow, a neurologist at Massachusetts General Hospital, who wrote an editorial accompanying the study. "There may be other tools that we need to detect sleep-wake disturbances in this patient population," he says.

One possibility is referring patients with concussions and other brain injuries for sleep studies. That's a costly option, Edlow says. But so is leaving a sleep disturbance undetected.

"Excessive daytime sleepiness can decrease people's productivity at work or at school," he says. In some cases, he says, it can even make it unsafe to drive.

It's not clear what's causing sleepiness so long after a brain injury. Doctors think that getting extra sleep soon after an injury helps the brain heal. But if sleepiness persists, it becomes a problem, Edlow says.

It's also surprising that sleepiness lingered longer-term, even in patients who had relatively mild injuries, Edlow says.

In severe injuries, the forces are so great that they actually tear apart circuits deep inside the brain. "It's the disruption of these circuits that is believed to cause sleep-wake disturbances," Edlow says.

But these circuits don't appear to be damaged in mild concussions, he says. "So there may be some other mechanism at work."

The challenge now, Edlow says, is to figure out what that mechanism is.

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After Combat Stress, Violence Can Show Up At Home

Wed, 04/27/2016 - 3:50pm
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April 27, 20163:50 PM ET Heard on All Things Considered

Stacy Bannerman testifies before the House Appropriations Subcommittee on Military Quality of Life and Veterans Affairs in 2006.

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Stacy Bannerman didn't recognize her husband after he returned from his second tour in Iraq.

"The man I had married was not the man that came back from war," she says.

Bannerman's husband, a former National Guardsman, had been in combat and been diagnosed with post-traumatic stress disorder. He behaved in ways she had never expected, and one day, he tried to strangle her.

"I had been with this man for 11 years at that point, and there had never been anything like this before," Bannerman said. "I was so furious and so afraid."

At first, she thought it was just a problem within her marriage. She called a hotline for military families to ask for help and learned something else she hadn't expected.

"The woman operating the hotline began weeping," Bannerman remembered. "She was getting so many of these calls from military spouses all over the country."

The debate about the relationship between domestic violence and post-traumatic stress disorder has waxed and waned since the invasions of Iraq and Afghanistan, but has never quite gone away. Headlines periodically reignite it, as when the son of former Alaska Gov. Sarah Palin, who is an Iraq vet, faced domestic violence allegations earlier this year.

When Stress Gives Way To Aggression

Veterans' advocates are anxious about the stereotype of combat vets as ticking time bombs, which is contradicted by the vast majority of former troops who live with post-traumatic stress and never hurt anyone.

There is a link, however, between PTSD and violence, said Dr. Casey Taft, a top researcher with the Department of Veterans Affairs. Vets with PTSD are three times more likely to be violent, he said.

"When one is exposed to war-zone trauma and combat trauma, they are going to be more likely to assume the worst and assume people are trying to do harm to them — and more likely to respond to that with aggressions," he said.

For many sufferers of post-traumatic stress, the terror and adrenaline of a life-threatening moment won't go away. When that builds into aggression, the target can often be a wife or girlfriend.

More than a third of women and about a fourth of men surveyed in the U.S. have experienced "intimate partner violence" at some point in their lives, according to public health statistics. Studies commissioned by the VA suggest those levels are about the same among active-duty troops and veterans, but more such research is ongoing.

Bannerman wrote a book about her experience, and says that today she hears from the partners of veterans almost every day. The stories tend to be similar.

"He was shrieking with his eyes open. And I went to shake him. He grabbed my wrist and twisted it. ... I knew my wrist was broken," one woman told NPR. "I took myself to the emergency room."

Another woman described how her husband shoved her down just after her son was born, ripping open the scar from her cesarean section.

A third woman found that her husband would sometimes just "go blank," she said. "You could see that he wasn't there."

The three women, all of whom are full-time caregivers to disabled combat veterans, talked with NPR about their experience after requesting that they not be identified in order to protect their privacy and allow them speak frankly.

They described, among other things, the shock they felt at how different their husbands were after returning home from deployments.

"It really took me by surprise," one said. "It was completely out of his character for the man that I met and fell in love with."

The women described how, initially, they began covering for the men. The woman whose childbirth surgery scar was torn told doctors in the hospital's emergency department that she had tripped over their dog and fell.

"I've never given the ER the correct info," said another woman about her many hospital visits.

Caregiving Burdens

Victims of domestic violence have many reasons for staying in their relationships. In the military, there are more reasons: reporting abuse can end a soldier's career badly, which can mean not only disgrace but no benefits for the family.

Some of the women who talked with NPR also said they thought that their husbands could get better with time and help.

"I wanted to keep my family together," one said. "We had three kids at this time. I didn't want his career to be over because of this — if I could just get him the help that he needs."

Serving as the caregiver for a wounded vet can be its own full-time job, with a stipend from the VA. For women in an abusive situation, leaving can also mean leaving behind that source of income.

"He would still have his pay every month," as one wife told NPR. "He wouldn't have to worry financially. If I were to walk out? I walk out with nothing. No job. I haven't been working since 2012."

All three of the women who spoke with NPR said they wanted to stay, to help their husbands recover from war. They went into their relationships with their eyes open, they said, and felt that caring for their sometimes violent husbands was its own form of service to the country.

"I thought, 'This is my job,' " one said. "He went and did his job, and this is mine. That's a prevalent thought among the wives of wounded soldiers. I see it all the time."

Most veterans with post-traumatic stress are not violent, but the VA is focused on researching those who are. One thing that's clear is that abusing drugs and alcohol makes the problems worse. Taft has set up a pilot program to try to help prevent domestic violence.

One challenge, however, is that the VA is focused on veterans, not their wives. And veterans' groups don't talk much about domestic violence — and most domestic violence groups don't have expertise about veterans and post-traumatic stress.

So even with the commitments and the patriotism that some wives express about riding out rough times with their families, the silence and the lack of support can still break a marriage.

One of the women who talked with NPR eventually left her husband after an incident that she said forced her to have a new perspective about her family.

"He had shoved me down. I looked up and all three of my kids were standing there in tears," the woman told NPR. "I thought, 'If a man ever treats one of my girls like this, or my son ends up like this, I will never forgive myself.' "

Her husband wasn't changing his behavior, she realized — "so I have to be the one who does something. I picked up the phone and I called the police. That was the first time I ever called them."

Another woman interviewed for this story moved with her family to a different state, where her husband found better results with the local VA.

"He's come around," she said. "He's started to become more the man I met and fell in love with. There hasn't been any sort of physical altercation since 2014."

The third woman who talked with NPR left her husband briefly but decided to go back. The problems returned, too, though.

"I haven't regretted anything," she said. "Have there been really hard times since then? Yeah. Have I gotten the s*** kicked out of me since then? Yeah."

The woman helps her husband, a Marine combat vet, get to his VA appointments on time. He has cut down on his drinking and attended a Christian retreat for veterans. Even so, there's no telling when something will come along that can create a potential crisis, as when the GPS navigation device in the car won't work.

He hasn't hit her since last year, the woman said, when he smashed her face in the shower and choked her. It was over something the former Marine acknowledged was "something very stupid. A lot of these things, I can't remember what I was so pissed off about," he said.

The couple was asked whether they felt they'd made it out of the woods.

"No, not even close," the former Marine said.

"And we never will be," his wife said.

The woman acknowledged that people urge her to leave the relationship, but she told NPR that she is staying. She does not blame anyone else who leaves a situation like hers, she said, but she is staying with her husband.

"He is not his post-traumatic stress disorder," she said. "He is not his brain injury. These are things he has gotten from serving his country. And that is what we deal with."

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Scans Show 'Brain Dictionary' Groups Words By Meaning

Wed, 04/27/2016 - 1:00pm

MRI scans suggests words stimulate different regions of the brain depending on their meaning.

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Scientists say they have made an atlas of where words' meanings are located in the brain. The map shows that words are represented in different regions throughout the brain's outer layer.

Moreover, the brains of different people map language in the same way. "These maps are remarkably consistent from person to person," says Jack Gallant, a neuroscientist at the University of California, Berkeley who led the study. The work appears in the journal Nature.

To make the language maps, Gallant's team placed seven people in functional MRI scanners. They then played the research subjects two hours of stories from The Moth Radio Hour. Researchers looked at many pea-size areas of the brain to gauge how each responded to words. They found that words with related meanings lit up similar parts of the brain. One area responded to words related to people. Another responded to numbers.

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Words' meanings could pop up in different places simultaneously. Hearing the word "top" caused regions associated with clothing and appearances to light up. But "top" could also stimulate a region associated with words related to numbers and measurements.

Although the study size was small, the researchers saw consistent patterns.

Gallant says the findings contradict two beliefs nonscientists commonly have about the brain. First, that only the left hemisphere handles language. Second, that the brain has localized regions that handle specific tasks.

Contrary to those ideas, he says, language and meaning are distributed. "It's not that there's one brain area and one function," he says.

But for Gallant, the real surprise is that the meanings of words triggered the same brain regions across multiple people in his study. "It's even hard to define what meaning means," he says. "It's kind of remarkable to me that it maps so systematically and so similarly across the brains of all these individual people."

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Ruling May Help Patients Keep More Of The Winnings When They Sue

Wed, 04/27/2016 - 5:00am
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Accidents happen, and if they are someone else's fault, you can go to court to try to get compensation for your medical expenses, lost wages and pain and suffering. If you win, though, the pot of gold you receive may be considerably smaller than you expect. Your health plan may claim some — or all — of the award as reimbursement for money it spent on your medical care.

That is completely legal and it happens all the time. But a recent U.S. Supreme Court decision gives consumers ammunition to push back against the health plan.

The basic facts of the case are common: In December 2008, a drunken driver ran a stop sign and hit Robert Montanile, seriously injuring him. Montanile had lumbar spinal fusion surgery and other medical treatment that cost $121,044 and was paid for by his health plan — the National Elevator Industry Health Benefit Plan. Montanile sued the drunken driver and won a settlement of $500,000. He paid his attorneys $263,788 in fees and expenses, leaving him $236,212.

Montanile's health plan claimed it was entitled to be reimbursed for his medical care.

Contract provisions that allow health plans to reimburse themselves if a member receives a personal injury settlement or jury award are routine; such clauses often assert that the plan should be first in line for money from an award or settlement. The notion is that if the injured person is permitted to keep the money that was paid on his behalf for medical expenses, he's essentially getting his medical bills paid twice — once by the insurer and then again under the settlement.

Montanile hired another lawyer to negotiate with the health plan. But when those talks reached an impasse, Montanile's attorney informed the plan's trustees that if he didn't hear from them in two weeks he would release the remaining settlement money to Montanile. And when the health plan didn't respond, that's what the attorney did.

The health plan later sued Montanile for the money, but he said he had already spent nearly all of it to pay his second lawyer and to care for himself and his daughter. Lower courts ruled that the health plan was entitled to reimburse itself from Montanile's general assets. The Supreme Court disagreed, ruling 8 to 1 in January that the health plan was entitled to take only the specific pot of money Montanile received in the settlement — or goods that could be traced to it.

The case was remanded back to a lower court, and the National Elevator Industry Health Benefit Plan may yet be able to recover some money from Montanile if it can trace assets to the settlement he received, said Radha Pathak, one of Montanile's lawyers at Stris and Maher, the Los Angeles-based law firm that represented him in the appellate and Supreme Court cases.

In the simplest sense, the case turned on a lapse in timing. If the health plan had responded to the letter sent by Montanile's attorney within 14 days, it might have received the funds it was entitled to.

"The clearest message is that if plans want to assert their rights, they need to do it promptly," said Leslie Anderson, a partner in the Washington Resource Group at benefits consultant Mercer.

But the Supreme Court's decision also has a significant impact on consumers, who are often fighting an uphill battle in these cases. The court ruling makes it clear that health plans can't seize an individual's general assets to pay themselves back for medical expenses. It may also improve consumers' odds of receiving a larger portion of any settlement or jury award by prompting the plan to respond quickly in negotiations.

In these cases, problems sometimes arise when there's not enough money to go around. The total — especially after paying legal bills — may not be large enough to cover the injured person's medical bills as well as the amounts awarded for lost wages and pain and suffering. In those cases, health plans may claim all or a significant portion of the settlement, leaving the injured person who brought the lawsuit with nothing, or at least much less than the amount that was awarded.

Jason Lacey, a partner at Foulston Siefkin in Wichita, Kan., who represents employers in such cases, says he understands how the process may seem unfair to somebody who has been hurt, and then taken on the task of going to court. " "I took the time to go out and file this lawsuit, and you're swooping in at last minute and feeding off my efforts,' " is how they might feel, Lacey said.

About half of all states have laws that limit or prohibit health plans from reimbursing themselves in this type of case until the consumer has received all that she was awarded, such as lost wages and pain and suffering. But those laws don't apply to self-insured companies that pay health care claims directly rather than buying insurance.

The Supreme Court's decision may encourage insurers to sit down and negotiate sooner with the person who was injured about how to divvy up any settlement or jury award in a way that feels fair to both sides, says Matt Wessler, a principal partner at Gupta Wessler in Washington, D.C., who has represented injured consumers in these types of cases.

It was hard in the past for health plan members and their lawyers to suss out whether a health insurer intended to assert a lien in these cases and if so, for how much, Wessler says. Now, after the Montanile decision, the person who won the award may have some leverage.

If health plans don't notify the worker or his lawyer early in the process that they have an interest in any potential award, Wessler says, "they risk the possibility that by the time they actually get something sorted out the money will be gone."

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

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Immunotherapy Tablets For Dust Mite Allergy Reduce Asthma Risk

Tue, 04/26/2016 - 12:37pm

Which would you choose — a daily tablet or a trip to the doctor for an allergy shot?

Eddie Lawrence/Dorling Kindersley/Getty Images

Immunotherapy tablets are starting to edge out shots as a treatment for allergies. And it looks like the pills can help reduce the frequency of asthma attacks, too.

Scientists reported Tuesday that immunotherapy tablets for dust mite allergy reduced the risk of an attack in people with moderate to severe asthma. The results were published in JAMA, the journal of the American Medical Association.

Allergies are a big trigger of asthma, and allergy to dust mites, tiny insects that live in homes, is the most common allergic asthma trigger.

The 693 people who completed the study had asthma that wasn't well controlled by inhaled corticosteroids. Half of the participants took a pill made of dust-mite allergen daily, letting it dissolve under the tongue. The immunotherapy tablet significantly reduced the risk of a moderate or severe asthma attack.

It's the first time sublingual immunotherapy tablets (often referred to as SLIT) have been tested as an asthma treatment, according to Dr. J. Christian Virchow, a professor of pulmonology at the University of Rostock in Germany and lead author of the study.

"It's the first large-scale study and I should be modest, but I think it's a bit of a milestone," Virchow told Shots. Earlier studies didn't look specifically at how immunotherapy shots affected asthma, he says. Rather they studied allergic rhinitis and then sifted out the people with asthma after the fact.

Allergy shots that inject an allergen extract under the skin have long been used to treat asthma, allergies and eczema, but they're a pain in many ways. So patients and doctors have been eager to see if the tablets could work as well to tame the runaway immune response that causes allergic symptoms.

In 2014, the Food and Drug Administration approved Oralair for grass allergies. It was the first sublingual allergy immunotherapy tablet approved for use in the United States. It then approved Grastek, also for grass allergies, and Ragwitek, for, you guessed it, ragweed.

The tablets typically are to be taken daily for three years, with protection from symptoms continuing after that. They're about as effective as allergy shots, and less likely to prompt anaphylactic shock. The risk of a rare life-threatening reaction is one big reason that allergy shots are given at a doctor's office.

None of the participants in the study had serious side effects. Some had local side effects like swelling of the lips and tongue or an itchy throat.

The dust mite tablets for asthma haven't been tested in children, but Virchow says he thinks the treatment might actually work better for them than for adults. The people in the study had had asthma for a mean of 13 years, he says, and may not have responded as well as a child who was recently diagnosed. "But we need to have a study in children."

"More research needs to be done" is a cliche of biomedicine, but here's a case where it's really true, according to an editorial that accompanies this study. Most people with allergies are allergic to more than one substance. As more sublingual allergen tablets are tested and approved, patients should be able to tailor their allergy or asthma treatment in a way that's been impossible before.

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Letters Telling Women About Breast Density Are Often Too Darn Dense

Tue, 04/26/2016 - 11:04am

Over the past decade, states have passed laws intended to help women understand the results of their breast cancer screening mammograms if they have dense breasts. But those notifications can be downright confusing and may, in fact, cause more misunderstanding than understanding.

A study published Tuesday in JAMA, the journal of the American Medical Association, finds the wording of some notifications so complex that only a Ph.D. could understand them. This lack of simple, direct information could lead to greater health disparities in diagnosis and treatment of breast cancer, since having dense breasts makes it a bit more likely that a woman will have breast cancer and also that cancer could be missed on a mammogram.

Breast density is normal and common, but the only way a woman can find out that she has dense breasts, which have more fibrous and glandular tissue, is by having a mammogram. Patient advocates have pushed for state laws requiring that mammography providers tell women about breast density when they send out their mammogram results. Connecticut was the first state to pass a breast density notification law, in 2009. Since then, 24 states have followed.

In this study, researchers analyzed the language and content of notifications in 23 states. They found wide variation in how the information was presented. Some states mention increased cancer risk; some recommend additional screening (such as ultrasound or MRI); and some advise women to consult their physician. But there was no uniformity.

Even more worrisome, researchers found that in many states the information was just too complicated. About 20 percent of the U.S. population reads below fifth-grade level. The language presented in the breast density notification was at or above the high school level, on average.

"Even just a few high-level words will make the material much more difficult to understand," says researcher Nancy Kressin, director of the Health and Healthcare Disparities Research Program at the Boston University School of Medicine. On average, the literacy level of the notes ranged from high school level to post-college graduate school level. So for women with low levels of literacy who are already less likely to get preventive screening, Kressin says these letters could "increase anxiety and confusion."

Take New Jersey. Kressin says that about 17 percent of the state's population has low literacy skills, yet the breast density notification reads like a graduate-level textbook. Complex terminology or jargon is in italics:

If your mammogram demonstrates that you have dense breast tissue which could hide small abnormalities, you might benefit from supplementary screening tests which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors.

The state of Alabama did far better. About 15 percent of state residents lack basic literacy skills, says Kressin, and the notification was written at seventh-grade literacy levels:

Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue may make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.

The information is clear and precise, and the recommendation to discuss with the doctor is straightforward and simple.

Kressin says the goal of the breast density notifications is to get every woman to consult with her doctor about her individual risk factors for cancer, because the answer might be that no more screening is needed. "We think those conversations should include benefits and possible harms of additional screening including additional exposure to radiation, additional cost, anxiety and even unneeded biopsies," she says.

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Only Human: A Birth That Launched The Search For A Down Syndrome Test

Tue, 04/26/2016 - 7:17am

Michael Herzenberg and his birth mother, Lee.

Mary Harris/WNYC

Only Human is a new podcast from WNYC Studios. Hosted by Mary Harris, Only Human tells stories we all can relate to. Because every body has a story. Subscribe to Only Human on iTunes or wherever you like to get your podcasts.

When Lee Herzenberg remembers the day her son Michael was born, she laughs and calls it a "cool birth." Her obstetrician was a friend, and she describes it almost like a party — "a little bit painful, but that you forget very quickly." Lee even got a kick out of the fact that a resident learned to do an episiotomy on her.

It was November 1961, and she was at the newly christened Palo Alto-Stanford Hospital Center; her husband, Len, was a biology professor on campus. Like most fathers at the time, he didn't attend the birth, which meant he wasn't there when Michael started turning blue.

The nurses whisked the newborn off to the nursery without telling Lee anything was wrong.

It was then that a doctor noticed the characteristic features of Down syndrome: floppy muscles, eyes that slanted upward. They got Michael breathing again, but doctors thought his prognosis was grim. They gave Michael just a few months to live. A daisy chain of physicians was called, and Lee says it was a pediatrics professor who told her husband what had happened. Then Len was dispatched to tell Lee.

She remembers the moment with uncharacteristic emotion. "We hugged each other, and it was a terrible conversation to realize that you'd lost the baby, but the baby was lost," Lee says now. "We knew immediately what we'd do. We had already made the decision that it was not a good thing to take the baby home, and so we didn't."

In the 1960s — an era before neurodiversity movements and early intervention programs — many people still called people with Down syndrome "mongoloids." Playwright Arthur Miller institutionalized his son, Daniel, in 1966. A few years later, an article in The Atlantic Monthly argued that "a Down's is not a person."

Lee and Len Herzenberg had seen friends struggle with the birth of a child with Down syndrome and had even gone with a colleague to an institution, where he dropped off his own infant daughter.

So, they decided Michael would never come home.

But Michael wasn't absolutely lost to them. Michael's birth sparked their search for a blood test that has revolutionized prenatal care in this country.

I made the mistake of telling one scientist I was reporting about "Len Herzenberg's lab." He corrected me instantly: "Len and Lee's lab." Because Lee Herzenberg was "leaning in" decades before Sheryl Sandberg coined the phrase. At 81, Lee, a professor of genetics, is still running the lab she and her husband founded more than 50 years ago. Len died in 2013.

The lab is a quirky place, even by Stanford standards. Lee rarely sits on chairs, preferring cushions on the floor. She's often accompanied by her bichon frise, Gigi. Researchers can often be found working in this basement office well into the night.

But Lee Herzenberg isn't just quirky. She is one of the few professors at Stanford — possibly the only one — never to have officially graduated from college. Instead, she trained by her husband's side, auditing courses while he got his Ph.D. at Caltech (women weren't allowed to attend at the time) and working at his labs at the Pasteur Institute in Paris and the National Institutes of Health.

And the science that's been done here has changed the course of medicine.

The Herzenbergs are best known as the creators of the modern-day fluorescence-activated flow cytometer, or FACS. It was a machine born out of frustration: Len couldn't stand squinting down a microscope looking at cells.

Before the FACS, a biologist peering at slides could feel like he was playing a really intense round of "Where's Waldo," staring at crowds of all kinds of cells, trying to pinpoint the exact ones he was looking for. Not only was it annoying — Len Herzenberg worried it wasn't particularly scientific. He wanted a way to find and describe cells that didn't rely on his worn-out eyes.

The FACS allows you to pour cells in, program the machine to find whatever it is you're looking for, and then it will spit out a little tube of just those cells alone. And the FACS gives you all kinds of information, too: how big the cells are and how much DNA they have inside.

The FACS was used to diagnose AIDS because the technology can quickly and easily sort out T cells. The FACS was used to find the first stem cells. When Len Herzenberg died, one colleague told The New York Times that "without Len, tens of thousands of people now alive would not be."

But in the 1970s, the Herzenbergs were still proving the value of this machine. That's when they started thinking about using it to create a blood test for Down syndrome.

One of Michael's albums, with a photo of his birth parents, Lee and Len Herzenberg.

Mary Harris/WNYC

Len had seen research from Finland claiming it was possible to see a fetus's cells in a mother's blood. It was hard to believe. But he figured that FACS, with its nearly magical sorting capabilities, could figure it out. So he took on a medical student named Diana Bianchi as a research associate and made sorting out these cells her project.

If they could isolate these cells, he could learn a lot about the developing fetus, including whether the fetus had chromosomal abnormalities.

"They had a very personal reason for doing this, because of their son Michael," Bianchi says now. "They wanted to have a test that could be offered to any pregnant woman — that would be noninvasive and would allow them to know if a child had Down syndrome. The first step, however, was to show that you could pull out fetal cells."

Scientists now estimate that for every 200 billion cells in a mother's bloodstream, about 10 of those are fetal cells. Bianchi was one of the first people to see them.

The New York Times quoted Len saying the work was a "first step" toward a blood test for Down syndrome for all pregnant women. But it would take 30 years for a practical test to become a reality.

As it turned out, Len's FACS wasn't the right tool for prenatal diagnosis. There weren't very many fetal cells to be sorted, and if a pregnant woman already had children, scientists couldn't be sure if the cells in her blood came from the current fetus or one of her older kids.

But in 2008, Len helped ensure the right tool was found.

A researcher named Stephen Quake had discovered a way to sequence chunks of fetal DNA floating in expectant mothers' blood. As a member of the National Academy of Sciences, Len made sure the paper was published in the academy's journal. Another researcher, Dennis Lo, confirmed Quake's findings. Three years later, the tests were on the market.

Now, at just 10 weeks into a pregnancy, a whole range of things can be revealed with this test. Not just Down syndrome, but a host of other chromosomal abnormalities as well as the sex of the child to be.

Until this test, doctors had to rely on amniocentesis, an invasive procedure that involves inserting a needle in the womb to sample amniotic fluid, or biopsying the placenta, to tell them with any reliability whether a fetus had a chromosomal abnormality. These tests aren't just uncomfortable; they come with a risk of miscarriage. By some estimates, in the past five years the number of these procedures performed in this country has plummeted by more than 50 percent.

To some parents, this knowledge can be alarming. Advocates in Ohio are trying to pass a law preventing abortions if Down syndrome is the reason (North Dakota and Indiana have already passed similar laws).

Lee Herzenberg is honest about what she would have done if she'd known early on in her pregnancy that Michael had Down syndrome.

"I'd say if I had the choice of not pushing Michael into this life — if I at that time would know I was carrying a Down syndrome child — I would have aborted the child," she says. "I see no reason Michael has to live the life he leads. The fact that we've made it very happy for him or that he's made it very happy for us — all of that is adapting to a situation, but I don't think it's fair or proper."

But Lee is alarmed that these tests are now being used to determine the sex of unborn babies. She worries about parents choosing to abort girls.

Diana Bianchi, that medical student from the Herzenberg lab, is now a professor at Tufts, where she founded the Mother Infant Research Institute. She's still working in prenatal testing. In fact, perfecting these tests has become her life's work.

But her focus has shifted. Now that she can detect Down syndrome so early, she wants to treat it early, too — in the womb. Because finding this chromosomal abnormality at 10 weeks means there's a window of opportunity: The brain changes associated with Down syndrome don't occur until a month or so later. Theoretically, you could treat a fetus before some brain changes occur at all.

Bianchi's work is still early. She's experimenting with mice, giving them existing drugs in utero to see if she can forestall brain damage.

There's an often-quoted statistic, that 90 percent of parents who find out that their fetus has Down syndrome will abort. But that statistic is from a study done in the United Kingdom. In the U.S., far fewer women terminate.

"We have to unpack this connection between prenatal testing and abortion," she says. "We have good data to suggest that approximately 40 plus percent of women who know their fetus has Down syndrome continue their pregnancy. There are many women who speak very highly of the fact that this allows them to prepare."

The Down syndrome baby who kicked off the search for this blood test is now a 54-year-old man. He lives in a squat house in Redwood City, Calif., just a 30-minute drive from his birth mother's home.

For years, Michael lived with a local woman named Barbara Jennings, who raised a number of children with developmental challenges. The Herzenbergs' pediatrician helped them find her when Michael was a newborn. The Herzenbergs would visit Michael every month or so, but they never felt they should bring him home. When Barbara died, Michael moved to this group home.

It's hard to know how much Michael understands when I speak to him, though he has learned to read and use a cellphone. And he's stubborn. A lot like his mother, actually. "Michael has the hardest head in the whole world," says Janet Thomas, the caretaker who runs this house. "He does whatever he wants to do. He does not care whatever you say. He's going to do whatever it is he wants to do — that's Michael."

I asked Lee if she ever regretted not raising Michael, and she said no. "It was a decision that was selfish, if you like, because we had things we wanted to do. In retrospect, a lot of things would never have gotten done. There would be no FACS had we decided to do this. Because it would have been a very intensive kind of upbringing."

As for Michael, he clearly loves his mother, no matter what she decided. In Michael's room, there are photos on almost every surface, with snapshots of his biological and adopted families. In the corner is a huge poster of his father, celebrating when he won the Kyoto Prize for his contributions to biotechnology. And deep in one album, there's a picture of Len and Lee together. The caption reads: "Michael's Other Mom + Dad."

Copyright 2016 WNYC Radio. To see more, visit WNYC Radio.
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Many Grouchy, Error-Prone Workers Just Need More Sleep

Tue, 04/26/2016 - 4:29am
Many Grouchy, Error-Prone Workers Just Need More Sleep Listen· 3:59 3:59
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April 26, 20164:29 AM ET Heard on Morning Edition

One Silicon Valley startup that encouraged its employees to think about work 24/7 found they missed market signals, tanked deals and became too irritable to build crucial working relationships.

Hill Street Studios/Blend Images/Getty Images

Hey! Wake up! Need another cup of coffee?

Join the club. Apparently about a third of Americans are sleep-deprived. And their employers are probably paying for it, in the form of mistakes, productivity loss, accidents and increased health insurance costs.

A recent Robert Wood Johnson Foundation report found a third of Americans get less sleep than the recommended seven hours a night. Another survey by Accountemps, an accounting services firm, put that number at nearly 75 percent in March. Bill Driscoll, Accountemps' regional president in the greater Boston area, says some sleepy accountants even admitted it caused them to make costly mistakes.

"One person deleted a project that took 1,000 hours to put together," Driscoll says. "Another person missed a decimal point on an estimated payment and the client overpaid by $1 million.

Oops.

William David Brown, a sleep psychologist at the University of Texas Southwestern Medical School and author of Sleeping Your Way to the Top, says Americans are sacrificing more and more sleep every year. Fatigue is cumulative, he says, and missing the equivalent of one night's sleep is like having a blood alcohol concentration of about 0.1 — above the legal limit to drive.

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"About a third of your employees in any big company are coming to work with an equivalent impairment level of being intoxicated," Brown says.

He says lack of sleep affects brain function, memory, heart health and makes people prone to depression and diabetes. That's why people with an "insomnia" diagnosis are twice as likely to miss work, Brown says, than somebody without the diagnosis.

And, not surprisingly, accidents are a consequence, too, mostly between midnight and early morning, as well as in midafternoon — the periods in the circadian cycle when humans tend to be most tired. Sleepy workers can make lethal mistakes; a 2007 report in the Joint Commission Journal on Quality and Patient Safety found, among other problems, that medical residents who worked 24-hour shifts made five times as many "serious diagnostic errors" as those who were able to get more sleep.

Accidents linked to sleep-deprivation are a problem the American Trucking Association is well aware of, says Dave Osiecki, the group's vice president. Regulators impose daily and weekly driving limits on truckers, he says, but "even more important than limiting work time is the quality of sleep, the length of sleep, and you can't regulate that."

The trucking association says some companies have started testing drivers for sleep apnea and treating those who start and stop breathing when they sleep.

For some people, sleep and work can get into a bad cycle where they negatively affect each other.

A short nap actually boosts productivity, and companies have woken up to that.

"I'm definitely pretty stressed, and it's difficult to sleep," says Ari Koelle-Pittel, a senior at Drexel University who also works as a writing tutor. "Sometimes I even have dreams where I'm just like thinking about things that I have to do the next day, and it feels like I haven't slept at all when I wake up." Once after that sort of restless night, Koelle-Pittel headed off to a warm, windowless room for office hours — and quickly conked out.

"I was completely out," Koelle-Pittel says. "I was right up at the front desk and I was pretty much the first thing that anyone could see when they walked in."

That wasn't just embarrassing. The sleep issue creates focus issues, too.

"There are times when I've just blanked out in the middle of a sentence," Koelle-Pittel says, "where I was trying to explain a concept and I had to stop and say, 'All right, we need to go back, I'm so sorry.' "

Most people aren't nice when they get too little sleep.

Mike Grandinetti worked in a Silicon Valley startup where the boss routinely demanded all-nighters and walked around with a baseball bat to enforce a sense of urgency. Grandinetti, who now works at a different firm, says the 24/7 approach of the firm backfired: People missed market signals and tanked deals, and the whole venture became so unpleasant because people were so doggone tired.

"Employees wind up becoming irritable, and they're less likely to socialize with one another outside of work, which is really critical in building relationships," he says.

If there's a growing crisis at the nexus of sleep and work, it's not clear what employers are doing about it. The Society for Human Resource Management says 6 percent of employers offered nap rooms in 2011. That dropped to 2 percent last year.

But according to Christopher Lindholst, the sale of napping pods at his company, MetroNaps, increased 38 percent last year. The pods look like New Age capsules that cocoon the napper's head, and dim the lights or offer soothing sounds. Lindholst says companies can track how often the pods are used and when, and that they're seeing benefits.

"A short nap actually boosts productivity," he says, "and companies have woken up to that."

Pun intended, of course.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Lesson Learned For Baltimore's Health Commissioner: 'I Like A Fight'

Mon, 04/25/2016 - 4:08pm
Lesson Learned For Baltimore's Health Commissioner: 'I Like A Fight' Listen· 5:23 5:23
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April 25, 20164:08 PM ET Heard on All Things Considered

North Stricker Street near Riggs Avenue in the Sandtown-Winchester neighborhood of Baltimore.

Lance Rosenfield/The Washington Post/Getty Images

To wrap up our series on public health in Baltimore, Audie Cornish met up with Baltimore City Health Commissioner Leana Wen in Freddie Gray's neighborhood of Sandtown-Winchester. The health department recently opened a new outpost of its violence prevention program Safe Streets there, employing ex-offenders to mediate conflicts before they erupt in violence.

Wen spoke about pushing a public health agenda in a city that has long struggled with poverty, violence and addiction. She also talked about what she, as an emergency physician, has learned in her first stint in government. Here are interview highlights, edited for length and clarity.

On her goal to make Baltimore a model for the country

We have gotten significant national recognition for some of our programs, including our programs to respond to the opioid overdose epidemic. I had the opportunity to testify in front of the U.S. Senate and House and was invited to speak with President Obama about Baltimore's work. I do believe that because of the way we've focused on addiction as a disease, that that's changing the conversation in our city and actually, is leading the way around the country. People are beginning to see Baltimore not as [the HBO drama] The Wire and heroin overdose but actually as a model for recovery and resilience.

On what she wants to tackle next

The unrest [after Freddie Gray] paradoxically opened the door for us to address trauma, which is a natural segue to talk about mental health and the bigger picture of emotional well-being. People finally felt like they could talk about the trauma they've experienced for so many years. It's the trauma of police brutality. It's the trauma of discriminatory practices. It's the trauma even of being poor. We now want to convene a citywide group to address this issue, which is very difficult because ultimately, the trauma work has to be done at the community level.

On her optimism, despite the challenges Baltimore faces

Dr. Leana Wen, Baltimore City health commissioner, visits a newly opened Safe Streets center in the Sandtown-Winchester neighborhood in West Baltimore.

Emily Bogle/NPR

I'm not blind to the problems that exist. But I also realize these problems have been in the making for decades. We're not going to be able to make a huge difference overnight. But there are things we can do along the way to demonstrate to our community that we hear you, and this is what we do in the meantime. We cannot solve the issue of addiction overnight, but we can reduce overdose deaths, and we have passed a Good Samaritan law [to protect people who help overdose victims] and we are introducing programs where individuals caught with drugs are not going to be incarcerated but actually, are going to be offered drug treatment. So we're showing that things can be done, and that we're taking small steps. And actually, our community gets it. If we just came to the community and said we're going to solve all of our crime problems overnight, they're not going to buy it. But if we say we know the success of Safe Streets, it's been demonstrated in four sites across our city, now we're going to open a fifth site in Sandtown, you can feel the energy and the optimism. And maybe that's why I'm so optimistic.

On what she's learned from the job since she began in January 2015

I was never in the political world, and I'm not from Baltimore. So coming here, everyone was new. It's been a really steep learning curve.

The things I've learned over the year have been a lot about myself, and who I am as a manager, who I am with navigating complicated politics and situations, but also what motivates me. And I've learned that I like a fight. I don't want to be in a situation where things are going well. I don't feel like I have anything to do in that case. In the ER, it's the patient dying in front of me. It's someone who is gravely ill, and my fight is the fight to save their life.

I see the same thing in Baltimore. There are so many problems. There are so many fights I can have every single day. It's the fight to get health on every agenda, to change legislation, to change public perception and mindset, to reduce stigma, to introduce new programs in a time of severe fiscal constraints. I like a fight, and I'm good at it, and that is what motivates me.

I'm learning now just how powerful that voice can be — to say, I'm not here as a politician. I'm here as a doctor and as a scientist. I'm here to give voice to all these issues that we've seen that are unfair — housing politics, policing policies, drug policies. And I'm saying from a health perspective how these policies have destroyed our community, and this is what we're doing about it now.

Dr. Leana Wen has been a contributor to Shots since 2013. You can read her account of why she decided to become Baltimore's health commissioner here.

Copyright 2016 NPR. To see more, visit NPR.
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Students Rally To Save Program That Produces Primary Care Doctors

Mon, 04/25/2016 - 1:01pm

The unique medical program at the University of California, Berkeley is housed in its School of Public Health.

Justin Sullivan/Getty Images

Budget woes at the University of California, Berkeley could force the shutdown of a program many people are unaware of — its medical program.

The Joint Medical Program, part of Berkeley's School of Public Health, is small. Just 16 students a year are admitted. Under a university budget restructuring process initiated in February by Berkeley's Chancellor Nicholas Dirks, the School of Public Health must cut expenses by roughly 3 percent — or about $900,000.

One of the items on the list to meet that target is closure of the Joint Medical Program. Losing 16 new doctors a year may not sound dramatic, but this particular population is unusual in medicine. While most medical students head into lucrative specialties, the majority of this program's graduates go into primary care.

John Balmes, acting director of the program, says California needs these doctors. The state, he says, "is 43rd in the nation in terms of primary care physicians." And with the Affordable Care Act increasing the number of insured Californians, "We need more primary care physicians, not less."

In 2014, just 12 percent of medical students nationally went into primary care residencies. By contrast, more than half of the graduates of the Berkeley program have gone into primary care. It's unclear exactly why so many students go into primary care. One clue lies in the program's unusual approach to curriculum.

The program, established in 1971, prides itself on avoiding lecture halls and instead focusing on what it calls "problem-based learning," where students review cases as a group. In addition, the medical program is one of few nationally, says second-year student Josh Pepper, that is housed within a school of public health, and that gives a broader focus to patients' lives.

"We're constantly having to question how things like socioeconomic status, insurance, housing and culture and addiction play a role in patients' health outcomes," Pepper said.

It gives a more holistic perspective, he says. "We develop a whole skill set you don't normally get at a traditional medical school." Pepper has helped launch an online petition in support of the program.

It's called a joint medical program because students do three years at Berkeley's School of Public Health, during which they do an original research project. They then go to the medical school at the University of California, San Francisco for two years of clinical rotation. They graduate with a master's in science and an M.D.

A report earlier this year commissioned by the California Primary Care Association detailed the shortfall in primary care providers in California. The state's ratio of primary care physicians in its Medicaid program, called Medi-Cal, is roughly half the federal recommendation, it said. By 2030, the analysis predicted a shortage of more than 8,000 primary care doctors.

"Certainly with the shortage we are facing, we should not eliminate any existing programs that we know have successful track records into funneling people into primary care," says Carmela Castellano-Garcia, president of the California Primary Care Association. "We cannot afford that at this time."

All of Cal's professional schools, including the School of Public Health, must trim expenses by the same rate, says Dan Mogulof, a spokesman for the university, and it's up to the schools themselves to determine how to meet the target.

Linda Anderberg, director of communications for the School of Public Health, said it is considering several options to achieve the budget cuts. "The school does not want to lose the program," she says.

She stressed that no decisions have been made and that the process would be completed during the summer. Most of the cuts would not go into effect until 2018, she said.

Meanwhile, staff and students are speaking out to try to save the program.

"If I had to go to medical school all over again, I'd want to do it in the Joint Medical Program," says acting director Balmes. He says there's an advantage to being in a small, supportive environment.

"I think that translates into very fine doctors, because they're good human beings as well as good doctors," he says.

This story was produced by member station KQED's blog State of Health.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
Categories: NPR Blogs

Pastoral Medicine Credentials Raise Questions In Texas

Mon, 04/25/2016 - 4:49am
Pastoral Medicine Credentials Raise Questions In Texas Listen· 6:32 6:32
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April 25, 20164:49 AM ET Heard on Morning Edition

From

Maria Fabrizio for NPR

You've probably heard of the credentials M.D. and R.N., and maybe N.P. The people using those letters are doctors, registered nurses and nurse practitioners. But what about PSC.D or D.PSc? Those letters refer to someone who practices pastoral medicine — or "Bible-based" health care.

It's a relatively new title being used by some alternative health practitioners. The Texas-based Pastoral Medical Association gives out "pastoral provider licenses" in all 50 states and 30 countries. Some providers call themselves doctors of pastoral medicine. But these licenses are not medical degrees. That has watchdog organizations concerned that some patients may not understand what this certification really means.

That includes patients like 60-year-old Mark Sarchioto, who lives just outside Dallas. Sarchioto has crippling neuropathy and has been searching for a treatment for decades. One leg is numb, and as he shifts from his walker to the couch, he holds out his left hand.

"It feels like somebody is puncturing it with needles," he says. "Right now it's cold and I can't keep it warm."

In 2013, he and his wife, Joan Sarchioto, heard an ad for a breakthrough therapy for neuropathy at HealthCore Center in Richardson, Texas. They jumped at the chance for a free evaluation. But it didn't take long to realize the free evaluation was going to cost them.

"We get in and the [medical assistant] or whoever takes the vitals and they go, 'We need to go take your X-rays and there's an evaluation fee of $35.' And I said, 'But I thought this was free,' " Joan Sarchioto says. "When they start ordering tests, I know what's BS — and I know what's not."

The founder of HealthCore Center is Karl Jawhari. He is a chiropractor, but says he practices "functional medicine" under his license from the Pastoral Medical Association.

HealthCore Center advertises natural weight loss, help for hypothyroidism and diabetes programs — and on its website it touts its employees as doctors of pastoral medicine. Jawhari's office walls are lined with framed certificates, and there's a Bible on his desk.

"We've seen people with an array of issues: thyroid issues, diabetes, blood pressure, cholesterol," Jawhari says. "We work with a lot of people to reduce their weight and so forth and we've had great success with that."

Jawhari hasn't always had success with state regulators. Last August, he was fined $2,500 by the Texas Board of Chiropractic Examiners for deceptive advertising. In June, the Texas Medical Board — which licenses, regulates and disciplines physicians, physician assistants and other practitioners — issued a cease and desist order demanding that Jawhari stop offering to treat conditions beyond his chiropractic training.

He says he's done that.

There may be people who take advantage of the pastoral license, he says, but he's not one of them.

"I've heard of a few people that are practicing that aren't even doctors," he says. "It's up to the consumer to do due diligence and figure out is this practitioner — does this doctor know what he's doing?"

In recent years, the Texas Medical Board has sent about a dozen cease and desist orders to people using the pastoral medicine certification. Some hawk dubious supplements like colloidal silver, promise extreme weight loss, treat thyroid disorders and discourage vaccine use.

The Texas Medical Board has just become aware of the term pastoral medicine in the past couple of years, says Mari Robinson, the board's president.

"Folks are purporting to treat and diagnose illness using that term," she says. "It's not a degree; it's not a license."

At least not a license recognized by the Texas Medical Board. NPR reached out to several other people in North Texas who have licenses from the Pastoral Medical Association. None agreed to talk.

Many of the practitioners who highlight their pastoral medical degrees have slick websites touting patient success stories.

Robinson says anyone in the United States who wants to create a website can do so, but it is illegal to diagnose what is wrong with someone, treat them, or offer to treat them without the appropriate training and licensing.

The Pastoral Medical Association didn't respond to several attempts to connect by phone. It did send a statement by email explaining it was founded by a group of Christians concerned with the increase in chronic illness. The association says it seeks to protect "the Almighty's Health Care workers."

According to the association's website, to obtain a license, applicants must pass "rigid standards" that the group wouldn't share. Members also have to pay processing and annual fees that can range from a few hundred dollars to a few thousand.

So, why might someone join?

People may feel they are more marketable if they get some credentials, says Stephen Barrett, a retired psychiatrist and founder of the consumer protection site Quackwatch.org.

"There are lots of credentials you can buy," he says, "and this is just one of many."

Barrett says the Pastoral Medical Association functions like a private club. Patients sign confidentiality agreements, pay out of pocket and are prohibited from suing if they're unhappy with the care they receive. Any disputes are handled by an ecclesiastical tribunal.

"They're claiming that 'Any advice we give you is pastoral in nature,' " Barrett says. "In other words, 'If I give you health advice that's not health advice, that's pastoral advice.' "

These practices do have supporters. Toni McElhaney of Plano, Texas, found out about HealthCore through a flier advertising a free thyroid seminar. She'd been taking medication for hypothyroidism but still felt exhausted.

She says she paid $300 for initial testing and $4,500 for a six-month treatment plan. None of her treatment is covered by health insurance.

McElhaney thinks the heavy metal detox, special diet and herbal supplements helped her lose weight and gain energy. So, does it matter to her that the woman she sees isn't actually a licensed doctor or nurse?

"No," she says. "It doesn't matter to me. I feel like she knows her stuff, and I have responded better to her treatment than I would have just going to an endocrinologist alone."

Sometimes traditional medicine doesn't have all the answers, and navigating what's legit in the world of alternative medicine can be tough. The key, according to Mari Robinson of the Texas Medical Board, is to really understand the qualifications of the person you are seeing. Just because someone puts doctor in front of their name doesn't mean they are medically qualified.

Copyright 2016 KERA. To see more, visit KERA.
Categories: NPR Blogs

Thousands Leave Maryland Prisons With Health Problems And No Coverage

Sun, 04/24/2016 - 8:26am

Stacey McHoul said she ran out of psychiatric medicine a few days after leaving jail last year and soon began using heroin again.

Courtesy of Kaiser Health News

Stacey McHoul left jail last summer with a history of heroin use and depression and only a few days of medicine to treat them. When the pills ran out she started thinking about hurting herself.

"Once the meds start coming out of my system, in the past, it's always caused me to relapse," she said. "I start self-medicating and trying to stop the crazy thoughts in my head."

Jail officials gave her neither prescription refills nor a Medicaid card to pay for them, she said. Within days she was back on heroin — her preferred self-medication — and sleeping in abandoned homes around Baltimore's run-down Sandtown-Winchester neighborhood.

Thousands of people leave incarceration every year without access to the coverage and care they're entitled to, jeopardizing their own health and sometimes the public's.

Advocates for ex-convicts held high hopes for the Affordable Care Act's Medicaid expansion that promised to deliver insurance to previously excluded single adults starting in 2014, including almost everybody released from prisons and jails.

Many former inmates are mentally ill or struggle with drug abuse, diabetes or HIV and hepatitis C infection. Most return to poor communities such as West Baltimore's Sandtown, which exploded in violence a year ago after Freddie Gray died from injuries sustained in police custody.

But Maryland's prison agency, which three years ago said it was "well positioned" to enroll released inmates in Medicaid, is signing up fewer than a tenth of those who leave prisons and jails every year, according to state data. Few other states that have expanded Medicaid under the health law are doing any better, specialists say.

Officials of the Maryland Department of Public Safety and Correctional Services say they do the best they can with limited resources, enrolling the most severely ill in Medicaid while letting most ex-inmates fend for themselves.

"We are battling, every one of us," to maximize coverage, said prison medical director Dr. Sharon Baucom, pointing to efforts to train sign-up specialists, get Medicaid insurance for hospitalized inmates and share information on mentally ill inmates with other agencies.

"There are handoffs that could be improved," she said. "With the resources that we currently have, and the process that we have in place, we could do more — and we just need some more help."

Coverage under Medicaid was seen as an unprecedented chance to transform care for ex-inmates by connecting them to treatment, reducing emergency room visits, controlling disease and putting them on a path to rehabilitation.

As many as 90 percent of people leaving prisons and jails are eligible for Medicaid in states such as Maryland that expanded the federally supported program for low-income residents under the health act, experts estimate. The law gave states the option of extending Medicaid coverage to all low-income adults under 65, not just the children, pregnant women and disabled adults who were mainly included before.

Sickest Inmates Are First In Line

Some 12,000 of Maryland's 21,000 prison inmates are designated at any given time as chronically ill with behavioral problems, diabetes, HIV, asthma, high blood pressure and other conditions, according to prison officials. But given limited means and the already tall order of connecting emerging prisoners with transportation, shelter and employment, the system must focus on enrolling the very sickest, Baucom said.

"It's a shame to have to make that call," she said.

Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.

"People frequently ran out of their medications and did not have access to the care they needed," said Stewart, an associate professor at the Johns Hopkins University medical school.

McHoul, 40, spent two short stays last year in Baltimore's Women's Detention Center. The first time the facility released her without Medicaid coverage. Shortly afterwards she landed in a hospital with an inflamed esophagus. She got out after a second jail stay in August without knowing the hospital had enrolled her in Medicaid between incarcerations, she said.

At neither time did she have more than two weeks' supply of any medication, including Depakote, a mood stabilizer, she said. For some prescriptions there was less than a week's store.

"It was whatever was left in the blister pack," said McHoul, who's now in a Baltimore drug treatment program. "It's like, 'Here's your supply. Sign this that we gave them to you. See you later.'"

State policy is to give exiting prisoners 30 days' worth of medicine. But a court ordered McHoul released shortly after she was arrested the second time, which didn't give the jail enough time to prepare medications, said a corrections spokesman.

A Burden For Emergency Departments

There are many Stacey McHouls.

"Maybe somebody needs prescription services and they're not enrolled and they don't know where to go," said Traci Kodeck, interim CEO of HealthCare Access Maryland, a nonprofit that connects consumers to coverage and has worked with the prison system. "Absolutely it happens. Many of them will end up in the emergency departments if we don't attempt to connect them to services prior to release."

Mark Pruitt, 46, from southwest Baltimore, said lapsed Medicaid coverage meant he couldn't enter an addiction recovery program last year after he was released.

Courtesy of Kaiser Health News

Mark Pruitt, 46, was released from a Baltimore facility in October with no Medicaid card and a craving for heroin, which he said he had used before he was incarcerated for a parole violation.

He desperately wanted to enter a drug treatment program, but signing up for Medicaid to pay for it was going to take weeks — far longer than he could wait.

"I knew what I wanted. I wanted help," he said. "I really wanted help. But it's a struggle when you're broke — no money, no insurance, feeling defeated. Where do you turn?"

If administrators at a Baltimore recovery facility hadn't gotten him enrolled in Medicaid, he said, "I think I'd be dead."

From January 2014, when the Medicaid expansion took effect, through March of this year, Maryland released almost 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.

But the corrections department said it enrolled only 1,337 released inmates in Medicaid from the beginning of 2014 through late March. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)

Many ex-prisoners are enrolled only when they experience a crisis and end up in an emergency room — the kind of expensive care health officials are trying to reduce. The law requires hospitals to treat emergency cases regardless of insurance coverage. They can retroactively sign those patients for Medicaid.

'They Don't Want To Do The Paperwork'

Monique Wright, 35, got out of Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spine curvature. Without Medicaid coverage or a primary care doctor, she said she had to seek emergency care at Johns Hopkins Bayview Medical Center.

"It's the paperwork" that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. "They don't want to do the paperwork. They don't have the staff to do the paperwork."

Advocates wonder why the corrections system is so poor at enrolling what, they often point out, is "literally a captive audience."

"They've had them housed for the past 10, 15 years," said a frustrated Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. "What's so hard about it?"

Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card doesn't arrive until after they're out. Computer problems slowed signups in late 2014.

One mistake made by Maryland and most other states is not considering inmates for Medicaid until their release dates approach, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process.

"It's a bad way to do it because you're getting a very small number" of enrollees by waiting, she said. A better alternative is to enroll inmates when they are booked, as Chicago's Cook County Jail has demonstrated, she said. Those incarcerated are generally ineligible for Medicaid, but putting them in the system when they enter makes it easier to trigger coverage when they leave, she added.

Ex-Inmates Struggle To Get Medicaid Without Help

If it's hard for the prison system to enroll inmates, it's even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don't bother.

For most leaving incarceration, "it's up to you to go there, make sure you get your health insurance," said Jamal McCoy, 21, who was living with family in West Baltimore on home detention before he was released. "Most people don't go. Some people take it easy when they get home."

Those who try often find that lack of identification is the first challenge. To prevent fraud, Maryland and other states require Medicaid applicants to show verified Social Security numbers.

But jails frequently lose inmate IDs, say prisoners and enrollment officials. Those locked up for years are non-persons for much of the system, with no credit records or driver's licenses.

That can mean delays of many weeks when released prisoners are especially vulnerable. Gaps in coverage and care of even a few days after fragile patients leave the corrections health system can make the difference between life and death.

"If you're the diabetic that hasn't been compliant with your medication, you need your medication now," said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. "You can't wait two weeks because you may drop dead."

Compared with the rest of the population, ex-prisoners in Washington state were a dozen times more likely to die in the first two weeks after release, according to research by Dr. Ingrid Binswanger, lead researcher for Kaiser Permanente Colorado's Institute for Health Research. Drug overdose, cardiovascular disease, homicide and suicide were the leading causes of death.

Prison officials helped enroll William Carter, 50, in Medicaid when he was released last year. But doctors told him the coverage wouldn'€™t pay for an expensive hepatitis C drug until the virus begins damaging his liver.

Courtesy of Kaiser Health News

"It's very important to manage that transition, to make sure people have continuity of care," she said. (Kaiser Permanente has no relationship with Kaiser Health News.)

Yet in some cases the prison system has stymied outside groups trying to arrange inmates' coverage. Stewart's group repeatedly sought permission — "continuously, for about three years," she said — to meet vulnerable prisoners inside the facility to get an early start on enrollment and post-release appointments. It never happened.

Baucom blamed the problem on "competing priorities" and staff turnover.

Acceptance into Medicaid by the state isn't the end of the story. Released inmates then must enroll in a private managed care organization hired by Maryland to provide coverage. That can take weeks longer.

Even when insured, ex-inmates face the same barriers to care experienced by other low-income Baltimoreans — or worse.

Many prison inmates are infected with hepatitis C, which can cause liver damage or cancer over time. But the high cost of curing the disease has prompted Maryland's and other Medicaid programs to limit access to treatment to those whose livers are already compromised.

"I guess I got to wait until damage is done to my liver," said William Carter, 50, adding that prison officials initiated Medicaid enrollment when he got out last year.

Released prisoners often have no idea that some Medicaid managed-care contractors allow them to use only certain doctors and pharmacies.

"So a patient goes to Walgreens or wherever to fill something and it's like, 'That'll be $150,'" because he should have gone somewhere else, said Stewart. "They don't understand what the problem was."

Even checking all the right boxes sometimes isn't enough for ex-inmates, who bear the double stigma of poverty and a criminal history.

One released prisoner got an appointment to renew his mental health prescription with a facility in Carroll County, Maryland — his home — that also accepted his Medicaid card, said Baucom. After the clinic learned he had a prison record it cancelled the visit.

"It's not enough to have a card," Baucom said. "You've got to have access."

Neighborhoods are at risk when former inmates with chronic illness return.

"You really need to think about this as a public health issue," said Scott Nolen, director of drug treatment programs for the Open Society Institute–Baltimore, a nonprofit that works on criminal justice policy. "There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care."

In few places is the burden greater than Sandtown-Winchester. Gray, 25, died of spinal injuries that prosecutors filing manslaughter and assault charges blamed on police who arrested him.

The Justice Policy Institute, a nonprofit, called Sandtown "ground zero for the use of incarceration" in Baltimore last year, estimating that nearly one resident in 30 is in prison.

At the same time, three West Baltimore ZIP codes including Sandtown showed the highest rates of HIV infection in Maryland in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.

The corrections department could use more computers, release planners and other enrollment resources, Baucom said.

"If you do the checkoff list, we've checked off everything we can do," she said, noting efforts not only to increase enrollment capacity but cooperation with the Maryland motor vehicle agency to get inmates state IDs.

Jesse Jannetta, a specialist at the Urban Institute in prisoner re-entry, believes Maryland's low signup rate "is not unusual" in other states. A study published in Health Affairs found prisons and jails nationwide had enrolled 112,520 people in Medicaid from late 2013 up to January 2015, although the authors believe the actual figure was higher.

Federal and state prisons released 636,000 people in 2014, according to the Justice Department. Millions more are estimated to cycle through jails each year.

Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates anytime soon.

"It's fair to say we're just at the tip of the iceberg" in prisoner enrollment, said Johns Hopkins' Barry, a co-author of the Health Affairs study. "Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don't have any of these types of programs in place."

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

This story came from a partnership with The Baltimore Sun and Capital News Service, which is run by the University of Maryland's Philip Merrill College of Journalism. KHN reporter Shefali Luthra and CNS reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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How Talking Openly Against Stigma Helped A Mother And Son Cope With Bipolar Disorder

Sun, 04/24/2016 - 7:57am
How Talking Openly Against Stigma Helped A Mother And Son Cope With Bipolar Disorder Listen· 11:02 11:02
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April 24, 20167:57 AM ET Heard on Weekend Edition Sunday NPR Staff LA Johnson/NPR

It was December 2012 when the country learned about the massacre at Sandy Hook Elementary School, that left 20 children dead at the hands of 20-year-old shooter Adam Lanza.

After the shock and the initial grief came questions about how it could have happened and why. Reports that Adam Lanza may have had some form of undiagnosed mental illness surfaced.

The tragedy drove Liza Long to write a blog post on that same day, titled "I Am Adam Lanza's Mother." She wasn't Lanza's mom, but she was raising a child with a mental disorder.

Her 13-year-old son had violent rages on a regular basis. He was in and out of juvenile detention. He had threatened to kill her. She detailed all this in her essay that took off online.

Now, four years later, her son is speaking out too.

This week on For The Record: a mother, a son and life on the edge of bipolar disorder.

Eric Walton, Liza Long's son, is now a 16-year-old high school sophomore in Boise, Idaho. After a series of misdiagnoses, he's been diagnosed with bipolar disorder.

But four years ago, he didn't know much about his condition.

"I knew that there were times when I would have rages, didn't like them. I knew that I wanted them to stop," Walton says.

Except he felt a loss of control in those moments. He describes the onset of these rages as a "blackout" of sorts.

"I would start getting angry," he says. "Then it's like being trapped inside a box inside your own head. It was like a television on the wall that shows you what you're seeing. You can feel everything, but you no longer have the video game controller to control your own body."

Walton's mom says when Eric would get into those states, "he would express a lot of suicidal thoughts, and hearing him just say, 'I want to die, I just want to end it.'"

Then, two days before the Newtown shooting, Eric Walton had another episode.

"It was a pretty eventful day, even for my rages," Walton recalls. "I'd woken up and I'd slipped on a pair of navy blue sweats. But my school has this policy that you have to be wearing black pants. So my mom and I got into an argument over whether navy blue was actually black."

The fight got bad and it escalated as it often did. Eric threatened to kill himself, and he threatened to kill his mom.

"At that point, we were almost to my school, but mom decided to take me to Intermountain [Hospital] instead," he says, referring to the mental health facility in Boise.

"It took I think three or four of the nurses to hold me down," he says. "They shoved a needle into my arm full of some kind of tranquilizer. And I woke up the next day in Intermountain."

That day left Liza Long feeling "completely hopeless."

"I really felt like a failure on that day," she says. "Here I had this child, he had seen multiple doctors, multiple specialists, numerous medications. Nothing had helped my child, he had been in juvenile detention four times at that point, every time for a behavioral symptom of a brain disease," she says.

Two days later, the news broke out of Newtown.

"I just put my head on my desk and started to cry," Long recalls. "I just had this overwhelming sense of empathy for Nancy Lanza. I know at that point people were already blaming her, but instead I could just see in my mind this little boy who probably had needed help."

She started writing about how tough it was to be the single mother of four kids, one of them a middle-schooler struggling with mental illness, a kid who could violently rage one hour, and turn back into a calm, sweet boy the next.

Days after she posted the essay on her anonymous blog and millions of shares later, the Huffington Post picked it up — and then it was everywhere.

Three days after she wrote the piece, she visited her son in the hospital and read it to him off her phone.

"It was very powerful piece," he says. "I had seen it as only from my point of view, but until that day, I hadn't considered what it was like for someone outside, looking in."

She got messages of support, but she also got criticism. People laid into her for comparing her son to a mass murderer, violating his privacy, and some suggested that she was somehow responsible for her son's condition. It stung, but for the most part she pushed it away.

"Mother-blaming is as old as Eve though, right, it's really easy for us to blame mothers, and that was exactly the point I was trying to make," Long says. "Families are suffering in shame and silence; I was suffering in shame and silence. So is my child. But when we don't share our stories, there's no chance that we're going to make change."

That could have been the end of the story, but that blog post ended up changing everything for Long and Walton.

Long was inundated with emails, as readers continued to reach out to her.

"One person was very persistent, and she kept saying 'I know someone who can help,' " Long says.

That person was a research assistant who worked for Dr. Demitri Papolos, director of research for the Juvenile Bipolar Research Foundation.

After meeting and talking with Walton and his mother, Dr. Papolos understood Walton's symptoms. It looked like a particular strain of bipolar disorder.

"The symptoms that occur within the manic domain are hyperactivity, agitation, racing thoughts, pressured speech," Dr. Papolos says. "In the bipolar form, you see psycho-motor retardation, lethargy, fatigue, oversleeping, depressed mood."

"Mania feels really, really good," says Eric Walton. "But it's also not that good because when you start moving at that speed, no one can keep up with you."

On the flip side of the disorder, "I go through 3-4 days of almost complete inactivity," he says. "I'm kind of depressed and lethargic, and I don't even want to get out of bed."

"They are overwhelmed with fear and they misperceive things as threatening when they're not," says Dr. Papolos.

Those symptoms check out with Walton. "Any time I felt attacked. It was like a defense mechanism type thing."

After Dr. Papolos diagnosed Walton with childhood bipolar disorder, everything got better.

"I got the correct diagnosis. I got put on the right medication. And I haven't had a rage, I think, since that day," Walton says. "It's funny, I don't even keep track anymore."

But the road to pinning down the diagnosis is often the hardest part, especially for parents, who often have to become psychiatric advocates for their children.

"The problem is that we are still relatively in infancy in terms of understanding the nature of psychiatric diagnosis, particularly in children," Dr. Papolos says. "I think [parents] have to do a lot of homework on their own. I wish I had another answer, but it's the way things are currently."

Today, Eric owns his diagnosis. "I choose to think of it as my superpower."

"I'm really, really creative. I'm very empathetic. I have a lot of skills that teenagers don't normally have: conflict resolution, mindfulness — just things I've had to pick up over the years because it kind of helped control myself before the right diagnosis."

His TED Talk in Boise early this month was the first time he outed himself publicly as the boy in that essay. And he used it to deliver a broader message:

"Mental illness should be treated with respect and kindness, not fear and stigma. People with mental illness are all human beings. And they deserve the same respect as anyone else."

And it was his mother's willingness to talk openly against mental stigma, a few years ago that helped him carry that message in the first place

"When I wrote that blog post, I was really concerned that my son's fate was prison or worse, and now we are talking every day about college, about what he'd like to major in," Liza Long says. "I don't think there are any right or wrong answers for Eric. There just a lot of great opportunities for Eric."

And her inbox is still overflowing.

"I have a tremendous sense of gratitude honestly mostly for all the — I still hear from families every day, some who just found that blog post for the first time. And to be able to connect people with resources, to be able to say 'look there is hope for you, don't give up on your kid,' that's been really powerful for me."

Copyright 2016 NPR. To see more, visit NPR.
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Florida Keys Weigh Options For Battling Mosquitoes And Zika

Fri, 04/22/2016 - 5:25pm
Florida Keys Weigh Options For Battling Mosquitoes And Zika Listen· 3:55 3:55
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April 22, 20165:25 PM ET Heard on All Things Considered

From

Key Haven, a Florida neighborhood about a mile east of Key West, is where a test of Oxitec's genetically engineered mosquitoes might take place later this year. Some neighbors have strongly dissented — at public meetings and via yard signs.

Nancy Klingener/WLRN

Billy Ryan visits Roy's Trailer Park on Florida's Stock Island every two months. It's part of his regular rounds as an inspector for the Florida Keys Mosquito Control District.

"Hey, I'm just checking on the yards for the mosquito control," he tells one resident, Marie Baptiste, as he heads into her yard. "OK?" No problem, she tells him.

People who live in the Keys are used to seeing mosquito control inspectors. Since an outbreak of dengue fever in 2009, the inspectors have conducted routine house-to-house checks in areas where the Aedes aegypti mosquito breeds.

And their eradication campaign — part education, part enforcement — has been effective. The last reported case of mosquito-borne dengue fever in the area was six years ago.

That same species of mosquito can carry the Zika virus. And although there have been no locally transmitted cases of the virus reported in Florida yet, and no signs that it's in local mosquitoes, state and local officials are more determined than ever to do what they can to protect residents from disease-carrying insects.

Ryan's eradication tools are pretty simple. He's got a turkey baster, a dipper — which is a stick with a cup at the end — and a plastic jar to collect samples. He also has pellets of larvicide to treat areas where mosquitoes breed.

In the narrow side yard next to Baptiste's trailer, Ryan finds a plastic barrel with a couple of inches of water at the bottom, and he spots some mosquito larvae bouncing around. Bingo. A. aegypti's favorite breeding ground.

Mosquito control inspector Billy Ryan climbs atop a stack of lobster traps on Stock Island, near Key West, to check a boat for water — and for mosquito larvae.

Nancy Klingener/WLRN

Ryan takes a sample and shows the larvae to Baptiste, as he tips over the bucket.

"I'm going to just flip this over, OK?" he says. "If you ever see anything holding water — or any little buckets or anything — please turn them over, because we don't want to get Zika, or chikungunya or dengue fever. OK?" Baptiste agrees.

This level of attention has been effective in the Keys, thanks largely to cooperation from residents. But another approach that local and state officials are considering to get rid of mosquitoes hasn't been as popular.

The British company Oxitec wants to hold its first U.S. trial of genetically modified mosquitoes in Key Haven, not far from the trailer park.

The plan is to release about 3 million male mosquitoes that have been engineered to produce offspring that die young and can't reproduce. According to Oxitec, experiments with this approach in other countries have reduced the population of A. aegypti mosquitoes in the test areas by as much as 80 or 90 percent.

The U.S. Food and Drug Administration's center for veterinary medicine issued a preliminary assessment in March that called the likelihood of any harm to humans, animals or the environment of the proposed Oxitec experiment in Florida negligible or low. (Members of the public have until May 13 to file formal comments on the FDA's preliminary finding.)

Oxitec releases almost exclusively male mosquitoes — and only female mosquitoes bite humans, so only female mosquitoes can transmit dengue, chikungunya or Zika viruses. But Derric Nimmo, chief of mosquito research at Oxitec, acknowledges that the sorting process isn't perfect. About one in 10,000 of the released insects, he says, will be female. Still, he says, that shouldn't worry anyone.

"We looked at the females and we found there was no difference between being bitten by one of our females to being bitten by a normal female," Nimmo says. "Those female [mosquitoes] are still sterile, so their offspring inherit the gene and they will not survive."

Nonetheless, at a public meeting of the mosquito control board this week, residents of the Keys had lots of questions and concerns. Assurances from Oxitec were not enough to persuade resident Michael Kane, for example, that the test is safe.

"Nature always adapts," Kane says. "No matter how much you think you tweaked it, something else is going to happen. There's going to be unintended consequences."

After all the questions and comments, the board decided to allow residents of Key Haven to weigh in further, via a vote in August on whether to go forward with the Oxitec field test. Though the vote will be nonbinding, three of five board members have said they will abide by the results — at least in regards to Key Haven.

Copyright 2016 WLRN Public Radio. To see more, visit WLRN Public Radio.
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More Marketplace Health Plans Ease Access To Some Expensive Drugs

Fri, 04/22/2016 - 12:21pm

If you need to reach for a top-shelf medicine, some marketplace plans are making it more affordable.

Tetra Images/Getty Images

Some people with cancer, HIV and multiple sclerosis have better access to high-cost specialty drugs in marketplace plans this year, yet a significant proportion of these plans still place many expensive drugs in cost-sharing categories that require the highest patient out-of-pocket costs.

The report released Tuesday by Avalere Health, a consulting firm, examined how silver-level plans handled 20 classes of medications that are used to treat complex and expensive diseases such as HIV, cancer, hepatitis C and bipolar disorder.

Health plans generally place covered drugs into tiers. Generics and preferred brand-name drugs are in lower tiers with lower cost sharing, while higher-priced drugs are often placed in tiers that require patients to pay a percentage of the cost of the drug rather than a flat copayment.

The study found that for five classes of drugs — two used to treat cancer, two for HIV and one class of multiple sclerosis drugs — fewer plans in 2016 placed all the drugs in the class in the top specialty drug tier with the highest patient cost-sharing requirements or charged patients more than 40 percent of the cost for every covered drug in the class.

For example, in 2015, 57 percent of silver marketplace plans put all cancer drugs called anti-angiogenic agents (which inhibit the growth of blood vessels) in the top specialty tier. In 2016, that dropped to 50 percent. Last year, a quarter of silver plans charged patients more than 40 percent coinsurance for every drug in that class. In 2016, 15 percent of such plans did so.

Likewise, 14 percent of 2015 silver plans placed protease inhibitors, a class of HIV drugs, in the top tier, compared with 10 percent in 2016. The percentage of plans charging more than 40 percent coinsurance for those drugs dropped to 6 percent in 2016 from 9 percent the previous year.

The changes are likely driven by protests and legal challenges from patient groups and from increased regulatory oversight, said Caroline Pearson, a senior vice president at Avalere. For example, California next year will prohibit insurers from placing most or all of the drugs for a specific condition in the highest cost tier. In addition, the federal Department of Health and Human Services has signaled in guidance to insurers that placing all or most of the drugs in a high-cost tier may be discriminatory.

"There's been a lot of discussion about discriminatory drug benefits, and that attention has moved health plans to make changes," said Pearson.

Carl Schmid, deputy executive director at the AIDS Institute, an advocacy group, said of the study results: "It does show some progress, which we are pleased to see."

The organization drew attention to the problem in 2014 when it filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that the plan designs of four Florida health plans were discriminatory because they discouraged people with HIV/AIDS from enrolling. The Florida Office of Insurance Regulation subsequently set maximum limits on cost-sharing for HIV medications in marketplace plans.

"We can celebrate this," Schmid said, but "our goal is zero, there should be no plans" that place all the HIV drugs in a class in the top tier and charge high coinsurance.

Please contact Kaiser Health News to send comments or ideas for future topics.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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