Abby Goodnough

Administration officials credited Trump with the resiliency of the law even as they echoed his contempt for it.

“The ACA simply doesn’t work and is still unaffordable for far too many,” Alex Azar, the secretary of health and human services, said on Monday. “But until Congress gets around to replacing it, President Trump will do what he can to fix the problems created by this system for millions of Americans.”

The 4% price decline is only the second time that average monthly premiums have dropped year-to-year since the marketplace opened in 2014, and it is a sign that the health law is stabilizing after several years of turmoil caused in part by Trump. Open enrollment for “Obamacare” starts Nov. 1, but looming over it is an impending court decision on the law’s constitutionality in a case supported by the Trump administration that seeks to overturn the law.

Premiums rose sharply in the final years of the Obama administration, as Trump officials like to point out, largely because of losses insurers suffered as they tried to gauge the health needs of their new customers. But after Trump and Republicans in Congress tried unsuccessfully to repeal the law in 2017, the president took a number of steps to weaken it, all of which led to uncertainty that resulted in insurers raising prices.

Now, a correction is taking place. Some of the states with the biggest premium increases this year, including Delaware and North Dakota, will see the biggest decreases in 2020. There will be 20 more insurers selling plans next year in the federal marketplace, which is used by people in 38 states, bringing the total to 175. That will be the largest number of issuers since 2016. Only two states, Delaware and Wyoming, will have a single insurer selling plans under the law next year, compared with five states currently.

For a 27-year-old, premiums for a benchmark “silver” plan will cost an average $388 per month next year; for a family of four, they will average $1,520 per month. That is still expensive, but most people will qualify for federal subsidies that cover much or most of the cost.

For many of those who do not qualify for subsidies under the health law — people earning more than 400% of the poverty level, which comes to just under $50,000 for a single person — premiums will remain out of reach.

Deductibles, too, will continue to rise, with the median amount rising to $4,604, from $4,471, for silver plans, which offer midlevel coverage. But people whose income is at or under 200% of the poverty level will have much lower deductibles, thanks to a different kind of discount required under the law that helps with out-of-pocket costs.

Prices and other information about next year’s Affordable Care Act plans in the 12 states, as well as the District of Columbia, that have their own marketplaces will be announced by those places. In all, 10.6 million people had health plans through the federal and state marketplace plans as of March, the last time the Trump administration released enrollment data.

As the market stabilizes, the health law is coming to serve almost exclusively the struggling families and individuals who qualify for federally subsidized coverage. In a call with reporters Monday, Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, which runs the online marketplace, said that from 2016 to 2018, the number of health-law enrollees who did not qualify for premium subsidies dropped by 2.5 million people, or 40%.

“It was inevitable that Obamacare’s affordability crisis would eventually increase the number of uninsured,” Verma said, pointing to new census data showing a rise in the number of higher-income Americans without insurance.

In 2018, 8.5% of the population lacked health insurance, according to the Census Bureau, up from 7.9% in 2017. But that was driven in large part by a decline in the number of children insured under government programs like Medicaid and the Children’s Health Insurance Program. The administration has taken steps to limit Medicaid eligibility for immigrants, and has supported efforts by some states to impose work requirements on Medicaid recipients.

The administration has also all but eliminated funding to promote enrollment under the law, through advertising and “navigators,” who once helped people sign up.

Verma and Azar praised Congress for zeroing out the tax penalty that the law imposed on people who go without health insurance; it did so as part of the 2017 tax overhaul. They also praised new rules pressed by Trump that encourage the sale of less expensive coverage that does not provide the comprehensive benefits required by the health law. Both moves, Verma said, elicited “a knee-jerk chorus of dire predictions” that had not come to fruition.

A major reason that premiums have stabilized, she said, is the reinsurance programs that the Trump administration has approved in 12 states. Under these programs, states help insurers pay their largest medical claims, partly using federal funds. Three of the states that will see the biggest drops in premium costs next year — Delaware, Montana and North Dakota — have adopted reinsurance programs, Verma said.

A bill to spread such programs across the country was drafted by Republican Sens. Lamar Alexander of Tennessee and Susan Collins of Maine in the last Congress, but it was never brought to the Senate floor for a vote.

As always, how much people pay for a marketplace plan will heavily depend on where they live. Wyoming will have the highest average premiums next year — $723 a month for the benchmark plan for a 27-year-old, an increase of 2%. New Mexico will have the lowest average premiums — $282 a month for the benchmark plan for a 27-year-old, a decrease of 6%.

Asked about the court case seeking to invalidate the health law, Azar said a ruling in the plaintiffs’ favor would not change anything immediately because the defenders of the law would appeal to the Supreme Court.

“Our message would be, ‘Keep calm and carry on,’” Azar said. “There will be no immediate disruption to anybody. We will run the program the day after such a ruling the same way we ran the program the day before.”

This article originally appeared in

Cheaper Plans and More Options as ACA Stabilizes From Onslaught

WASHINGTON — Nearly three years into President Donald Trump’s aggressive efforts to undermine the Affordable Care Act, prices for the most popular type of health insurance plan offered through the health law’s federal marketplace will actually drop next year, and the number of insurers offering plans will go up.

Prices and other information about next year’s Affordable Care Act plans in the 13 states that have their own marketplaces will be announced by those states. In all, 10.6 million people had health plans through the federal and state marketplace plans as of March, the last time the Trump administration released enrollment data.

In 2018, 8.5% of the population lacked health insurance, according to the Census Bureau, up from 7.9% in 2017. But that was driven in part by a decline in the number of children insured under government programs like Medicaid and the Children’s Health Insurance Program. The administration has taken steps to limit Medicaid eligibility for immigrants, and has supported efforts by some states to impose work requirements on Medicaid recipients.

A bill to spread such programs across the country, drafted by Republican Sens. Lamar Alexander of Tennessee and Susan Collins of Maine, has yet to be brought to the Senate floor for a vote.

Health Law Premiums to Fall and Number of Insurers to Rise Next Year

The Department of Health and Human Services published a guide intended to be a course correction of sorts. In 2016, after years of rising addiction rates and deaths from prescription painkiller overdoses, the Centers for Disease Control and Prevention issued nonbinding guidelines for primary care doctors that urged more cautious prescribing. A backlash ensued, particularly from some doctor and patient groups who said the guidelines were hurting people with severe chronic pain, many of whom had been on high doses of opioids for years without becoming addicted.

After more than 300 medical providers, pharmacists, patient advocates and others emphasized these concerns in a letter to the CDC earlier this year, the agency put out a clarifying statement saying the guidelines did “not support abrupt tapering or sudden discontinuation of opioids,” and warning doctors not to misapply them.

The new tapering guide goes deeper, detailing potential harms to patients who abruptly stop taking opioids and laying out factors to consider and steps to take before starting a taper. It includes several examples of tapering protocols.

“We need to maintain a balance,” said Adm. Brett Giroir, the department’s assistant secretary for health, adding that “it is a false choice to say we could only limit opioid use disorder or addiction or have pain control.”

Annual opioid prescriptions in the United State peaked at 255 million in 2012 after increasing every year for more than a decade — a rise that fueled the epidemic of overdose deaths that continues to plague the nation. But by 2017, the number of opioid prescriptions had fallen to 191 million, a drop that President Donald Trump has pointed to as a victory, even as his administration has begun responding to chronic pain patients angry about being forced off the drugs.

While deaths from prescription opioids have fallen — they are the main reason why fatal overdoses dipped slightly overall last year for the first time since 1990 — the number of people dying from illicit fentanyl, another opioid, continues to rise. Prescription painkillers were the main cause of overdose deaths until heroin, and then fentanyl, surpassed them over the last decade. Critics have argued that curbing prescriptions for legal painkillers drove some people to seek illegal opioids, like heroin and fentanyl.

The tapering guide was written by a work group led by Giroir, with members from the CDC, the National Institutes of Health, the Substance Abuse and Mental Health Services Administration and other federal agencies that fall under the health and human services department. Giroir and two others who helped lead the group — including Dr. Deborah Dowell of the CDC, the lead author of the 2016 guidelines — also published an article about the guide Thursday in the medical journal JAMA. The CDC had already published its own “pocket guide” for doctors on tapering.

The new guide stated that doctors “should never abandon” pain patients, and warns of risks including “acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources.”

It said that opioid doses are typically reduced by between 5-20% a week, but that slower tapers are often better tolerated, partly because they are less likely to trigger withdrawal symptoms.

But the guide also laid out reasons to consider tapering patients off opioids, stressing that the benefits of staying on the drugs need to outweigh the risks. Those risks are substantial, including addiction and overdose, but many chronic pain patients and their doctors said they have been able to stay on high doses of opioids and function competently.

A growing body of research has found that opioids are usually not the best treatment for long-term pain other than from cancer and certain other conditions, and that over-the-counter ibuprofen, physical therapy and other approaches may work better, with far fewer risks.

Salimah Meghani, an associate professor of nursing and pain researcher at the University of Pennsylvania who has criticized the CDC prescribing guidelines, said the new guide “provides important and much-needed clarification.”

But she added that state-level crackdowns on opioid prescribing also need to be reconsidered, particularly those that limit daily opioid doses to below 90 morphine milligram equivalents. The 2016 guidelines advised not to increases doses above that level, but that prompted many states and insurers to set it as a limit for all noncancer patients, including those who were already taking more.

That, Meghani said, has “led to wide-scale inappropriate opioid tapering or simply dumping of complex-pain patients.”

Health Officials Urge Caution in Reducing Opioids for Pain Patients

WASHINGTON — The Trump administration Thursday instructed doctors to use more caution when taking chronic pain patients off opioid medications, a response to reports that many have been cutting off prescriptions too quickly, in some cases even dismissing patients from their practice.

Pelosi’s plan, which she laid out at a morning news conference, would allow the government to negotiate the price of insulin and as many as 250 name-brand drugs each year for Medicare beneficiaries — an idea that many Republicans hate but that President Donald Trump embraced during his 2016 campaign. Drug companies would also have to offer agreed-on prices to private insurers or face harsh penalties, which could give the package broader appeal with voters.

The hit to noncompliant companies would be even stiffer than the penalty in a draft of her plan that circulated last week. The penalty extracted from a company unwilling to comply would be equal to 65% of the previous year’s sales of the drug in question, but would gradually increase by 10 percentage points every quarter that the company refused to offer the government’s price, to a maximum of 95%. Pelosi said that the House Energy and Commerce Committee would hold the first hearing on the bill Wednesday and that she hoped the committees of jurisdiction would begin drafting final legislation next month.

But even as Pelosi introduced the bill, Republicans on that committee indicated that they had no intention of getting behind it. In a statement, all 24 accused Pelosi of “pushing a socialist proposal to appease her most extreme members.”

“It does not have to be this way,” Republican members, led by Rep. Greg Walden, R-Ore., said. “There are bipartisan solutions to bring down prices for patients and create real transparency and accountability for this system.”

The bill’s main competition for now is a bipartisan but embattled drug-pricing package from leaders of the Senate Finance Committee, Sens. Charles Grassley, R-Iowa, and Ron Wyden, D-Ore., who are lobbying fiercely to build support for it.

Most notably, the bill would require drug companies to pay rebates to Medicare if they raised prices faster than inflation, and it would cap out-of-pocket drug costs for Medicare beneficiaries, proposals that are also in the Pelosi bill. Most Republicans on the committee voted against it, saying it smacked of government price fixing. But Grassley has been working hard to win more support, using Pelosi’s bill as a cudgel as he warns that the speaker’s prescriptions could succeed if his fail.

The speaker could also prompt the president to act. He has made drug prices a major theme of his reelection campaign but has not scored an accomplishment to take on the trail next year. The question now is whether Trump will get behind the Finance Committee bill, stepping up pressure on Sen. Mitch McConnell, the majority leader, or possibly even side with Pelosi, whose bill includes a version of an idea he really likes: to base the price Americans would pay for some drugs on the lower prices paid in other countries.

“Hopefully we can come to some agreement about what is best for the American people,” Pelosi said at the news conference at the Capitol, flanked by Reps. Richard Neal of Massachusetts, Ways and Means Committee chairman, and Frank Pallone of New Jersey, Energy and Commerce chairman. “My conversations with the president have been about making this a priority; I believe he considers it one, and so we can work together.”

On Thursday afternoon, the president posted his support on Twitter for the congressional negotiations. “I like Sen. Grassley’s drug pricing bill very much, and it’s great to see Speaker Pelosi’s bill today,” he tweeted. “Let’s get it done in a bipartisan way!”

Trump could also go his own way, following through on a promise to put out a proposed rule or executive order basing prices for certain drugs in Medicare on those in other countries. That idea makes Republicans in Congress just as queasy as letting Medicare negotiate with drug companies, but it appeals to Trump’s “America First” sensibility and would be more limited.

“You’ve got the makings of a Trump-Pelosi alliance here on drug pricing, and that would be a powerful combination,” said Rep. Peter Welch, D-Vt., who serves on the Energy and Commerce Committee. “Trump is the one who asked the practical question: Why do we get ripped off, why are we the suckers paying the highest prices in the world? Now he has an opportunity to address that.”

Pelosi would first have to bring both liberals and centrists in her caucus on board; she has already worked to win liberals by dropping an initial proposal that would have let the Government Accountability Office, an independent investigative arm of Congress, decide a drug’s price if the government and manufacturer could not agree. Liberals did not want to farm that job out to a third party.

But some liberals are still unsatisfied with the number of drugs designated for annual price negotiations; for one thing, the bill would allow for a minimum of 25 per year and a maximum of 250.

“We think 25 a year is too low to have our constituents really appreciate” it, said Rep. Mark Pocan, D-Wis. and co-chairman of the Congressional Progressive Caucus. He added that his group also thought the penalty for noncompliant drug companies should be even harsher, pointing to a bill from Rep. Lloyd Doggett, D-Texas, that would allow other companies to produce cheaper generic versions of any drug whose price the brand-name manufacturer refused to negotiate with the government.

A far bigger challenge would be getting Pelosi’s bill through the Senate, where it could die a fast death given the Republican aversion to several of its main provisions. In that, Trump is a wild card: His administration has been discussing drug pricing with Pelosi’s office for months, according to Deere.

Another big question is whether the pharmaceutical industry — which has been fighting fiercely against all the ideas in play, spending millions on ad campaigns and direct lobbying — will thwart a deal. Chances of a drug-pricing deal could also crumble if a federal appeals court decides this fall to uphold a lower court decision invaliding the entire Affordable Care Act, which would create a crisis for Trump and his party and become the central rallying cry for Democrats.

Immediate reaction from the drug industry was not favorable. Its main trade group, the Pharmaceutical Research and Manufacturers of America, called the legislation “radical.”

It added: “It would fundamentally restructure how patients access medicines by giving the federal government unprecedented, sweeping authority to set medicine prices.”

Jim Greenwood, president and chief executive of another trade group, the Biotechnology Innovation Organization, said the legislation not only “abandons any pretense of allowing a free and fair market system to determine the value of prescription medicines” but would also “surrender to foreign bureaucracies the power to dictate the value of medicines and the treatments available to America’s patients.”

“Lawmakers must reject this extreme proposal and work on real reforms that lower costs for patients and protect America’s leadership in medical innovation,” Greenwood said.

Pelosi Details Drug-Price Plan, Adding to a Stalled Debate

WASHINGTON — House Speaker Nancy Pelosi on Thursday released her long-awaited plan to curb soaring prices of prescription drugs, a political chess move that could prod the Senate to move and heat up congressional negotiations with the White House on a popular but elusive goal.

Her suit comes four months after a federal judge ordered a county jail outside Boston to let an incoming inmate stay on methadone instead of requiring him to go through forced withdrawal, as was its policy. It adds to growing pressure on the criminal justice system to provide methadone or other evidence-based treatments to the staggering number of inmates with opioid addiction.

The plaintiff, Stephanie DiPierro of Everett, Massachusetts, was sentenced to a year and a day in federal prison after pleading guilty last fall to theft of public funds; she had collected disability benefits and food stamps without reporting income from a job. DiPierro, now 38, became addicted to opioids as a teenager after her mother died of cancer.

Since 2005, she has gone to a clinic for daily doses of methadone, a kind of opioid that was approved decades ago to control cravings and withdrawal symptoms in people addicted to narcotic painkillers and heroin.

“Methadone gave me my life back,” DiPierro, who declined to be interviewed, wrote in a sworn statement attached to the lawsuit. Without the treatment in prison, she added, she fears that upon her release, “I will lose control of my addiction and I will relapse, overdose and die.”

The federal prison system has estimated that about 40 percent of its roughly 180,000 inmates have a substance use disorder. But while it uses methadone to detox new inmates who are dependent on opioids, it does not allow anti-craving medications as ongoing treatment except for pregnant women, who can take methadone, according to a spokesperson.

With overdose deaths from synthetic fentanyl continuing to rise, and newly released inmates at much higher risk because they lose their opioid tolerance while incarcerated, prisons and jails around the country face increasing pressure to offer anti-craving medications. But only Rhode Island and Vermont are offering state prisoners all three medications approved by the FDA to treat opioid addiction: methadone, buprenorphine and naltrexone.

At the urging of the Trump administration, the prisons bureau recently started offering naltrexone to inmates who are about to be released to halfway houses. The spokesperson said naltrexone is being offered in 23 prisons in the Northeast and will eventually be expanded, but would not say how many inmates had received naltrexone injections so far.

Many in law enforcement favor naltrexone, marketed as Vivitrol, because unlike methadone and buprenorphine, it is not an opioid itself and is taken once a month instead of daily. But there is less evidence backing its effectiveness, and some studies have found people don’t stay on it as long.

More than 250 jails in 33 states now offer Vivitrol to at least some addicted inmates, typically just before their release, according to Andy Klein, a senior scientist for Advocates for Human Potential, a company that provides training to prisons and jails with addiction treatment programs.

“It’s been practically doubling every year,” Klein said, though he added that only a few dozen jails offer buprenorphine (also known as Suboxone) or methadone.

DiPierro’s lawsuit alleges that in prohibiting medication for a diagnosed condition, the Bureau of Prisons is violating the Eighth Amendment’s ban on cruel and unusual punishment. It also accuses the prisons bureau of violating the Rehabilitation Act of 1973, which protects people with disabilities from discrimination by federal agencies.

“The Bureau of Prisons is denying her a reasonable accommodation as a result of her disability, and also discriminating between different disabilities,” said Jessie Rossman, a staff lawyer at the American Civil Liberties Union of Massachusetts, which is representing DiPierro and also represented the plaintiff in last year’s county-level case. “Inmates with chronic conditions like diabetes are allowed to continue to take their medically necessary treatment.”

Rossman said the case appeared to be the first challenge to the Bureau of Prisons policy on medication-assisted treatment, adding, “What’s now coming across loud and clear is that the standard of care to treat opioid use disorder is medication-assisted treatment, and it’s ineffective and unlawful to prevent individuals from accessing their treatment and medication for that disease.”

The prisons bureau declined to comment on the lawsuit.

Giving DiPierro naltrexone before her release would do nothing to help her withdrawal symptoms and cravings while in custody, Rossman said, and staying on methadone was safer for DiPierro regardless, because it had worked for her.

Other state chapters of the ACLU — in Maine and Washington state — have filed cases seeking methadone or buprenorphine treatment in jails.

In Rhode Island, an early evaluation of the system found that nine people recently released from prison there died of an overdose in the first six months of 2016, compared with 26 people over the same period in 2016.

DiPierro wrote that she had received a diagnosis of anxiety and bipolar disorder, and feared that going through withdrawal from methadone, even if she was tapered off it, could compel her to attempt suicide.

“I am afraid of what it will mean to lose my methadone treatment at the exact moment when I am put in the most anxiety-producing situation of my life,” she wrote. “I am afraid for my life and my safety if the Bureau of Prisons withholds medicine that I know I need.”

This article originally appeared in <a href="https://www.nytimes.com/2019/03/15/health/methadone-prisons-opioids.html" id="17293ba9-6c80-3593-a821-e6746732903c">The New York Times</a>.

A Massachusetts woman recovering from heroin addiction sued the Federal Bureau of Prisons on Friday over its policy prohibiting methadone treatment, which she wants to continue when she starts a yearlong sentence next month.

Methadone Helped Her Quit Heroin. Now She's Suing U.S. Prisons to Allow the Treatment.

The study, by researchers at the Urban Institute, a nonprofit research group, adds to the evidence that former President Barack Obama’s 2010 health care law is playing a significant role in addressing the opioid epidemic. The researchers found that the number of Medicaid-covered prescriptions for buprenorphine, which eases cravings and withdrawal symptoms, increased almost fivefold nationally — to 6.2 million from 1.3 million — between 2011 and 2018.

“Expanding Medicaid is probably the most important thing states can do to increase treatment rates,” said Lisa Clemans-Cope, the study’s lead author. “But even some states that did expand Medicaid look like they are falling short in meeting the treatment needs.”

During the period the researchers studied, the opioid epidemic was worsening and many states — led mostly by Democrats, but sometimes by Republicans — chose to expand coverage under Medicaid, the joint federal and state health insurance program for poor people. The Affordable Care Act gave states the option of covering many more adults through Medicaid, which covers a disproportionate share of people with opioid addiction, starting in 2014.

The law also vastly expanded access to addiction treatment by designating it as an “essential benefit” that must be covered through the “Obamacare” marketplaces and expanded Medicaid. Buprenorphine is one of three medications that the Food and Drug Administration has approved to treat opioid addiction; there is substantial evidence that it sharply reduces the risk of dying from an overdose.

Hundreds of thousands of Americans have died from opioid overdoses during the past decade, including nearly 48,000 last year, and most people with opioid addiction are not getting treatment, according to government studies.

The study found that, on average, the rate of Medicaid-covered prescriptions for buprenorphine was much lower in states that did not expand the program; most of those states are in the South and Great Plains. In all, 33 states and the District of Columbia have expanded Medicaid since 2014 and 14 have not; they are largely led by Republicans who oppose it on partisan, ideological and fiscal grounds. In three other states — Idaho, Nebraska and Utah — voters approved ballot measures last fall directing their legislatures to expand Medicaid, but they have not yet done so.

All five of the states with the highest buprenorphine prescribing rates for Medicaid recipients — Vermont, West Virginia, Kentucky, Montana and Ohio — expanded Medicaid. West Virginia, Kentucky and Ohio also have among the highest overdose rates in the nation, but overdose deaths fell in all three states last year.

Only one of the five states with the lowest buprenorphine prescribing rates in Medicaid — Arkansas — expanded the program. The other four were Texas, South Dakota, Florida and Kansas. The researchers noted that there could be other reasons for the lower number of prescriptions in some states, such as lower rates of opioid addiction or more restrictions on prescribing buprenorphine, as Arkansas has. But such factors, they said, could not explain the huge difference in prescribing rates.

Between 2011 and 2018, Medicaid-covered prescriptions for buprenorphine increased from 40 to 138 per 1,000 enrollees in states that expanded the program, the study estimated using data from the federal Centers for Medicare and Medicaid Services. In comparison, such prescriptions increased from 16 to 41 per 1,000 enrollees in states that did not expand Medicaid.

States that have chosen not to expand Medicaid have depended on several billion dollars in grants that Congress has doled out since 2017 for treatment, prevention and recovery services, but the money is scheduled to run out next year. The Trump administration is also supporting a Republican-led court case seeking to overturn the Affordable Care Act, including the expansion of the Medicaid program.

Even among the states with large increases in buprenorphine prescribing, there was wide variation. Vermont had by far the highest rate: 1,210 buprenorphine prescriptions for every 1,000 Medicaid enrollees in 2018. The next highest rate, in West Virginia, was 827 prescriptions per 1,000 enrollees.

Vermont has had one of the most ambitious expansions of opioid addiction treatment in the country, including in prisons and hospital emergency rooms. The researchers said its high prescribing rate could also reflect higher dosing — patients taking two 8-milligram tablets of buprenorphine at a time, for example.

The study did not look at prescribing data for naltrexone, another medication approved to treat opioid addiction. A third medication, methadone, is dispensed at highly regulated clinics rather than prescribed. It is possible that in some regions with low buprenorphine prescribing rates, naltrexone or methadone are more commonly used.

Dr. G. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, said that the findings were useful but that researchers should also study the quality of care that people on buprenorphine are getting from state to state.

“Expanding the use of these evidence based, FDA-approved treatments is an important first step in improving care for opioid-use disorder,” he said. “But all too often, treatment courses are short, and care for opioid addiction is fragmented from all of the other health care needs that people have.”

This article originally appeared in <a href="https://www.nytimes.com/2019/08/21/health/opioids-treatment-medicaid.html" id="eeeac758-4f5c-3b2d-ab15-87621df8dce3">The New York Times</a>.

Opioid Treatment Is Used Vastly More in States That Expanded Medicaid

States that expanded Medicaid under the Affordable Care Act have seen a much bigger increase in prescriptions for a medication that treats opioid addiction than states that chose not to expand the program, a new study has found.

When Jake Tapper asked Sen. Bernie Sanders whether his Medicare for All health care plan was “bad policy” and “political suicide,” it set off a half-hour brawl that drew in almost every one of the 10 candidates on the stage. Suddenly, members of the party that had been all about protecting and expanding health care coverage were leveling accusations before a national audience at some of their own — in particular, that they wanted to take it away.

“It used to be Republicans that wanted to repeal and replace,” Gov. Steve Bullock of Montana said in one of the more jolting statements on the subject. “Now many Democrats do as well.”

Those disagreements set a combative tone that continued for the next 90 minutes. The health care arguments underscored the powerful shift the Democratic Party is undergoing, and that was illustrated in a substantive debate that also included trade, race, reparations, border security and the war in Afghanistan.

In the end, it was a battle between aspiration and pragmatism, a crystallization of the struggle between the party’s left and moderate factions.

It is likely to repeat itself during Wednesday night’s debate, whose lineup includes former Vice President Joe Biden Jr. and Sen. Kamala Harris of California. He supports building on the Affordable Care Act by adding an option to buy into a public health plan. She released a proposal this week that would go further, eventually having everyone choose either Medicare or private plans that she said would be tightly regulated by the government.

Democrats know all too well that the issue of choice in health care is a potent one. When President Barack Obama’s promise that people who liked their health plans could keep them under the Affordable Care Act proved to be untrue, Republicans seized on the fallout so effectively that it then propelled them to majorities in both the House and Senate.

On Tuesday night, Rep. Tim Ryan of Ohio evoked those Republican attacks of years ago on the Affordable Care Act, saying the Sanders plan “will tell the union members that give away wages in order to get good health care that they will lose their health care because Washington is going to come in and tell them they have a better plan.”

Republicans watching the debate may well have been smiling; the infighting about taking away people’s ability to choose their health care plan and spending too much on a pipe-dream plan played into some of President Donald Trump’s favorite talking points. Trump is focusing on health proposals that do not involve coverage — lowering drug prices, for example — as his administration sides with the plaintiffs in a court case seeking to invalidate the entire Affordable Care Act, putting millions of people’s coverage at risk..

It was easy to imagine House Democrats who campaigned on health care, helping their party retake control of the chamber, being aghast at the fact that not a single candidate mentioned the case.

Sanders’ plan would eliminate private health care coverage and set up a universal government-run health system that would provide free coverage for everyone, financed by taxes, including on the middle class. John Delaney, the former congressman from Maryland, repeatedly took swings at the Sanders plan, suggesting that it was reckless and too radical for the majority of voters and could deliver a second term to Trump.

Sanders held firm, looking ready to boil over at times — “I wrote the damn bill,” he fumed after Ryan questioned whether benefits in his plan would prove as comprehensive as he was promising. Sen. Elizabeth Warren of Massachusetts, the only other candidate in favor of a complete overhaul of the health insurance system that would include getting rid of private coverage, chimed in to back him up.

At one point she seemed to almost plead. “We are not about trying to take away health care from anyone,” she interjected. “That’s what the Republicans are trying to do.”

Delaney has been making a signature issue of his opposition to Medicare for all, instead holding up his own plan, which would automatically enroll every American under 65 in a new public health care plan or let them choose to receive a credit to buy private insurance instead. He repeatedly disparaged what he called “impossible promises.”

He was one of a number of candidates — including Beto O’Rourke, the former congressman from Texas; Sen. Amy Klobuchar of Minnesota and Mayor Pete Buttigieg of South Bend, Indiana — who sought to stake out a middle ground by portraying themselves as defenders of free choice with plans that would allow, but not force, people to join Medicare or a new government health plan, or public option. (Some candidates would require people to pay into those plans, while others would not.)

The debate moderators also pressed Sanders and Warren on whether the middle class would have to help pay for a Sanders-style plan, which would provide a generous set of benefits — beyond what Medicare covers — to every American without charging them premiums or deductibles. One of the revenue options Sanders has suggested is a 4% tax on the income of families earning more than $29,000.

In defending his plan, Sanders repeatedly pointed out how many Americans are uninsured or underinsured, unable to pay high deductibles and other out-of-pocket costs and thus unable to seek care.

Analysts often point out that the focus on raising taxes to pay for universal health care leaves out the fact that in exchange, personal health care costs would drop or disappear.

“A health reform plan might involve tax increases, but it’s important to quantify the savings in out-of-pocket health costs as well,” Larry Levitt, executive vice president for health policy at the nonpartisan Kaiser Family Foundation, tweeted during the debate. “Political attacks don’t play by the same rules.”

A Kaiser poll released Tuesday found that two-thirds of the public supports a public option, although most Republicans oppose it. The poll also found about half the public supports a Medicare for all plan, down from 56% in April. The vast majority of respondents with employer coverage — which more than 150 million Americans have — rated it as excellent or good.

In truth, Delaney’s own universal health care plan could also face political obstacles, not least because it, too, would cost a lot. He has proposed paying for it by, among other steps, letting the government negotiate drug prices with pharmaceutical companies and requiring wealthy Americans to cover part of the cost of their health care.

Had Sanders not responded so forcefully to the attacks, it would have felt like piling on, although some who criticized his goals sounded more earnest than harsh.

“I think how we win an election is to bring everyone with us,” Klobuchar said, adding later in the debate that a public option would be “the easiest way to move forward quickly, and I want to get things done.”

This article originally appeared in <a href="https://www.nytimes.com/2019/07/30/health/democratic-debate-health-medicare.html" id="8c0d0a72-f71c-30ca-a229-55b059a28226">The New York Times</a>.

WASHINGTON — It took only one question — the very first — in Tuesday night’s Democratic presidential primary debate to make it clear that the issue that united the party in last year’s congressional elections in many ways now divides it.

Democratic Debate Turns Ferocious Over Health Care

Republicans watching the debate may well have been smiling; the infighting about taking away people’s ability to choose their health care plan and spending too much on a pipe-dream plan played into some of President Donald Trump’s favorite talking points. Trump is focusing on health proposals that do not involve coverage — lowering drug prices, for example — as his administration fights in court to overturn the Affordable Care Act.

It found that counties where opioid manufacturers offered a large number of gifts and payments to doctors had more overdose deaths involving the drugs than counties where direct-to-physician marketing was less aggressive.

The study, published Friday in JAMA Network Open, said the industry spent about $40 million promoting opioid medications to nearly 68,000 doctors from 2013 through 2015, including by paying for meals, trips and consulting fees. And it found that for every three additional payments that companies made to doctors per 100,000 people in a county, overdose deaths involving prescription opioids there a year later were 18 percent higher.

From 2013 through 2015, roughly 1 in 12 doctors received opioid-related marketing, according to the study, including 1 in 5 family practice doctors.

The authors, from Boston Medical Center and New York University School of Medicine, found that counties where doctors received more industry marketing subsequently saw an increase in both the number of opioids prescribed and opioid-related overdose deaths.

In response to the study, Dr. John Cullen, president of the American Academy of Family Physicians, said, “A limitation of the study, as acknowledged by the authors, is the many unknown variables that prevent drawing a direct causal link between pharmaceutical marketing and opioid-related deaths.”

The authors acknowledged that the study could not differentiate between overdose deaths involving painkillers that are prescribed versus illicitly acquired.

“We acknowledge that our work describes only one part of the very complex opioid overdose crisis in this country,” said the lead author, Dr. Scott Hadland. “Even still, prescription opioids remain involved in one-third of all opioid overdose deaths, and are commonly the first medications that people encounter before transitioning to heroin or fentanyl.”

Areas with large numbers of payments and high overdose rates included four cities in Virginia — Salem, Fredericksburg, Winchester and Norton — as well as Cabell County, West Virginia, which has one of the highest overdose death rates in the nation. Lackawanna County, Pennsylvania, also ranked high in both measures, as did Erie County, Ohio.

The authors said they were particularly struck by the fact that the number of marketing interactions with doctors — such as frequent free meals — was more strongly associated with overdose deaths than the amount spent.

“Each meal seems to be associated with more and more prescriptions,” Hadland said.

This article originally appeared in <a href="https://www.nytimes.com/2019/01/18/health/opioids-doctors-overdose-deaths.html" id="dc83a553-43dc-32e0-a15b-cdae9c8249cd">The New York Times</a>.

WASHINGTON — A new study offers some of the strongest evidence yet of the connection between the marketing of opioids to doctors and the nation’s addiction epidemic.

Study Links Drug Maker Gifts to Doctors to More Overdose Deaths

Even as the opioid epidemic was killing more and more Americans, such marketing practices remained widespread. From 2013 through 2015, roughly 1 in 12 doctors received opioid-related marketing, according to the study, including 1 in 5 family practice doctors.

He added, “We’re very much aware of the critical and devastating impact of the opioid epidemic and work every day, with every patient interaction, to fight it. At the same time, we must protect the physician’s ability to provide adequate pain management.”

The authors acknowledged several caveats in the study, including that it could not differentiate between overdose deaths involving painkillers that are prescribed versus illicitly acquired.

“We acknowledge that our work describes only one part of the very complex opioid overdose crisis in this country,” said the lead author, Dr. Scott Hadland, a pediatrician and researcher at Boston Medical Center’s Grayken Center for Addiction. “Even still, prescription opioids remain involved in one-third of all opioid overdose deaths, and are commonly the first medications that people encounter before transitioning to heroin or fentanyl. It is critical that we take measures now to prevent marketing from unnecessarily exposing new people to opioids they may not need.”

The study found that opioid-related spending on doctors was most highly concentrated in counties in the Northeast; the Midwest had the lowest concentration.

Areas with large numbers of payments and high overdose rates included four cities in Virginia — Salem, Fredericksburg, Winchester and Norton — as well as Cabell County, West Virginia, which has one of the highest overdose death rates in the nation. Lackawanna County, Pennsylvania, which includes Scranton, also ranked high in both measures, as did Erie County, Ohio.

“Each meal seems to be associated with more and more prescriptions,” Hadland said. He added that while pharmaceutical company payments to doctors seem to have started dropping, the practice of companies buying meals for doctors “remains alive and well.”

The study noted that while some states have sought to limit the total amount drug companies spend promoting their products to doctors — New Jersey, for example, recently adopted a new regulation limiting such spending to $10,000 per doctor, per year — what may matter more is for states or health systems to limit the number of interactions.

“I think what seems to be less important is the amount of money spent,” Hadland said, “compared with the number of interactions.”

The study linked information from 2013 to 2016 across three national databases: the Open Payments database, which includes all payments made by pharmaceutical companies to physicians, which companies are required to report under a section of the Affordable Care Act; drug overdose data from the Centers for Disease Control and Prevention; and CDC data on opioid prescriptions dispensed at pharmacies.

It measured opioid marketing in three ways: the total dollar value of marketing received by doctors; the number of payments made by the pharmaceutical industry; and the number of physicians receiving any marketing.

The study builds on another that Hadland and his co-author, Dr. Magdalena Cerda, an associate professor of population health at the NYU School of Medicine, published earlier this year. It found that for every meal a doctor received related to an opioid drug in 2014, there was an increase in opioid claims by that doctor for Medicare patients the following year.

As the opioid epidemic reached crisis proportions over the past few years, more than 30 states have responded by passing laws that restrict opioid prescribing. Critics say these policies are misguided because most overdose deaths now are from illicit opioids like synthetic fentanyl, and because the restrictions hurt patients with chronic pain.

But the policies may be having an impact, as opioid prescribing rates overall have been falling. Still, Hadland pointed out, prescribing rates remain uneven, with some regions still seeing widespread prescribing of opioids.

One company, Purdue Pharma, the maker of OxyContin, announced last year that it would stop marketing its painkillers to doctors, including by no longer sending salespeople to medical offices to talk about the drugs. According to a newly public filing in a lawsuit brought by Massachusetts against Purdue, a member of the Sackler family, which owns the company, had boasted in 1996 that “the launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition.”

An analysis last year by ProPublica found that payments to doctors related to opioid drugs dropped significantly in 2016 — a sign that public pressure on the companies in the wake of the opioid epidemic had begun having an effect. ProPublica found that in 2016, drugmakers spent $15.8 million on doctors in the form of speaking and consulting fees, meals and travel related to opioid drugs. That was 33 percent less than in 2015, when they spent $23.7 million, and 21 percent less in 2014, when they spent $19.9 million.

MURFREESBORO, Tenn. — Just past a cemetery along a country road, an addiction treatment center called JourneyPure at the River draws hundreds of patients a month who are addicted to opioids and other drugs. They divide their days between therapy sessions, songwriting, communing with horses and climbing through a treetop ropes course. After dinner, they’re driven into town in white vans for 12-step meetings.

It is a common regimen at residential treatment programs, but as the opioid epidemic persists, JourneyPure is evolving. Though its glossy website doesn’t mention it, the company is ramping up its use of medications to blunt the torturous withdrawal symptoms and cravings that compel many with opioid addiction to keep using.

There is substantial evidence backing this approach, which is supposed to be used in tandem with therapy. But because two of the three federally approved medicines are opioids themselves, it is spurned by people who believe taking drugs to quit drugs is not real recovery.

Addiction experts say such resistance is obstructing efforts to reduce overdose deaths and help Americans with addictions get their lives back on track, even as many drain their savings or go into debt paying for repeated stints in residential rehab. Two-thirds of the patients admitted to JourneyPure’s program over the last three months said it wasn’t their first time in treatment.

“I’m watching the dominoes fall on our industry,” said David Perez, JourneyPure at the River’s new chief executive, who has helped lead the push toward using more medication-assisted treatment. “People are dying, and we are feeling more and more impotent to stop it. That is what’s shifting beliefs, more than anything.”

The internal tensions over JourneyPure’s changing policy, and how proactively it should promote medication as an option, reflect an often reluctant shift taking place in the drug treatment world.

At the same time, the Trump administration’s view on medication-assisted treatment has evolved from critical to fully supportive. Tom Price, President Donald Trump’s first Health and Human Services secretary, appalled many addiction experts by saying, “If we’re just substituting one opioid for another, we’re not moving the dial much.” But Price’s successor, Alex Azar, a former pharmaceutical executive, has embraced the approach.

When the administration announced $1 billion in new grants to expand access to treatment earlier this year, it emphasized that only programs that made these medicines available were eligible. Azar has also enlisted his agency’s Center for Faith and Opportunity Initiatives to reach out and explain the importance of medication to religiously affiliated providers of treatment and recovery services, which tend to embrace an abstinence-only approach.

More than 70,000 people in the United States died of overdoses in 2017, and opioids were the main driver. But nationally, 49 percent of the nearly 3,000 residential programs that treat opioid addiction still don’t use any of the medications proven to save lives, according to an analysis by amfAR, a foundation that funds AIDS research. Even so, that is an improvement over 2016, when 58 percent weren’t using any of them.

The strong evidence for medication-assisted treatment has yet to win over not only many treatment providers, but patients themselves. Heather Ramsey, 30, who is six months pregnant, was prescribed one of the medications, buprenorphine, at JourneyPure. Addicted to pain pills and Xanax for half her life, she had finally sought treatment because, she said, “My body can’t take it no more.”

Despite her doctor’s assurances that medication was the safest, surest protocol for her, Ramsey, from rural East Tennessee, feels guilty about it.

“I feel like I’m kind of, in a sense, cheating the program,” she said one afternoon in the living room of a residential cottage, adjusting her ponytail after a group meeting with a recovery coach. “Because I’m still depending on a substance to make me feel normal, and that’s not why I came here.”

Anti-craving medications are not a silver bullet; relapse is common even among people who take them, and some in fact do better with an abstinence approach. But there is substantial evidence that buprenorphine and a similar drug, methadone — which has faced ideological resistance on and off for decades — reduce the mortality rate among people addicted to opioids by half or more; they are also more successful at keeping people in treatment than abstinence-based approaches. A federally funded study last year found that naltrexone, a non-opioid medication that JourneyPure has offered to some patients since it opened in 2015, was just as effective as buprenorphine.

But naltrexone, also known by the brand name Vivitrol, is more expensive and people tend not to stay on it as long. It is also harder to start because it requires a long detox period first.

Insurers are starting to pressure providers to use medication assisted treatment, or MAT.

“It’s really the linchpin of our strategy going forward — I can’t overemphasize that,” said Daniel Knecht, vice president of clinical strategy and policy at Aetna. “But too often you have to convince the caregivers, as well as the patients, that MAT is the cornerstone.”

Sam MacMaster, JourneyPure’s co-founder and chief clinical officer, is among the wary. He acknowledges the power of medication to “stop the chaos” that envelops the lives of people with addictions, but worries it will squeeze out therapies that help them learn “how to connect, attach to other people and healthy things.”

“My fear is we are heading in the direction where it’s enough; that there’s a wholly pharmaceutical solution to addiction.”

It’s true that if medications became the main form of addiction treatment, the pharmaceutical industry would benefit — an outrageous outcome, critics of the approach believe, given the industry’s role in creating the opioid epidemic. But medication-focused treatment would also threaten residential programs like JourneyPure, a for-profit company with locations in Florida and Kentucky as well as Tennessee. It charges an average of $15,000, and up to $26,000, for a monthlong stay, though many of its patients have private insurance that covers most of the cost.

Change started to come to the JourneyPure program in Murfreesboro with the hiring of Perez as chief executive a year ago. He came from a center in Memphis that has long used medication, and was struck by the resistance to it in Middle Tennessee, where even liberal Nashville still has just one methadone clinic.

A few months later, JourneyPure hired Dr. Stephen Loyd, who had been the medical director for the Tennessee Division of Substance Abuse Services. Loyd himself went through treatment for addiction to painkillers in 2004 and, in his state role, became an evangelist for MAT.

Now he has a similar role as medical director for JourneyPure’s Middle Tennessee programs, where a few months ago he presented his bosses with a “manifesto” outlining how he wanted the company to use medications more aggressively, including by expanding its outpatient clinics and providing buprenorphine to more patients.

“You’ve got these two warring factions — the MAT side and the abstinence-based side,” he said. “It’s almost like our national politics. Where’s the John McCain? Here, it’s going to be me.”

The medication that JourneyPure and other residential treatment programs use most is naltrexone, because it is not an opioid. It blocks the brain’s opioid receptors, preventing any high in patients who try to use opioids while on it. JourneyPure typically offers patients an initial shot near the end of their stay, with the option of returning monthly for more.

At Loyd’s urging, JourneyPure has also decided to let residential patients take buprenorphine, also known as Suboxone, if he recommends it. In the past, the company had used the medication only to help detoxing patients get through withdrawal.

JourneyPure uses an approach known as trauma-informed care, where patients explore traumatic experiences from their past that might help explain their addiction, and learn new ways to cope. Most patients also have mental illnesses like bipolar disorder or post-traumatic stress disorder that need to be treated, MacMaster said.

Songwriting and spending time with horses not only help people open up and feel valued, company leaders say, but add to the allure of residential treatment.

“If we went purely science-based, nobody would come to treatment because it would be boring,” Perez said.

Some of Loyd’s patients have been arrested for taking the very medications that he and many researchers feel are crucial to their recovery. Miranda Nichols, 25, initially came to JourneyPure a year and a half ago for heroin addiction. When she left after a month, she said, she got a Vivitrol shot but it was so expensive — her co-payment was $600 — that she never got another.

She returned to shooting heroin, then got pregnant and switched to buprenorphine she bought on the street back home in Alabama because, she said, she could not afford the cash-only clinics that prescribed it there. There, she was charged with theft and “chemical endangerment of a child,” the latter because she was taking buprenorphine without a prescription. After a stint in jail, she returned to JourneyPure with a court’s permission for more treatment.

Loyd, who had just started working at JourneyPure when she returned, put her back on buprenorphine; Nichols gave birth to a healthy son in June, after spending three months at the center. She is working for a plant company in Nashville and living with the baby at a recovery home that allows buprenorphine. She lost custody of her two older children after her arrest; her case is supposed to go to trial next year, and Loyd is writing a letter of support.

“People are getting more educated on buprenorphine now,” Nichols said. “They see my story and what kind of person I am, and they see how it actually works.”

“But,” she added, “back in Alabama, I could still go to jail for up to 20 years.”

In Tennessee — where overdose deaths rose by 9 percent in 2017, to 1,776, the highest number on record — the state did little to promote medications for addiction treatment until recently.

Over the past year, though, it has started doling out federal funds for expanding medication-assisted treatment to 15 nonprofit programs around the state. State health officials are training employees of the programs on how to use the medications and, at times, talking them through their reticence.

“They had to change their business rules, their philosophy,” said Taryn Sloss, assistant commissioner for the Tennessee Department of Mental Health and Substance Abuse Services. “A lot of them were abstinence-based and had people in recovery on their boards who thought, ‘If it was good enough for me, it’s good enough for everyone else.'”

Because they’re not eligible for government grants, for-profit companies like JourneyPure don’t face as much pressure to embrace medication-assisted treatment. They are regulated through a state licensing process, but Tennessee, like most states, doesn’t require medication to be part of their treatment protocol for opioid addiction. Nor do accrediting bodies like the Commission on Accreditation of Rehabilitation Facilities, although the commission has started requiring programs to help patients access medication if they want it.

“We should make it the standard in terms of running a treatment program that’s licensed by a state in the 21st century,” said Michael Botticelli, who served as the drug czar under President Barack Obama and now leads the Grayken Center for Addiction at Boston Medical Center.

— Helping the Vulnerable

It was late summer at JourneyPure; the horses were grazing behind the barn, and a river burbled behind the cluster of cottages where patients live. Around a table in the main building, tensions were crackling over medication-assisted treatment.

Loyd was there, as were MacMaster and Patrick Dunn, the company’s chief of operations development.

Abby Goodnough

Articles written by the author

Cheaper Plans and More Options as ACA Stabilizes From Onslaught

Health Law Premiums to Fall and Number of Insurers to Rise Next Year

Health Officials Urge Caution in Reducing Opioids for Pain Patients

Pelosi Details Drug-Price Plan, Adding to a Stalled Debate

Methadone Helped Her Quit Heroin. Now She's Suing U.S. Prisons to Allow the Treatment.

Opioid Treatment Is Used Vastly More in States That Expanded Medicaid

Democratic Debate Turns Ferocious Over Health Care

Democratic Debate Turns Ferocious Over Health Care

Study Links Drug Maker Gifts to Doctors to More Overdose Deaths

Study Links Drug Maker Gifts to Doctors to More Overdose Deaths

Debating the Use of Drugs to Curb Drug Abuse

Debating the Use of Drugs to Curb Drug Abuse

Feud Over Use of Drugs to Curb Abuse of Drugs

Feud Over Use of Drugs to Curb Abuse of Drugs

On the doorstep with a plea: will you support medicare for all?

Judge blocks work requirements for medicaid recipients in Arkansas and Kentucky

Medical school run by Kaiser plans to waive student tuition

It was going to be the 1st safe injection site for opioid users, but the Trump administration is suing to block it