Tag Archives: medical

Warren wants to pull pot shops out of banking limbo

As pot shops sprout in states that have legalized the drug, they face a critical stumbling block — lack of access to the kind of routine banking services other businesses take for granted.

U.S. Sen. Elizabeth Warren, a Massachusetts Democrat, is leading an effort to make sure vendors working with legal marijuana businesses, from chemists who test marijuana for harmful substances to firms that provide security, don’t have their banking services taken away.

It’s part of a wider effort by Warren and others to bring the burgeoning $7 billion marijuana industry in from a fiscal limbo she said forces many shops to rely solely on cash, making them tempting targets for criminals.

After voters in Warren’s home state approved a November ballot question to legalize the recreational use of pot, she joined nine other senators in sending a letter to a key federal regulator, the Financial Crimes Enforcement Network, calling on it to issue additional guidance to help banks provide services to marijuana shop vendors.

Twenty-eight states have legalized marijuana for medicinal or recreational use.

Warren, a member of the Senate Banking Committee, said there are benefits to letting marijuana-based businesses move away from a cash-only model.

“You make sure that people are really paying their taxes. You know that the money is not being diverted to some kind of criminal enterprise,” Warren said recently. “And it’s just a plain old safety issue. You don’t want people walking in with guns and masks and saying, ‘Give me all your cash.””

A spokesman for the Financial Crimes Enforcement Network said the agency is reviewing the letter.

There has been some movement to accommodate the banking needs of marijuana businesses.

Two years ago, the U.S. Department of the Treasury gave banks permission to do business with legal marijuana entities under some conditions. Since then, the number of banks and credit unions willing to handle pot money rose from 51 in 2014 to 301 in 2016.

Warren, however, said fewer than 3 percent of the nation’s 11,954 federally regulated banks and credit unions are serving the cannabis industry.

Taylor West, deputy director of the National Cannabis Industry Association, a trade organization for 1,100 marijuana businesses nationwide, said access to banking remains a top concern.

“What the industry needs is a sustainable solution that services the entire industry instead of tinkering around the edges,” Taylor said. “You don’t have to be fully in favor of legalized marijuana to know that it helps no one to force these businesses outside the banking system.”

Sam Kamin, a professor at the University of Denver Sturm College of Law who studies marijuana regulation, said there’s only so much states can do on their own.

“The stumbling block over and over again is the federal illegality,” he said.

The federal government lumps marijuana into the same class of drugs as heroin, LSD and peyote. Democratic President Barack Obama’s administration has essentially turned a blind eye to state laws legalizing the drug, and supporters of legalizing marijuana hope Republican President-elect Donald Trump will follow suit.

Trump officials did not respond to a request for comment. During the presidential campaign, Trump said states should be allowed to legalize marijuana and has expressed support for medicinal use. But he also has sounded more skeptical about recreational use, and his pick for attorney general, Alabama U.S. Sen. Jeff Sessions, is a stern critic.

Some people in the marijuana industry say the banking challenges are merely growing pains for an industry evolving from mom-and-pop outlets.

Nicholas Vita, CEO of Columbia Care, one of the nation’s largest providers of medical marijuana products, said it’s up to marijuana businesses to make sure their financial house is in order.

“It’s not just as simple as asking the banks to open their doors,” Vita said. “The industry also needs to develop a set of standards that are acceptable to the banks.”

Minnesota is leading the rest of country in banning germ-killer triclosan

Minnesota’s first-in-the nation ban on soaps containing the once ubiquitous germ-killer triclosan takes effect Jan. 1, but the people who spearheaded the law say it’s already having its desired effect on a national level.

The federal government caught up to Minnesota’s 2014 decision with its own ban that takes effect in September 2017. Major manufacturers have largely phased out the chemical already, with some products being marketed as triclosan-free.

And it’s an example of how changes can start at a local level.

“I wanted it to change the national situation with triclosan and it certainly has contributed to that,” said state Sen. John Marty, an author of Minnesota’s ban.

Triclosan once was widely used in anti-bacterial soaps, deodorants and even toothpaste. But studies began to show it could disrupt sex and thyroid hormones and other bodily functions, and scientists were concerned routine use could contribute to the development of resistant bacteria. And University of Minnesota research found that triclosan can break down into potentially harmful dioxins in lakes and rivers.

The group Friends of the Mississippi River and its allies in the Legislature, including Marty, got Gov. Mark Dayton to sign a ban in 2014 that gave the industry until Jan. 1, 2017, to comply.

In September, the FDA banned triclosan along with 18 other anti-bacterial chemicals from soaps nationwide, saying manufacturers had failed to show they were safe or more effective at killing germs than plain soap and water. However, the FDA allowed the use of some triclosan products such as Colgate Total toothpaste, saying it’s effective at preventing gingivitis.

Marty and Trevor Russell, the water program director for Friends of the Mississippi River, acknowledged they can’t take direct credit for the FDA’s action because that rulemaking process began in 1978, though it didn’t finalize the rule until after a legal battle with the Natural Resources Defense Council.

However, the Minnesota men hope their efforts helped turn opinions against the chemical and are confident the state’s ban helped prod manufacturers to accelerate a phase-out that some companies such as Procter & Gamble and Johnson & Johnson had already begun.

Most major brands are now reformulated, said Brian Sansoni, spokesman for the American Cleaning Institute, a lobbying group. Soaps containing triclosan on store shelves are likely stocks that retailers are just using up, he said.

Russell noted he recently found Dial liquid anti-bacterial hand soap at two local Wal-Marts, two supermarkets and a Walgreens.

The industry is now submitting data to the FDA on the safety and effectiveness of the three main replacements, benzalkonium chloride, benzethonium chloride and chloroxylenol.

“Consumers can continue to use these products with confidence, like they always have,” Sansoni said.

By going first, Russell said, Minnesota can identify any issues with implementing the ban and share it with the rest of the country.

The Minnesota Department of Health will remind consumers and businesses of the ban’s start.

Trump action on health care could cost Planned Parenthood

One of President-elect Donald Trump’s first, and defining, acts next year could come on Republican legislation to cut off taxpayer money from Planned Parenthood.

Trump sent mixed signals during the campaign about the 100-year-old organization, which provides birth control, abortions and various women’s health services. Trump said “millions of women are helped by Planned Parenthood,” but he also endorsed efforts to defund it. Trump once described himself as “very pro-choice.” Now he’s in the anti-abortion camp.

The Republican also has been steadfast in calling for repeal of President Barack Obama’s health care law and the GOP-led Congress is eager to comply.

One of the first pieces of legislation will be a repeal measure that’s paired with cutting off money for Planned Parenthood.

While the GOP may delay the impact of scuttling the law for almost four years, denying Planned Parenthood roughly $400 million in Medicaid funds would take effect immediately.

“We’ve already shown what we believe with respect to funding of Planned Parenthood,” House Speaker Paul Ryan, R-Wis., told reporters last month. “Our position has not changed.”

Legislation to both repeal the law and cut Planned Parenthood funds for services to low-income women moved through Congress along party lines last year. Obama vetoed it; Trump’s win removes any obstacle.

Cutting off Planned Parenthood from taxpayer money is a long-sought dream of social conservatives, but it’s a loser in the minds of some GOP strategists.

Planned Parenthood is loathed by anti-abortion activists who are the backbone of the GOP coalition. Polls, however, show that the group is favorably viewed by a sizable majority of Americans — 59 percent in a Gallup survey last year, including more than one-third of Republicans.

“Defunding Planned Parenthood as one of their first acts in the New Year would be devastating for millions of families and a huge mistake by Republicans,” said incoming Senate Minority Leader Charles Schumer, D-N.Y.

Democrats pledge to defend the group and they point to the issue of birth control and women’s health as helping them win Senate races in New Hampshire and Nevada this year. They argue that Trump would be leading off with a political loser.

But if he were to have second thoughts and if the Planned Parenthood provision were to be dropped from the health law repeal, then social conservatives probably would erupt.

“They may well be able to succeed, but the women of America are going to know what that means,” said Rep. Diana DeGette, D-Colo., citing reduced access to services Planned Parenthood clinics provide. “And we’re going to call Republicans on the carpet for that.”

At least one Republican senator, Susan Collins of Maine, may oppose the effort.

Collins has defended Planned Parenthood, saying it “provides important family planning, cancer screening, and basic preventive health care services to millions of women across the country.” She voted against the health overhaul repeal last year as a result.

Continued opposition from Collins, which appears likely, would put the repeal measure on a knife’s edge in the Senate, where Republicans will have a 52-48 majority next year.

Senate GOP leaders could afford to lose just one other Republican.

Anti-abortion conservatives have long tried to cut Planned Parenthood funds, arguing that reimbursements for nonabortion services such as gynecological exams help subsidize abortions. Though Planned Parenthood says it performed 324,000 abortions in 2014, the most recent year tallied, the vast majority of women seek out contraception, testing and treatment of sexually transmitted diseases, and other services including cancer screenings.

The defunding measure would take away roughly $400 million in Medicaid money from the group in the year after enactment, according to the nonpartisan Congressional Budget Office, and would result in roughly 400,000 women losing access to care.

One factor is that being enrolled in Medicaid doesn’t guarantee access to a doctor, so women denied Medicaid services from Planned Parenthood may not be able to find replacement care.

Planned Parenthood says private contributions are way up since the election, but that they are not a permanent replacement for federal reimbursements. “We’re going to fight like hell to make sure our doors stay open,” said Planned Parenthood spokeswoman Erica Sackin.

Doctors, hospitals say ‘show me the money’ before treating patients

Tai Boxley needs a hysterectomy. The 34-year-old single mother has uterine prolapse, a condition that occurs when the muscles and ligaments supporting the uterus weaken, causing severe pain, bleeding and urine leakage.

Boxley and her 13-year-old son have health insurance through her job as an administrative assistant in Tulsa, Oklahoma. But the plan has a deductible of $5,000 apiece, and Boxley’s doctor said he won’t do the surgery until she prepays her share of the cost. His office estimates that will be as much as $2,500. Boxley is worried that the hospital may demand its cut as well before the surgery can be performed.

“I’m so angry,” Boxley said. “If I need medical care I should be able to get it without having to afford it up front.”

At many doctors’ offices and hospitals, a routine part of doing business these days is estimating patients’ out-of-pocket payments and trying to collect it up front.

Eyeing retailers’ practice of keeping credit card information on file, “there’s certainly been a movement by health care providers to store some of this information and be able to access it with patients’ permission,” said Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Massachusetts, who works with hospitals on addressing financial barriers to care.

But there’s a big difference between handing over a credit card to cover a $20 copayment versus suddenly being confronted with a $2,000 charge to cover a deductible, an amount that might take months to pay off or exceed a patient’s credit limit. Doctors may refuse to dispense needed care before the payment is made, even as patient health hangs in the balance.

The strategy leaves patients financially vulnerable. Once a charge is on a patient’s credit card, they may have trouble contesting a medical bill. Likewise, a service placed on a credit card represents a consumer’s commitment that the charge was justified, so nonpayment is more likely to harm a credit score.

Approximately three-quarters of health care and hospital systems ask for payment at the time services are provided, a practice known as “point-of-service collections,” estimated Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an industry group. He could not say how many were doing so for higher priced services or for patients with high-deductible plans, situations that would likely result in out-of-pocket outlays of hundreds or thousands of dollars.

“For providers, there’s more risk with these higher deductibles, because the chance of being able to collect it later diminishes,” Gundling said.

But the practice leaves many patients resentful.

After arriving by ambulance at the emergency department, Susan Bradshaw lay on a gurney in her hospital gown with a surgical bonnet on her head, waiting to be wheeled into surgery to remove her appendix at a hospital near her home in Maitland, Fla. A woman in street clothes approached her. Identifying herself as the surgeon’s office manager she demanded that Bradshaw make her $1,400 insurance payment before the surgery could proceed.

“I said, ‘You have got to be kidding. I don’t even have a comb,’” Bradshaw, a 68-year-old exhibit designer, told the woman on that night eight years ago. “I don’t have a credit card on me.”

The woman crossed her arms and Bradshaw remembers her saying, “You have to figure it out.”

As providers aim to maximize their collections, many contract with companies that help doctors and hospitals secure payments up front, often providing scripts that prompt staff to talk with patients about their payment obligations and discuss payment scenarios as well as software that can estimate what a patient will owe.

But as hospitals and doctors push for point-of-service payments to reduce bad debt from patients with increasingly high deductibles, the risk is that patients will delay care and end up in the emergency room, Rukavina said. “Patients are essentially paying for their procedures up front,” he said. “It may not be a significant amount compared to their salary, but they don’t necessarily have it available at the time of service.”

The higher their deductible, the less likely patients are to pay what they owe, according to an analysis of 400,000 claims by the Advisory Board, a health care research and consulting firm. While more than two-thirds of patients with a deductible of less than $1,000 were likely to pay at least some portion of what they owe, just 36 percent of those with deductibles of more than $5,000 did so, the analysis found.

Fifty-one percent of workers with insurance through their employer had a deductible of at least $1,000 for single coverage this year, according to the Kaiser Family Foundation’s annual survey of employer health insurance. (KHN is an editorially independent program of the foundation.)

Boxley pays $110 a month for her family plan. She could not afford the premiums on plans with lower deductibles that her employer offered. She plans to talk with the doctor and hospital about setting up a payment plan so she can get the surgery in January.

“I’ll make payments,” Boxley said, although she acknowledged what she could pay monthly would be small. If that doesn’t pan out, she figures she’ll have to use student loan money she got for graduate school to cover what she owes.

Still, experts say that trying to pin patients down for payment in more acute settings, such as the emergency department, may cross a line.

Under the federal Emergency Medical Treatment and Labor Act (EMTALA), a patient who has a health emergency has to be stabilized and treated before any hospital personnel can discuss payment with them. If it’s not an emergency, however, those discussions can occur before treatment, said Dr. Vidor Friedman, an emergency physician who is the secretary-treasurer of American College of Emergency Physicians’ board of directors.

Bradshaw finally got her appendix removed by calling a friend, who read his MasterCard number over the phone. The surgery was uneventful and Bradshaw was home within 24 hours.

“It’s a very murky, unclear situation,” Friedman said of Bradshaw’s experience, noting that a case might be made that her condition wasn’t life threatening. “At the very least it’s poor form, and goes against the intent if not the actual wording of EMTALA.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Published courtesy of Kaiser Health News.

For Trump and GOP, ‘Obamacare’ repeal is complex and risky

Here’s the idea: Swiftly pass a repeal of President Barack Obama’s health care law, perhaps soon enough for Donald Trump to sign it the day he takes the presidential oath.

Then approve legislation restructuring the nation’s huge and convoluted health care system — despite Republican divisions, Democratic opposition and millions of jittery constituents.

What could go wrong?

With Republicans controlling the White House and Congress in January, they’re faced with delivering on their long-time promise to repeal and replace “Obamacare.”

Here are hurdles they’ll face:

SPEED VS DELIBERATION

Trump and congressional Republicans will be under intense pressure from their core conservative supporters to repeal Obama’s 2010 health care law — and fast. After all, Congress already sent Obama a repeal bill last January, which he vetoed, and many GOP voters will see no reason for delays this time.

But there probably won’t be anything fast about Congress’ effort to replace Obama’s law, which is likely to take many months.

While the replacement effort is underway, Republicans will risk aggravating up to 30 million people who are covered by the law or buy policies with prices affected by its insurance marketplace. Democrats will be sure to accuse the GOP of threatening the health care of millions.

A SOLUTION

Nothing’s been decided, but here’s one likely scenario:

The new Congress, which convenes Jan. 3, tries to quickly approve legislation repealing Obama’s health care law, maybe completing it by Trump’s Jan. 20 inauguration or soon after. But the repeal would not take effect until the future, perhaps a year later, to give lawmakers time to fashion a replacement. The version Obama vetoed had a two-year delay.

Seemingly acknowledging that two-step process, Vice President-elect Mike Pence said Sunday on “Fox News Sunday” that Trump “wants to focus out of the gate on repealing Obamacare and beginning the process of replacing Obamacare.”

Because Republicans will control the Senate by just 52-48, Congress will first have to approve special budget procedures to prevent Democrats from stopping repeal legislation by filibuster. Bill-killing filibusters require 60 votes to end.

But those special rules would apply only to items that affect the federal budget. Republicans, for example, would need a simple Senate majority to end IRS penalties against people who don’t buy insurance but would still need 60 votes — requiring Democratic support — for other changes such as raising limits on older people’s premiums.

House Budget Committee Chairman Tom Price, R-Ga., says that will restrain Republicans’ ability to ram a “lock, stock and barrel” repeal through Congress.

GOP RISKS

One GOP danger: Congress and Trump might repeal Obama’s law, but while they’re laboring on a replacement, nervous insurance companies begin pulling out of markets and raising premiums. Insurers have been doing that under Obama, but now it would occur under a Republican government.

Another hazard: Congress’ work could spill into the 2018 campaign season, when the entire House and a third of the Senate face re-election. Republicans will grow increasingly timid about anything that might anger voters.

“We want to be the rescue party instead of the party that pushes millions of Americans who are hanging by the edge of their fingernails over the cliff,” says Sen. Lamar Alexander, R-Tenn., who chairs the Senate Health committee.

GOP PATHWAYS

Virtually all Republicans want to get rid of the health law’s mandates that individuals buy coverage or risk IRS fines, and that large employers insure workers.

They also want to erase taxes on higher-earning people and the health care sector. And they’d like to retain parts of the law guaranteeing coverage for people with pre-existing medical problems and keeping children under age 26 on family plans.

Unifying Republicans much beyond that is a work in progress.

Trump’s health care views have varied and lack detail. His campaign website touts tax deductions for health insurance premiums and permitting policies to be sold across state lines. He’d also revamp Medicaid, which subsidizes health coverage for low-income people, directing fixed amounts of money to states and letting them structure benefits.

House Speaker Paul Ryan, R-Wis., last summer unveiled an outline of the House GOP’s solution, though it lacked cost estimates and details. It would provide tax credits, impose taxes on the most generous employer-provided health care plans, revamp Medicaid and let Medicare beneficiaries pick private plans instead of today’s fee-for-service coverage.

Senate Finance Committee Chairman Orrin Hatch, R-Utah, has also advanced a framework relying heavily on tax credits.

REMAINING QUESTIONS

Thirty-one states — including Pence’s Indiana, where he is governor — plus the District of Columbia have expanded Medicaid coverage to 9 million additional people under Obama’s law. Curtailing that program will divide Republicans.

Taxing the value of some employer-provided health plans, aimed at curbing the growth of costs, is “a political land mine,” says GOP economist Douglas Holtz-Eakin. Republicans have long resisted tax increases.

Obama’s law mandates coverage for individuals because without that requirement many healthy people would forgo policies, driving up costs for everyone else and destabilizing insurance markets. Ryan has proposed shielding people from higher premiums if they’ve had “continuous coverage,” allowing higher rates for people who have not had policies, but Republicans have yet to decide how to keep insurance markets viable.

Minnesota court overturns ban on transition-related surgery

A Minnesota district court ruled this week that transgender people on the state’s Medical Assistance program deserve access to medically necessary services related to gender transition.

Since 2005, surgical treatments for gender dysphoria have been excluded from coverage even though equivalent treatments were covered under the federal Medicare program and private insurance plans.

In December 2015, the American Civil Liberties Union, along with the ACLU of Minnesota, filed a lawsuit on behalf of OutFront Minnesota and Evan Thomas, a transgender man, challenging Minnesota’s ban on coverage.

Thomas was denied coverage for transition related surgery, despite being diagnosed with gender dysphoria.

In a statement to the press released on Nov. 16, Thomas said, “I’m so happy we’ve won. The judge’s ruling is a forceful statement that transgender people deserve equal treatment under the law. Right now, when we’re suddenly facing a path that’s so much rougher than it looked a few days ago, this victory looks even more important, and I’m proud to have been part of this case. I thank the ACLU for taking it on and winning such a good ruling — it’s been a privilege to work with these wonderful, dedicated people.”

OutFront, Minnesota’s largest LGBTQ rights organization, also was a  plaintiff.

“OutFront Minnesota is delighted by this ruling, confirming what we knew all along: targeting transgender people like this is discriminatory, unconstitutional, and wrong.  Since filing this suit, we have been contacted by many individuals and families whose access to health care has been unjustly harmed. At last we can provide some hopeful news that the care they need may now be within reach,” Phil Duran, legal director of OutFront Minnesota, said in a news release.

Added Joshua Block, senior staff attorney with the ACLU’s LGBT Project: “The victory will bring immediate relief to the scores of transgender people living in Minnesota being denied the medical care they need. Singling out groups of people and denying them medically necessary care for no legitimate reason is wrong and harmful. We are glad the court agreed with respecting the dignity of people.”

The case was filed in Ramsey County District Court against Emily Johnson-Piper, the commissioner of Minnesota’s Department of Human Services.

 

Pot-legalization movement seeks first foothold in Northeast

Having proven they can win in the West, advocates for recreational marijuana hope the Nov. 8 election brings their first significant electoral victories in the densely populated Northeast, where voters in Massachusetts and Maine will consider making pot legal for all adults.

Supporters believe “yes” votes in New England would add geographical diversity to the legalization map, encourage other East Coast states to move in the same direction and perhaps build momentum toward ending federal prohibitions on the drug.

“We have to get to a point where we can win legalization voter initiatives in other parts of the country,” said Keith Stroup, founder of the National Organization for the Reform of Marijuana Laws, or NORML, a leading group in the legalization movement.

Three other states — California, Arizona and Nevada — are also voting on recreational pot. If the California initiative passes, marijuana will be legal along the entire West Coast. Washington, Oregon, Colorado and Alaska have already voted to permit it. The District of Columbia also passed a legalization measure in 2014, but it has no regulatory framework for retail sales and possession remains illegal on federal property.

Several Eastern states are among the 25 that already allow some form of medicinal marijuana, but none in the region has approved recreational pot.

Big money is at stake, which helps explain why marijuana supporters have raised more than $6 million in Massachusetts and about $1.3 million in Maine, most from outside those states.

Analysts from Cowen and Co. issued a report last month forecasting a $50 billion legal cannabis market in the U.S. by 2026, a nearly tenfold increase over today. But such growth would be predicated on federal legalization. Passage of the November state referendums would be a “key catalyst” toward that end, analysts wrote.

Higher marijuana usage in the West may help explain why the region has been a more fertile ground for legalization, said Matt Simon, New England director for the Marijuana Policy Project, another major pro-legalization group.

“More people have direct experience with marijuana or know someone who has, and that leads to it being demystified,” Simon said.

Recent polls on the New England ballot questions, which propose significantly lower tax rates than those in Colorado and Washington, indicate the “yes” sides trending ahead in both states. Still, passage is far from guaranteed.

In Massachusetts, a socially liberal state, voters previously decriminalized small amounts of marijuana and approved it for medicinal use. This year’s initiative has met formidable opposition from politicians, business leaders, clergy and even billionaire casino magnate Sheldon Adelson, who recently donated $1 million to opposing groups.

The state’s popular Republican Gov. Charlie Baker and Boston’s Democratic Mayor Marty Walsh are among many elected officials fighting the idea. Their arguments include concerns that edible pot products resembling candy or other treats could fall into the hands of children, and that marijuana can be a “gateway” to far more dangerous drugs.

“The availability of marijuana for adolescent users already constitutes an environmental factor for the later use of other illicit drugs,” the state’s four Roman Catholic bishops said in a recent statement. “Its legalization will only serve to worsen this problem.”

A TV ad urging a “no” vote imagines a neighborhood overrun by pot shops and a mother shocked to see her own son emerge from one of the stores. Legalization proponents dismissed the ad as a “smear-and-fear” tactic.

“There is a puritanical streak that runs through New Englanders,” said NORML’s Stroup, a onetime Boston resident.

The Puritans lost their influence centuries ago, and the phrase “banned in Boston” is an anachronism. Yet uneasiness persists when it comes to issues that would have once been considered sinful. Massachusetts, for example, only recently authorized casino gambling and did so in a limited and highly regulated form.

In Maine, critics worry about disrupting the state’s well-established medical marijuana program.

“We want to make sure patients don’t lose access and that small growers will still be able to flourish,” said Catherine Lewis, director of education for Medical Marijuana Caregivers of Maine.

Portland, the state’s largest city, legalized possession of up to 2.5 ounces of marijuana in 2013, but the statewide prohibition still makes buying and selling the drug illegal.

Marijuana companies that have focused largely on Western states are watching developments closely, sensing new regional opportunities for investment and growth.

“The Northeast specifically is going to be a very powerful market because of the population density,” said Derek Peterson, chief executive of Terra Tech Corp., which operates cannabis cultivation, production and retail facilities.

Marc Harvill, client services and training manager for Denver-based Medicine Man Technologies, said the firm has already fielded inquires for consulting services from potential retail operators in New England should the ballot questions pass.

“The sky’s the limit,” he said.

Frustration runs deep for those forced to routinely change health plans

Andrea Schankman’s three-year relationship with her insurer, Coventry Health Care of Missouri, has been contentious, with disputes over what treatments it would pay for. Nonetheless, like other Missourians, Schankman was unnerved to receive a notice from Coventry last month informing her that her policy was not being offered in 2017.

With her specialists spread across different health systems in St. Louis, Schankman, a 64-year-old art consultant and interior designer, said she fears she may not be able to keep them all, given the shrinking offerings on Missouri’s health insurance marketplace. In addition to Aetna, which owns Coventry, paring back its policies, UnitedHealthcare is abandoning the market. The doctor and hospital networks for the remaining insurers will not be revealed until the enrollment period for people buying individual insurance begins Nov. 1.

“We’re all sitting waiting to see what they’re going to offer,” said Schankman, who lives in the village of Westwood. “A lot of [insurance] companies are just gone. It’s such a rush-rush-rush no one can possibly know they’re getting the right policy for themselves.”

Doctor and hospital switching has become a recurring scramble as consumers on the individual market find it difficult or impossible to stay on their same plans amid rising premiums and a revolving door of carriers willing to sell policies. The instability, which preceded the health law, is intensifying in the fourth year of the Affordable Care Act’s marketplaces for people buying insurance directly instead of through an employer.

“In 2017, just because of all the carrier exits, there are going to be more people making involuntary changes,” said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation, a New Jersey philanthropy. “I would imagine all things being equal, more people are going to be disappointed this year versus last year.”

Forty-three percent of returning consumers to the federal government’s online exchange, healthcare.gov, switched policies last year. Some were forced to when insurers stopped offering their plans while others sought out cheaper policies. In doing so, consumers saved an average of $42 a month on premiums, according to the government’s analysis. But avoiding higher premiums has cost many patients their choice of doctors.

Jim Berry, who runs an internet directory of accountants with his wife, switched last year from Blue Cross Blue Shield of Georgia to Humana after Blue Cross proposed a 16 percent premium hike.

Despite paying Humana $1,141 in premiums for the couple, Berry, who lives in Marietta, a suburb of Atlanta, said they were unable to find a doctor in the network taking new patients. They ended up signing up with a concierge practice that accepts their insurance but also charges them a $2,700 annual membership, a fee he pays out of pocket. Nonetheless, he said he has been satisfied with the policy.

But last month Humana, which is withdrawing from 88 percent of the counties it sold plans in this year, told Berry his policy was not continuing, and he is unsure what choices he will have and how much more they will cost.

“It’s not like if I don’t want to buy Humana or Blue Cross, I have five other people competing for my business,” Berry said. “It just seems like it’s a lot of money every year for what is just basic insurance, basic health care. I understand what you’re paying for is the unknown — that heart attack or stroke — but I don’t know where the break point is.”

To be sure, the same economic forces — cancelled policies, higher premiums and restrictive networks — have been agitating the markets for employer-provided insurance for years. But there is more scrutiny on the individual market, born of the turmoil of the Affordable Care Act.

Dr. Patrick Romano, a professor of medicine at the UC Davis Health System in Sacramento, Calif., said the topic has been coming up in focus groups he has been convening about the state insurance marketplace, Covered California. Switching doctors, he said, “is a disruption and can lead to interruptions in medications.”

“Some of it is unintentional because people can have delays getting in” to see their new doctor, he said. “Some of it may be because the new physician isn’t comfortable with the medication the previous physician prescribed.”

Dr. John Meigs, an Alabama physician and president of the American Academy of Family Physicians, said that whatever the source of insurance, changing doctors disrupts the trust a patient has built with a physician and the knowledge a doctor has about how each patient responds to illnesses. “Not everything is captured in a health record” that can be passed to the next doctor, Meigs said.

There is little research about whether switching doctors leads to worse outcomes, said Dr. Thomas Yackel, a professor of medicine at Oregon Health & Science University in Portland. In some cases, he said, it can offer unexpected benefits: “Having a fresh set of eyes on you as a patient, is that really always a bad thing?”

With the shake-up in the insurance market, access to some top medical systems may be further limited. Blue Cross Blue Shield of Tennessee, which has included the elite Vanderbilt University Medical Center in its network, is pulling out of the individual marketplace in the state’s three largest metro areas: Nashville, Memphis and Knoxville. Bobby Huffaker, CEO of American Exchange, an insurance firm in Tennessee, said so far, no other carrier includes Vanderbilt in its network in the individual market.

In St. Louis, Emily Bremer, an insurance broker, said only two insurers will be offering plans next year through healthcare.gov. Cigna’s network includes BJC HealthCare and an affiliated physicians’ group, while Anthem provides access to other major hospital systems, including Mercy, but excludes BJC and its preeminent academic medical center Barnes-Jewish Hospital.

“These networks have little or no overlap,” she said. “It means severing a lot of old relationships. I have clients who have doctors across multiple networks who are freaking out.”

Aetna said it will still offer policies off the healthcare.gov exchange. Those are harder to afford as the federal government does not provide subsidies, and Aetna has not revealed what its networks will be. In an email, an Aetna spokesman said the insurer was offering those policies to preserve its option to return to the exchanges in future years; if Aetna had completely stopped selling individual policies, it would be banned from the market for five years under federal rules.

Even before St. Louis’ insurance options shrunk, Bremer said she had to put members of some families on separate policies in order for everyone to keep their physicians. That can cost the families more, because their combined deductibles and maximum out-of-pocket payments can be higher than for a single policy, she said.

“Every year our plan disappears,” said Kurt Whaley, a 49-year-old draftsman in O’Fallon, Mo., near St. Louis. After one change, he said, “I got to keep my primary care physician, but my kids lost their doctors. I had to change doctors for my wife. It took away some of the hospitals we could get into.”

Brad Morrison, a retired warehouse manager in Quincy, Ill., said he has stuck with Coventry despite premium increases — he now pays $709 a month, up from $474 — because the policy has been the cheapest that would let him keep his doctor. “That’s the one thing I insisted on,” he said. “I love the guy.”

With Coventry leaving the Illinois exchanges, Morrison is unsure whether his alternatives will include his physician. His bright spot is that he turns 65 next spring. “I’m trying to hold out until I get to Medicare,” he said.

This report originally appeared in Money. It was made available by Kaiser Health News through a Creative Commons license. KHN is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

UNICEF calls for end to dire situation in Aleppo

UNICEF’s representative in Syria called Saturday for an end to the violence that has beset northern Aleppo, causing dire humanitarian and psychological impacts on both sides of the divided city.

U.N. agencies are on “standby” to deliver needed assistance, Hanaa Singer of the U.N.’s children agency told The Associated Press.

With the key powers deeply divided, the U.N. Security Council on Saturday once again failed to agree on the course of action in war-ravaged Aleppo, and Syria in general. Russia vetoed a resolution drafted by France demanding an immediate halt to the bombing of Aleppo. A resolution put forward by Russia that called for a separation of moderate and extremist forces in Syria but making no mention of a bombing halt in Aleppo failed to get the minimum nine “yes” votes required for passage.

Also on Saturday, Syrian state media and a Syria monitoring group said pro-government troops advanced in a northern district of eastern Aleppo, wrestling control from rebel fighters in their latest push into the besieged area.

Singer said conditions in besieged Aleppo are “terribly dire,” with hospitals hit, doctors overwhelmed, and over 100 children killed in bombings since Sept. 19. Conditions for thousands of displaced in the government-held part of the city are also deteriorating, with some of them being displaced for up to six times in the last three years, she said.

Singer returned earlier this week from a week-long trip to the government-held part of Aleppo where she was visiting thousands of displaced Syrians. Most are crammed in makeshift shelters, mosques, parks and churches after recently fleeing clashes on the frontline between rebels and pro-government forces. In one case, a mother so desperate from the continuous displacement, stabbed her baby girl thinking she will save her the misery of living on handouts and without a home, Singer said.

Describing the dramatic situation for thousands of families living in shelters in government-controlled Aleppo, Singer said: “These (are) the horrors in western Aleppo. God knows what is happening, (in the case of) mental health or the psychological situation on the eastern (rebel-held) side.”

Western Aleppo, controlled by the government, is separated from eastern rebel-held Aleppo by a few meters, sometimes by a single plastic sheet or pockmarked building. An estimated 275,000 people are living in the rebel-held part of Aleppo, with no international aid reaching the area since the first week of July. Besides the scarce assistance, it is also difficult to assess the needs with the ever-evolving violent situation, and lack of access for international aid groups, she said.

“I think we all agree, and especially if you have been so close in the area there and seeing the dire situation in the west, hearing about the horrible situation in the east, all we need now is (for) the violence to stop,” Singer said. “The violence has to stop and once the violence stops, the U.N., we absolutely stand ready. We are ready. We are actually on standby.”

Singer says U.N. plans are in place for government-held Aleppo to accommodate residents that may evacuate the besieged part of the city if a cease-fire takes effect.

According to medical charity Doctors Without borders, hospitals in the eastern side of Syria’s Aleppo have been attacked 23 times since July, damaging all eight facilities that have not yet been shuttered or destroyed. Since the U.S-Russian cease-fire broke down on Sept. 19, the situation in besieged Aleppo has immensely deteriorated under a relentless bombardment campaign. Water stations and civil defense centers have also been hit, while over 320 people have been killed in eastern Aleppo in nearly three weeks of violence.

“In eastern Aleppo, the situation is terribly dire. Lots of schools and of hospitals have been hit we understand that there are only 30 doctors there. We have information that at least over 100 children have been killed. We hear that because of the lack of services and lack of health facilities that some children, that doctors can’t cope with all the cases, and some children in dire situation are left to die,” Singer said.

On Saturday, amid intensive air raids, pro-government forces seized the al-Awijeh district in northeastern rebel-controlled Aleppo, according to the Britain-based Syrian Observatory for Human Rights. The Observatory also reported clashes on the southern edge of the rebel-held area. There was no immediate word on casualties.

Syrian State TV reported that government and allied troops took control of al-Awijeh, moving toward the Jandoul roundabout and getting closer to crowded residential areas in Aleppo’s rebel-controlled eastern districts.