Pre-Existing Conditions Deserve Affordable Treatment

By Dr. Lynn Webster, PNN Columnist

The National Institutes of Health reports that about 10 percent of Americans experience a substance use disorder (SUD) at some point in their lives. Most of those who suffer from an SUD receive no treatment.

About twice as many Americans – 20 percent -- have chronic pain. Many of them also cannot find adequate treatment or even a provider willing to treat them. 

Making treatment accessible for both of these conditions -- which are defined as pre-existing for insurance purposes -- is always a topic of concern. These days, it is of paramount concern that access to treatment is available. And it requires us to take action.

We’re All at Risk for Pain and Drug Abuse

Poverty and hopelessness are risk factors for drug abuse, even though not everyone who is economically challenged develops an SUD. Unfortunately, prevention and treatment programs for SUDs are less available to those who cannot pay for them and who most need them.

Anyone can suffer from chronic pain, but even those with resources may not have access to adequate pain management.

My concern is more than theoretical. It is personal. I have friends, former patients and family members who suffer from SUDs. If the Affordable Care Act (ACA) — widely known as Obamacare — ends and we lose coverage of pre-existing conditions, I fear they will be abandoned in exactly the same way as people in pain have been abandoned ever since the CDC issued its 2016 opioid prescribing guideline.

In recent years, I have received hundreds of emails and calls from people in pain. Their medications have been tapered and they don't know where to turn for help. Untreated chronic pain, as well as untreated SUDs, can result in ruinous consequences: disability, destitution, isolation, poverty and suicide.

We need to help healthcare providers find more effective ways to treat their patients. The Centers of Excellence in Pain Education (CoEPEs) program was created to teach healthcare professionals about pain and its treatment. Since this is something most doctors do not study adequately during medical school, it's important to have continuing medical education opportunities to learn about the stigma associated with pain treatment and substance abuse disorders.

Abolishing ACA Could Have Devastating Consequences

The current administration has appealed to the Supreme Court to abolish the ACA. President Trump has said that Obamacare "must fall." Given the fact that we're in the middle of a pandemic and millions of people are unemployed and may have lost access to employer-sponsored healthcare, the timing seems terrible.  

But even without a pandemic, reversing the ACA would be devastating for millions of Americans who have an SUD or chronic pain. President Trump signed an executive order on September 24 that claims to protect people with pre-existing conditions. However, experts dispute whether his executive order can actually do what it promises.

Regardless, eliminating the ACA will likely allow insurance companies to charge higher rates for people with pre-existing conditions. This would essentially render treatment for chronic pain and SUD unaffordable for many people, leading to an increase of the terrible consequences mentioned above. And, of course, SUDs and chronic pain are only two of the pre-existing conditions that would no longer be protected. 

It is time for everyone to understand the consequences that losing the ACA may have for their community, family, friends and themselves. There is still time to be heard, but you have to act quickly. Click here to find your federal, state, and local elected officials and express your views.  

Let us also send healing thoughts and prayers to President Trump, the First Lady and everyone else infected with COVID-19.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. You can find Lynn on Twitter: @LynnRWebsterMD. 

Obamacare Prevented Thousands of Opioid Overdose Deaths

By Pat Anson, PNN Editor

The expansion of Medicaid under the Affordable Care Act – widely known as Obamacare -- was associated with a six percent lower rate of opioid overdose deaths, according to a new study that estimates thousands of overdoses may have been prevented by expanding access to healthcare for millions of Americans.

Researchers also found a significant and unexpected increase in overdoses involving methadone, an addiction treatment drug sometimes used to treat chronic pain.

Thirty-two states and the District of Columbia opted to expand Medicaid eligibility under the Affordable Care Act (ACA), providing healthcare coverage to uninsured low-income adults. ACA requires that individuals who receive coverage be provided with mental health and substance use disorder treatment.

Researchers at the NYU Grossman School of Medicine and University of California, Davis looked at death certificate data from 49 states and the District of Columbia between 2001 and 2017— looking for changes in overdose rates in counties that expanded Medicaid under ACA compared to those that did not.

Their findings, published online in JAMA Network Open, suggest that Medicaid expansion prevented between 1,678 and 8,132 opioid overdose deaths from 2015 to 2017.

Overall, there was a 6% lower rate of opioid overdose deaths, an 11% lower rate of heroin overdoses, and a 10% lower rate of death involving fentanyl and synthetic opioids other than methadone in states that adopted the ACA.

"The findings of this study suggest that providing expanded access to health care may be a key policy lever to address the opioid overdose crisis," said senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the Department of Population Health at NYU Langone Health.

Methadone Overdoses Rose

Cerdá and her colleagues also found a concerning 11% increase in methadone overdose rates in states that expanded Medicaid under the ACA. Methadone is an opioid that has long been used to treat addiction, but it is also prescribed by some doctors to treat chronic pain.

“Although the rate of methadone-related mortality is relatively low compared with other opioid classes, our finding that Medicaid expansion was associated with increased methadone overdose deaths deserves further investigation,” researchers said.

“Past research has found high rates of methadone use to treat pain among Medicaid beneficiaries and that the drug is disproportionately associated with overdose deaths among individuals in this population, underscoring the importance of ongoing local, state, and federal actions to address safety concerns associated with methadone for pain in tandem with Medicaid expansion.”

In 2014, the methadone prescribing rate among Medicaid patients was nearly twice that of commercially insured patients. Medicaid patients were also slightly more likely to be prescribed methadone for pain (1.1% vs. 0.85%) as opposed to addiction.

Expansion Reduced Opioid Deaths

The ACA became law at a time when opioid overdose deaths were rising sharply. Some critics of Obamacare claimed that expanding access to low-cost opioid pain relievers would create an incentive for low-income Medicaid beneficiaries to sell their drugs.

“It stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem,” a 2018 report by Sen. Ron Johnson (R-WI) claimed. “The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014. Drug overdose deaths have risen rapidly, at a much faster pace than before expansion.”

The NYU and UC Davis study found that theory to be false.

"Past research has found Medicaid expansion is associated with not only large decreases in the number of uninsured Americans, but also considerable increases in access to opioid use disorder treatment and the opioid overdose reversal medication naloxone," said lead author Nicole Kravitz-Wirtz, PhD, an assistant professor in the Department of Emergency Medicine at UC Davis.

"Ours was the first study to investigate the natural follow-up question: Is the expansion associated with reductions in local opioid overdose deaths? On balance, the answer appears to be yes." 

Medicaid Expansion Did Not Fuel Opioid Crisis

By Pat Anson, PNN Editor

A new study is debunking claims that increased access to healthcare and pain management helped to fuel the opioid crisis. If anything, the opposite appears to be the case.

The study, published in the Journal of General Internal Medicine, found that early Medicaid expansions in Arizona, Maine and New York may have led to lower overdose rates in those states.

"These findings suggest that Medicaid expansions were unlikely to have contributed to the subsequent rise in drug overdose deaths, and may even have been protective," said lead author Atheendar Venkataramani, MD, PhD, an assistant professor of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania.

Venkataramani and co-author Paula Chatterjee, MD, looked at state-level data on drug overdoses from 1999 to 2008, comparing overdose mortality rates in the three Medicaid-expansion states to those in other states.

By 2008, Arizona, Maine and New York had about 7 fewer overdose deaths per 100,000 people compared to the other 47 states.

The differences were even greater when the three states were only compared to adjacent states: They had 17 fewer deaths per 100,000 people.

Overall, the study suggests that drug overdose deaths were nearly 20 percent lower in the early expansion states.

"The results should provide reassurance to policymakers who are concerned that state Medicaid expansions, including the recent expansions implemented as part of the Affordable Care Act, promote rises in drug overdose mortality," said Venkataramani.

The Affordable Care Act (ACA) – widely known as Obamacare – greatly expanded Medicaid coverage for millions of poor Americans, starting in 2014. But some critics have claimed the ACA made the opioid crisis worse by giving patients easier access to opioids.

“The Medicaid expansion may be fueling the opioid epidemic in communities across the country,” Wisconsin Sen. Ron Johnson (R) wrote in a 2017 letter to the Health and Human Services inspector general. “Because opioids are so available and inexpensive through Medicaid, it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

The Penn Medicine study wasn't designed to determine why Medicaid expansion appeared to lower overdose death rates in New York, Arizona and Maine. But it does suggest that better access to healthcare was a factor.

“Improving people’s access to health care could have a number of effects. It may be that people had better access to substance use disorder treatment or better access to mental health or pain management. Or it may be that providing health insurance reduced the risk of financial ruin, which helped downward socioeconomic spirals that could lead to substance use disorder,” Venkataramani wrote in an email to PNN.

“If Medicaid expansions did increase access to opioids, then the effect of doing so was far outweighed by other forces that actually reduced mortality rates from drug use order. The mechanisms again are not known because of data limitations in this study, but access to regular health care, access to substance use disorder treatment, and improved socioeconomic circumstances all may have contributed to the slower growth in drug overdose mortality in Medicaid expansion states.”

The Affordable Care Act expanded Medicaid coverage to about 12 million Americans in the 31 states and the District of Columbia that opted to receive it. A recent study found that opioid prescriptions decreased slightly in those states, while prescriptions for addiction treatment drugs like Suboxone rose significantly.

Don’t Drown in Anxiety Over Healthcare Bill

By Barby Ingle, Columnist  

With everything going on with the American Health Care Act (AHCA), there is a lot of anxiety and stress over possible changes to our health coverage.

There were people who took to social media to start their protests before all of the facts were in. I have yet to read the actual bill and when I reached out to others who were commenting on it -- as if they read it and knew what was in it – well, they have not read it yet either.

So I kept looking and found an interview with House Speaker Paul Ryan, which talked about the biggest concern most of us have – pre-existing conditions. Before the Affordable Care Act (Obamacare) became law, people with pre-existing conditions paid several times more than others — if they could afford or be approved for a policy in the first place.

The latest version of the ACHA passed by the House would allow states to seek waivers from existing federal law and create “high risk pools” that would allow insurers to charge more for pre-existing conditions if someone lets their insurance lapse.

To help combat the increased premiums and out-of-pocket costs, GOP Reps. Fred Upton (MI) and Billy Long (MO) crafted a provision to provide $8 billion to states to help fund high risk pools or subsidy programs for people with pre-existing conditions. It would be left to each individual state to decide how to spend the money.

If you have a pre-existing condition, what can you do? First, contact your state legislators and make sure that your health conditions are covered under any pool or subsidy program. It is up to us to raise our voices, share our stories, and demand that our lawmakers remember us and our conditions as they move forward.

Luckily for us, there are many steps to go in this process and we don’t know what the outcome will be. The U.S. Senate still has to vote on the ACHA and is likely to make changes.  It is also important to note that the House version of the ACHA does not spell out what sort of pre-existing conditions insurers may cover if states seek a waiver. In the past, some insurers identified domestic violence, sexual assault, caesarean birth and postpartum depression as grounds for denying coverage or charging higher premiums.

Letting ourselves drown in hearsay, low expectations of the current administration, and sharing information that is not accurate to make a point is not going to fix or change anything. It will only cause us anxiety, stress and energy pennies that as chronically ill patients we don’t have the ability to recover from.

Is it time to act? YES. Is it time to over-react? NO. The water is rising, but it’s only up to our knees and we’re still standing. Before the tide comes in further, make sure you are doing what you can to be heard and in ways that will matter for our pain communities. VOTE, make phone calls, be willing to testify in person if needed, answer calls from the media to discuss how the ACHA will affect you if the conditions you are living with are not covered.

Don’t exaggerate or give false information about a list of pre-existing conditions that won’t be covered. Remember, each state will decide what pre-existing conditions will be included if they get the waiver granted. Instead, bring to light that our healthcare costs are already higher than healthy patients, because we have more doctor visits and treatments, and are paying more in out of pocket costs.

Our options are already limited and we need to have a seat at the table of decision makers. We can get that by being factual and accurate, and by voting for people who will remember our stories.  

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Will End of Obamacare Hurt the Chronically Sick?

By Barby Ingle, Columnist

When a pebble is thrown into a pond, it creates a ripple effect that is noticeable, but no long-term damage occurs.

But if an asteroid were to land in the ocean, it could be catastrophic to all life on earth. We are simply not prepared for such a disaster.

The chronic pain community was hit by an asteroid of sorts last year with the release of the CDC’s opioid prescribing guidelines. The tsunamis are still hitting patients in its aftermath. To make any change to the healthcare system without having something to replace it is never a good idea.

Now we are anxiously waiting for details on what President-Elect Donald Trump and the Republican-led Congress will offer to replace Obamacare.

Although things won’t change overnight, the early signs are that “Trumpcare” could affect the already limited healthcare that the poor, elderly and chronically ill receive.

Some of you who are not chronically ill may feel like I am saying the sky is falling. But many of us are already unable to afford proper and timely treatment with the coverage we have now, because the system is set up to give priority to acute care, not chronic care.

Republican lawmakers can’t wait until Obamacare is repealed and replaced. But they need to take the time to develop a system that is effective for patients, providers, educational institutions, insurance companies, pharmaceutical companies and government agencies. Patients and providers are far too often left out of the discussion about treating the chronically ill and appropriate compensation for those providing their care.

In the first few days of 2017, GOP leaders such as House Speaker Paul Ryan and Health and Human Services Secretary-nominee Dr. Tom Price announced that they will target the Medicare system with major restructuring. They have not yet offered any details on their plans, but say they will lower healthcare costs for taxpayers. 

Medicare is an east target. With the number of elderly increasing as baby boomers move into retirement age, it’s inevitable that health care costs are going to increase. In 2015, Medicare spending grew 4.5% to $646 billion, and Medicaid grew twice as fast, by 9.7% to $545 billion.

"Value-Based" Medicine

Based on their recent announcement, congressional leaders are likely to try to convert Medicaid from an entitlement program for low-income, elderly and disabled Americans to one that is “value based” with fixed federal contributions to the states. They have not yet offered details on how those payments would be calculated or whether they would keep pace with inflation. 

Measuring a providers’ pay using a value based system is not going to work with chronic illness. There is not enough incentive in the current system that gives providers the compensation they need. We have already seen many providers across the country choose to stop treating people with chronic pain diseases. 

Every patient is also different. There is no one-size-fits-all cure for any disease. Two people can be given the same medication for cancer, and while it may work for one patient, the other one may have to try other treatments. This is the same for every single chronic disease. 

A person who breaks a bone can go to the emergency room, get the bone set, and wear a cast while it heals. They don’t have to think about how they are going to keep living with an incurable disease and the roadblocks they have to face in getting treatment.

Now we have people who don’t understand the complexity of treatment for chronic care patients deciding what additional roadblocks they can put up to keep costs down. 

Can we start by paying Congress with a value based system, like they want to do with our providers? Can we punish lawmakers with fines for needing extra hearings to get a bill passed or blocked? I don’t think so. Yet the current leadership wants states to provide better healthcare at a lower cost by giving them greater flexibility in setting eligibility and benefits. I see it as taking away even more of the limited coverage we currently have. 

Without federal guidelines, states will push poor people out of programs, eliminate important benefits, and cut already-low payment rates to providers to save money.

I remember a time in Arizona when poor men and women qualified for state assistance for health and food. Now, you must have children to qualify for many of our assistance programs. 

Every state is different in what its Medicaid program covers and the eligibility requirement. Giving additional incentives states to “cut costs” instead of putting the focus on patient care is a big mistake and will cost society more in the long run. 

It reminds me of something I have seen in the insurance industry. Insurers want to lower emergency room costs, so they put payment practices in place to discourage chronic care patients from seeking the care they need. 

I have personally been in the position of not wanting to go to the ER because I knew they wouldn’t do anything to help me. As soon as the attending doctor sees my complicated medical history, they don’t want to treat me for the acute issue that I am having due to the extra precautions they need to take due to my chronic disease. They spend more time trying to find another hospital to transfer me to than they spend working on me! 

This past September, I had two hospital doctors fight in front of me because one didn’t want to be my attending provider. I am a complicated case, and he knew he was not going to be compensated properly for taking care of me. The outcome was leaving me in the emergency room for over 12 hours before getting me a room. This gave him enough time to pressure me to check myself out and head to another hospital, which was suggested more than once. 

The emergency room provider knew I needed to be in the hospital, so she loudly spoke up to keep me there and worked hard to help me as best she could. The delays in getting me treatment only wound up increasing the insurance bill.

New congressional proposals would phase out enhanced federal payments to the states to cover low-income adults. States need to save money as well, so what will they do to offset these costs? They will either raise taxes or cut what is covered to those in need. Long-term care coverage items seem to get cut first, as they are the most costly. 

President-elect Trump campaigned on not touching Medicare and promised to make sure everyone has access to healthcare. But we don’t know whether he will go along with the healthcare agendas of top congressional leaders. We do know that the Trump administration is receptive to the states' Medicaid waiver proposals. This would impose more patient-responsibility requirements. Chronic care patients already have trouble paying insurance premiums, sustaining employment, and dealing with illnesses that last a lifetime. Putting time limits on benefits for a chronically ill person is ridiculous.

Congressional leaders are now saying they are working to turn Medicare into a program that would pay private plans and the traditional fee-for-service program a fixed amount per beneficiary by 2024. If traditional Medicare competes with private plans on equal terms, there will be a loss in coverage of long-term care needs for the chronically ill. 

We are not equal to a healthy working individual and our coverage needs are critically different. It is also important to remember those who are disabled and qualify for Medicare have earned it by paying into the system when they could work. Demanding someone to be engaged in meaningful work to receive Medicare benefits when they are disabled is ridiculous.  

Let’s not wait to move until the asteroid hits. Let us unite and voice our needs so we are not overlooked as these new policies are developed. Let’s demand that our congressional leaders give chronically ill patients a seat at the table, and take the time to create a health system that is right for all Americans. Don’t let them forsake the chronically ill to save money. 

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the Power of Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Can Trump Make Healthcare Great Again?

By Barby Ingle, Columnist

As a chronic pain patient, I know that the Affordable Care Act (ACA) has not been so affordable for some people. Here in Arizona, monthly insurance premiums are going up 75 percent and the national average is seeing a double digit increase.

Running a foundation for the past decade, I have heard many stories of patients unable to afford proper and timely healthcare. Since the enactment of Obamacare in 2010, I've heard even more stories of regret, loss of care and rising costs. Premiums have gone up so much that many would rather pay the penalty for not having insurance, instead of getting it.

I am not sure if President-elect Donald Trump can "repeal and replace" the ACA in a timely manner. It will take an act of Congress to completely repeal ACA and eliminate the individual mandate.

We need to broaden healthcare access for all Americans, especially those of us living with chronic illnesses. Let’s look at the 7 steps proposed by Trump during the presidential campaign.

1. Completely repeal Obamacare and eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.

I agree with not mandating the purchase of insurance, but I also see why it was put into the plan. It was thought if we force everyone to pay into the system, it will be easier to bear the costs of caring for the elderly and disabled. 

Current enrollment for Obamacare shows that less than 12.7 million of the 40 million without insurance are now covered. That's progress, but even with subsidies, many people in pain (not on disability) are unable to afford coverage. Also, many with insurance were cut from their long-time providers as their plans were no longer accepted by the provider.

2. Modify existing law that prohibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in the market, insurance costs will go down and consumer satisfaction will go up.

This is one provision I would like to see. I travel currently for my pain management care. I would like to see the sale of health insurance across state lines, as I believe it will offer me better in-plan coverage. Paying out of network is very costly for patients like myself.

As we allow the free market to play a bigger role, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it. I don’t believe that basic Medicaid covers enough treatments for chronic pain patients.

I would also want multiple patient representatives and caregivers to play a role on boards and advisory committees that make these decisions. There is no plan in place for the involvement of the patient voice that I am aware of.

3. Allow individuals to fully deduct health insurance premium payments on their tax returns.

I would like the ability to fully deduct my health insurance premiums. Businesses are allowed to take these deductions, so why wouldn’t Congress allow individuals the same exemptions?

4.  Allow more individuals to use Health Savings Accounts (HSAs). Contributions to HSAs should be tax-free and should be allowed to accumulate from year to year. These accounts could become part of the estate of the individual and could be passed on to heirs. HSA funds could then be used by any member of a family without penalty. 

As someone who has participated in an HSA in past years, I found that they were not a benefit for me as a chronic pain patient. I spent everything in my HSA account as fast as it went in from my husband’s paychecks.

But for others who don't have to worry about paying for long-term chronic care needs, I have seen the HSA system work and help spread out costs throughout the year. HSA accounts would be particularly attractive to healthy young people with high-deductible insurance plans.  

5. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.

I believe in 100% price transparency from all providers, insurance companies, pharmacies and hospitals. We should be able to easily see the costs of our care.

6. Give Medicaid block grants directly to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal oversight. States will have the incentives to seek out and eliminate fraud, waste and abuse.

I like this as well. Giving each state the ability to fund and provide their own Medicaid benefits will be beneficial. We have to cut down on fraud and get proper and timely access of care to those who need it most.

7. Remove barriers that prevent foreign drug makers from offering safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Allowing consumers access to imported and cheaper drugs will save money.

We need more abuse resistant medications, along with drugs that are more affordable. I agree that allowing consumers access to imported drugs will give us more options and help cut prices.

These seven steps are just the start of what we need to make the system work better. The process will take years to figure out. Let’s keep our voices loud as patients and advocates, so that we keep the good parts of our healthcare system and increase access for those who need it by lowering costs and opening access to alternative treatments. We also need to address the abuse of opioid medication, while maintaining access for those that truly need it. 

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.