A tale of two states: Arizona and Florida diverge on how to expand kids’ health insurance

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Daniel Chang | KFF Health News (TNS)

Arizona and Florida — whose rates of uninsured children are among the highest in the nation — set goals last year to widen the safety net that provides health insurance to people 18 and younger.

But their plans to expand coverage illustrate key ideological differences on the government’s role in subsidizing health insurance for kids: what to charge low-income families as premiums for public coverage — and what happens if they miss a payment.

“It’s a tale of two states,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

That divergence represents more than just two states taking their own path. It showcases a broader breakthrough moment, Alker said, as the nation rethinks how government works for families following the covid-19 pandemic. The divide also underscores the policies at stake in the 2024 presidential election.

Republican-led legislatures in Florida and Arizona worked across party lines in 2023 to pass bills to expand their states’ Children’s Health Insurance Program — widely known as CHIP — which covers anyone younger than 19 in families earning too much to be eligible for Medicaid.

A photo illustration showing Arizona colored bright green and Florida colored in bright yellow. They are on separate ends of the canvas with small grid designs behind them. (Eric Harkleroad/KFF Health News illustration/Getty Images/TNS)

Florida Republican Gov. Ron DeSantis and Arizona Democratic Gov. Katie Hobbs then signed bills into law last year that increased the amount of money a family can make and still be eligible for their states’ CHIP programs. That’s where the similarities end.

Arizona began to enroll newly eligible children in March. That state has adopted policies that align with the Biden administration’s efforts to apply Affordable Care Act-style protections to CHIP, such as eliminating annual and lifetime limits on coverage and lockouts if families don’t pay premiums.

Arizona’s CHIP plan, called KidsCare, suspended its monthly premiums in 2020 and has yet to reinstate them. State officials are considering whether it’s worth the expense to manage and collect the payments given that new federal rules forbid the state from disenrolling children for nonpayment, said Marcus Johnson, a deputy director for the state’s Medicaid agency.

“We’re trying to understand if the juice is worth the squeeze,” he said.

By contrast, Florida has yet to begin its expanded enrollment and is the only state to file a federal lawsuit challenging a Biden administration rule requiring states to keep kids enrolled for 12 months even if their families don’t pay their premiums.

A judge dismissed Florida’s lawsuit on May 31, saying the state could appeal to federal regulators. The state’s CHIP expansion now awaits federal regulatory approval before newly eligible children can be enrolled.

“No eligible child should face barriers to enrolling in CHIP or be at risk of losing the coverage they rely on,” said Sara Lonardo, a spokesperson for the federal Department of Health and Human Services.

Florida’s CHIP expansion calls for significantly raising premiums and then boosting them by 3% annually. The state estimates expansion will cost an additional $90 million in its first full year and expects to collect about $23 million in new premiums to help fund the expansion of what it calls Florida KidCare.

But Florida officials have said that complying with a provision that bars children from being disenrolled for unpaid premiums would cause the state to lose $1 million a month. The state’s 2024 budget allocates $46.5 billion to health care and projects a $14.6 billion surplus.

Florida officials have flouted federal regulations and removed at least 22,000 children from CHIP for unpaid premiums since the rule banning such disenrollments took effect on Jan. 1, according to public records obtained by the Florida Health Justice Project, a nonprofit advocacy group.

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DeSantis’ office and Florida’s Medicaid administration did not respond to KFF Health News’ repeated requests for comment about CHIP. But in legal filings, Florida said its CHIP plan is a “personal responsibility program.” It is “a bridge from Medicaid to private insurance,” the administration said on social media, to get families used to premiums, cost sharing, and the risk of losing coverage when missing a payment.

For some Floridians, like Emily Dent in Cape Coral, the higher premiums proposed in the state’s expansion plan would create a financial burden, not open a path to self-sufficiency.

Dent, 32, said her 8-year-old son, James, was disenrolled from Medicaid in April because the family’s income was too high. Although James would qualify for CHIP under Florida’s proposed expansion, Dent said the $195 monthly premium would be a financial struggle for her family.

Leaving James uninsured is not an option, Dent said. He is severely disabled due to a rare genetic disorder, Pallister-Killian syndrome, and requires round-the-clock nursing.

“He has to have health insurance,” she said. “But it’s going to drain my savings, which was going to be for a house one day.”

Research shows the cost of premiums can block many families from obtaining and maintaining CHIP coverage even when premiums are low.

And premiums don’t offset much of a state’s costs to operate the program, said Matt Jewett, director of health policy for the Children’s Action Alliance of Arizona, a nonprofit that promotes health insurance coverage for kids in the Grand Canyon State.

He noted that the federal government pays 70% of Florida’s program costs and 75% of Arizona’s — after deducting all premiums collected.

“Premiums are more about an ideological belief that families need to have skin in the game,” he said, “rather than any practical means of paying money to support the program.”

Republican-leaning states are not alone in implementing monthly or quarterly premiums for CHIP. Twenty-two states, including Democratic-leaning states such as New York and Massachusetts, charge premiums.

States have had wide discretion in how they run CHIP since the program became law in 1997, including the ability to charge such premiums and cut people’s access if they failed to pay. That’s been part of its success, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF.

“Especially in more conservative states, the ability to create CHIP as a separate program — independent from Medicaid — enabled and fostered that bipartisan support,” Tolbert said.

But in the decades since CHIP was enacted, government’s role in health insurance has evolved, most significantly after President Barack Obama in 2010 signed the Affordable Care Act, which introduced coverage protections and expanded assistance for low-income Americans.

Former President Donald Trump didn’t prioritize those things while in office, Tolbert said. He has suggested that he is open to cutting federal assistance programs if reelected, while the Biden administration has adopted policies to make it easier for low-income Americans to enroll and keep their health coverage.

Just as for Dent, the question of CHIP premiums in this debate isn’t abstract for Erin Booth, a Florida mom who submitted a public comment to federal regulators about Florida’s proposed CHIP expansion. She said she would have to pay a high premium, plus copayments for doctor visits, to keep her 8-year-old son covered.

“I am faced with the impossible decision of whether to pay my mortgage or to pay for health insurance for my son,” she wrote.

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Me, a chef? Well, yes, thanks to America’s Test Kitchen

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I am not a good cook. I’m impatient, lazy and too easily throw in the towel when challenged. I could never be a professional chef; no fish nor bones would touch my plate.

If I attempt a recipe and it fails, it’s doubtful I will try again. When I watch my friends cook, they are quick. They chop vegetables, trim meat, measure ingredients and have dinner simmering in no time. For me, chopping an onion or slicing tomatoes takes forever.

Want to learn to make chocolate roulade? There are no better teachers than Julia Child and Jacques Pépin. (Getty Images iStockphoto)

However, I have found more than a few recipes through cooking shows that help me impress my friends. Chocolate roulade, Hungarian goulash, chuck roast with wine gravy, and braised red potatoes have all received rave reviews. My self-basting Thanksgiving turkey one year earned praise and tears from my mother.

The chocolate roulade with a chantilly cream filling was courtesy of “Julia and Jacques Cooking at Home,” with Julia Child and Jacques Pépin. The goulash came from watching Martha Stewart. Bolstered by those successes, I got into watching “America’s Test Kitchen” on PBS.

I watch all the episodes I can (even the ones featuring fish). The show’s equipment testing, gadget recommendations, taste tests and sessions on the science of cooking all fascinate me.

The fact that all ATK recipes are repeatedly tested gives me confidence, and I can watch how the chefs do it. I trust them as if they are old friends. I’ve spent many an hour with Julia Collin Davison and Bridget Lancaster, among others.

One day, years ago, while watching the Old-Fashioned Stuffed Turkey episode with my mom, she asked me to make it for her that next Thanksgiving. It looked like a complicated process and I had never made a turkey before. To me, turkey is more of an annual obligation than a delight, like a table centerpiece to the wonderful sides.

I kept the episode on my DVR and watched it a few times to study. On the big day, I ran back and forth from kitchen to living room and watched the steps to prepare the bird. I didn’t bother with the ATK stuffing — Mom wanted her traditional stuffing — but I followed the technique of preparing the turkey for roasting and topping with salt pork slices to make it self-basting.

Mom loved it so much that she felt guilty after declaring it the best she had ever had. She hoped my grandmother didn’t hear that from beyond, and that thought brought a tear to her eye.

She said it was moist with a crisp skin. To me, it was just turkey.

I own the large ATK cookbook with the series’ combined seasons and often use it as a weight during construction projects. Recently, I bought the updated version as an e-book. Now the recipes are at my fingertips.

Braised red potatoes in the skillet are fun to make. I place small, halved potatoes, cut-side-down, in a nonstick skillet, pour in the water, add butter and garlic, and top with coarse salt. I sit in the next room and watch TV;  when I hear the butter sizzle in the pan, I know the water has evaporated. The potatoes finish with a crispy crust and the inside is perfectly creamy. (I skip the lemon/garlic step called for in the recipe and just throw some minced garlic in with the rest of the ingredients.)

I will try any recipe once if it is appealing enough. The Old-Fashioned Pot Roast wasn’t as complicated as I thought it would be, and now I make it often. The gravy that comes from blending the cooked vegetables and red wine from the pot is wonderful.

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And often, I will alter the recipes, sometimes for my taste, sometimes just by accident. Either way, it helps me claim ownership.

Lately, my friends and I have been seeking out Indian recipes. A successful combination of butter chicken and saag makes for a wonderful Indian night. The ATK technique of broiling yogurt-coated boneless chicken thighs is brilliant. For the saag, I skip the paneer and add either broiled chicken or chunks of steamed sweet potatoes. I buy the naan and samosas from the freezer section of the grocery store because, like I said earlier, I am lazy. I may try the vegetable fritters next, but deep frying seems messy and cumbersome. However, it would give me something to dip into my own ATK-inspired mint chutney.

Get the recipes

A video of Julia Collin Davison making the butter chicken is on YouTube. The comment section includes suggestions for making the dish more authentic, including adding fenugreek. My friends like to add a little more peppers to give it more heat, and we put the tomato paste in right after cooking the vegetables to give it that roasted flavor.

Here are the official names of the ATK recipes, in case you want to find them: Braised Red Potatoes with Lemon and Chives; Old-Fashioned Pot Roast; Old-Fashioned Stuffed Turkey; Murgh Makhani (Indian Butter Chicken); Saag Paneer.

The chocolate roulade is included in the “Cooking with Julia and Jacques” cookbook, and you can watch a video of them preparing the dessert on Martha Stewart’s Facebook page.

‘We’re flying blind’: CDC has 1M bird flu tests ready, but experts see repeat of COVID missteps

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Amy Maxmen | (TNS) KFF Health News

It’s been nearly three months since the U.S. government announced an outbreak of the bird flu virus on dairy farms. The World Health Organization considers the virus a public health concern because of its potential to cause a pandemic, yet the U.S. has tested only about 45 people across the country.

“We’re flying blind,” said Jennifer Nuzzo, director of the Pandemic Center at the Brown University School of Public Health. With so few tests run, she said, it’s impossible to know how many farmworkers have been infected, or how serious the disease is. A lack of testing means the country might not notice if the virus begins to spread between people — the gateway to another pandemic.

“We’d like to be doing more testing. There’s no doubt about that,” said Nirav Shah, principal deputy director of the Centers for Disease Control and Prevention. The CDC’s bird flu test is the only one the Food and Drug Administration has authorized for use right now. Shah said the agency has distributed these tests to about 100 public health labs in states. “We’ve got roughly a million available now,” he said, “and expect 1.2 million more in the next two months.”

But Nuzzo and other researchers are concerned because the CDC and public health labs aren’t generally where doctors order tests from. That job tends to be done by major clinical laboratories run by companies and universities, which lack authorization for bird flu testing.

As the outbreak grows — with at least 114 herds infected in 12 states as of June 18 — researchers said the CDC and FDA are not moving fast enough to remove barriers that block clinical labs from testing. In one case, the diagnostics company Neelyx Labs was on hold with a query for more than a month.

“Clinical labs are part of the nation’s public health system,” said Alex Greninger, assistant director of the University of Washington Medicine Clinical Virology Laboratory. “Pull us into the game. We’re stuck on the bench.”

The CDC recognized the need for clinical labs in a June 10 memo. It calls on industry to develop tests for the H5 strain of bird flu virus, the one circulating among dairy cattle. “The limited availability and accessibility of diagnostic tests for Influenza A(H5) poses several pain points,” the CDC wrote. The points include a shortage of tests if demand spikes.

Researchers, including former CDC director Tom Frieden and Anthony Fauci, who led the nation’s response to COVID, cite testing failures as a key reason the U.S. fared so poorly with COVID. Had COVID tests been widely available in early 2020, they say, the U.S. could have detected many cases before they turned into outbreaks that prompted business shutdowns and cost lives.

In an article published this month, Nuzzo and a group of colleagues noted that the problem wasn’t testing capability but a failure to deploy that capability swiftly. The U.S. reported excess mortality eight times as high as other countries with advanced labs and other technological advantages.

A COVID test vetted by the WHO was available by mid-January 2020. Rather than use it, the United States stuck to its own multistage process, which took several months. Namely, the CDC develops its own test then sends it to local public health labs. Eventually, the FDA authorizes tests from clinical diagnostic labs that serve hospital systems, which must then scale up their operations. That took time, and people died amid outbreaks at nursing homes and prisons, waiting on test results.

In contrast, South Korea immediately rolled out testing through private sector laboratories, allowing it to keep schools and businesses open. “They said, ‘Gear up, guys; we’re going to need a ton of tests,’” said Frieden, now president of the public health organization Resolve to Save Lives. “You need to get commercials in the game.”

Nuzzo and her colleagues describe a step-by-step strategy for rolling out testing in health emergencies, in response to mistakes made obvious by COVID. But in this bird flu outbreak, the U.S. is weeks behind that playbook.

Ample testing is critical for two reasons. First, people need to know if they’re infected so that they can be quickly treated, Nuzzo said. Over the past two decades, roughly half of about 900 people around the globe known to have gotten the bird flu died from it.

Although the three farmworkers diagnosed with the disease this year in the United States had only mild symptoms, like a runny nose and inflamed eyes, others may not be so lucky. The flu treatment Tamiflu works only when given soon after symptoms start.

The CDC and local health departments have tried to boost bird flu testing among farmworkers, asking them to be tested if they feel sick. Farmworker advocates list several reasons why their outreach efforts are failing. The outreach might not be in the languages the farmworkers speak, for example, or address such concerns as a loss of employment.

If people who live and work around farms simply see a doctor when they or their children fall ill, those cases could be missed if the doctors send samples to their usual clinical laboratories. The CDC has asked doctors to send samples from people with flu symptoms who have exposure to livestock or poultry to public health labs. “If you work on a farm with an outbreak and you’re worried about your welfare, you can get tested,” Shah said. But sending samples to public health departments requires knowledge, time, and effort.

“I really worry about a testing scheme in which busy clinicians need to figure this out,” Nuzzo said.

The other reason to involve clinical laboratories is so the nation can ramp up testing if the bird flu is suddenly detected among people who didn’t catch it from cattle. There’s no evidence the virus has started to spread among people, but that could change in coming months as it evolves.

The fastest way to get clinical labs involved, Greninger said, is to allow them to use a test the FDA has already authorized: the CDC’s bird flu test. On April 16 the CDC opened up that possibility by offering royalty-free licenses for components of its bird flu tests to accredited labs.

Several commercial labs asked for licenses. “We want to get prepared before things get crazy,” said Shyam Saladi, chief executive officer of the diagnostics company Neelyx Labs, which offered COVID and mpox tests during shortages in those outbreaks. His experience over the past two months reveals the types of barriers that prevent labs from moving swiftly.

In email exchanges with the CDC, shared with KFF Health News, Saladi specifies the labs’ desire for licenses relevant to the CDC’s test, as well as a “right to reference” the CDC’s data in its application for FDA authorization.

That “right to reference” makes it easier for one company to use a test developed by another. It allows the new group to skip certain analyses conducted by the original maker, by telling the FDA to look at data in the original FDA application. This was commonplace with COVID tests at the peak of the pandemic.

At first, the CDC appeared eager to cooperate. “A right of reference to the data should be available,” Jonathan Motley, a patent specialist at the CDC, wrote in an email to Saladi on April 24. Over the next few weeks, the CDC sent him information about transferring its licenses to the company, and about the test, which prompted Neelyx’s researchers to buy testing components and try out the CDC’s process on their equipment.

But Saladi grew increasingly anxious about the ability to reference the CDC’s data in the company’s FDA application. “Do you have an update with respect to the right of reference?” he asked the CDC on May 13. “If there are any potential sticking points with respect to this, would you mind letting us know please?”

He asked several more times in the following weeks, as the number of herds infected with the bird flu ticked upward and more cases among farmworkers were announced. “Given that it is May 24 and the outbreak has only expanded, can CDC provide a date by which it plans to respond?” Saladi wrote.

The CDC eventually signed a licensing agreement with Neelyx but informed Saladi that it would not, in fact, provide the reference. Without that, Saladi said, he could not move forward with the CDC’s test — at least not without more material from the agency. “It’s really frustrating,” he said. “We thought they really intended to support the development of these tests in case they are needed.”

Shah, from the CDC, said test manufacturers should generate their own data to prove that they’re using the CDC’s test correctly. “We don’t have a shortage such that we need to cut corners,” he said. “Quality reigns supreme.”

The CDC has given seven companies, including Neelyx, licenses for its tests — although none have been cleared to use them by the FDA. Only one of those companies asked for the right of reference, Shah said. The labs may be assisted by additional material that the agency is developing now, to allow them to complete the analyses — even without the reference.

“This should have happened sooner,” Saladi told KFF Health News when he was told about the CDC’s pending additional material. “There’s been no communication about this.”

Greninger said the delays and confusion are reminiscent of the early months of COVID, when federal agencies prioritized caution over speed. Test accuracy is important, he said, but excessive vetting can cause harm in a fast-moving outbreak like this one. “The CDC should be trying to open this up to labs with national reach and a good reputation,” he said. “I fall on the side of allowing labs to get ready — that’s a no-brainer.”

Clinical laboratories have also begun to develop their own tests from scratch. But researchers said they’re moving cautiously because of a recent FDA rule that gives the agency more oversight of lab-developed tests, lengthening the pathway to approval. In an email to KFF Health News, FDA press officer Janell Goodwin said the rule’s enforcement will occur gradually.

However, Susan Van Meter, president of the American Clinical Laboratory Association, a trade group whose members include the nation’s largest commercial diagnostic labs, said companies need more clarity: “It’s slowing things down because it’s adding to the confusion about what is allowable.”

Creating tests for the bird flu is already a risky bet, because demand is uncertain. It’s not clear whether this outbreak in cattle will trigger an epidemic or fizzle out. In addition to issues with the CDC and FDA, clinical laboratories are trying to figure out whether health insurers or the government will pay for bird flu tests.

These wrinkles will be smoothed eventually. Until then, the vanishingly slim numbers of people tested, along with the lack of testing in cattle, may draw criticism from other parts of the world.

“Think about our judgment of China’s transparency at the start of COVID,” Nuzzo said. “The current situation undermines America’s standing in the world.”

___

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

Suffering from back pain? Scientists say walk it off

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Hunter Boyce | The Atlanta Journal-Constitution (TNS)

Walk it off. It’s more than just a jesting turn of phrase for ‘90s tough guys. When it comes to back pain, according to a recent study, it might be the key to relief.

New research from Sydney-based Macquarie University’s Spinal Pain Research Group revealed walking can even have a “profound impact” on managing the condition. Published in the Lancet medical journal, the study — known as the WalkBack trial — followed 701 adults for one to three years. The participants were recently affected by lower back pain.

The participants were allocated to either a walking program helmed by a physiotherapist and featuring six education sessions on back pain prevention or placed in a no-intervention control group. Those in the walking program were pain-free for almost twice as long as the control group.

“The intervention group had fewer occurrences of activity-limiting pain compared to the control group, and a longer average period before they had a recurrence, with a median of 208 days compared to 112 days,” Macquarie professor and senior study author Mark Hancock said in a news release.

The Atlanta-based Centers for Disease Control and Prevention reported 39% of U.S. adults in 2019 had back pain. While just under 65 million Americans experience it in some form today (800 million worldwide), 8% of U.S. adults (16 million) suffer from chronic back pain, as well.

“We don’t know exactly why walking is so good for preventing back pain, but it is likely to include the combination of gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and the release of ‘feel-good’ endorphins,” he added.

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It’s an often debilitating condition that is also costing Americans a tidy sum. Lower back pain is the sixth most costly condition in the country, according to Georgetown University, creating a $12 billion strain on the U.S. each year. Walking can cheapen the financial blow by reducing doctor visits and time away from work.

“It not only improved people’s quality of life, but it reduced their need both to seek health care support and the amount of time taken off work by approximately half,” postdoctoral fellow and lead study author Dr. Natasha Pocovi said in the news release.

“The exercise-based interventions to prevent back pain that have been explored previously are typically group-based and need close clinical supervision and expensive equipment, so they are much less accessible to the majority of patients. Our study has shown that this effective and accessible means of exercise has the potential to be successfully implemented on a much larger scale than other forms of exercise.”

©2024 The Atlanta Journal-Constitution. Visit at ajc.com. Distributed by Tribune Content Agency, LLC.