PALM BEACH GARDENS, Fla. — Rita Gorenflo’s 7-year-old son Nathaniel was in severe pain from a sinus infection.

But since the boy was covered by Medicaid, she couldn’t immediately find a specialist willing to see him.  After days of calling, she was finally able to get Nathaniel an appointment nearly a week later near their South Florida home. That was in 2005.

Last month, ruling in a lawsuit brought by the state’s pediatricians and patient advocacy groups, a federal district judge in Miami determined Nathaniel’s wait was “unreasonable” and that Florida’s Medicaid program was failing him and nearly 2 million other children by not paying enough money to doctors and dentists to ensure the kids have adequate access to care.

The Florida case is the latest effort to get federal judges to force states to increase Medicaid provider payment rates for the state and federal program that covers about 70 million low-income Americans. In the past two decades, similar cases have been filed in numerous states, including California, Illinois, Massachusetts, Oklahoma, Texas and the District of Columbia– with many resulting in higher pay.

But while providers and patient advocates nationwide hailed the Florida decision, they are deeply worried about a U.S. Supreme Court case  that they say could restrict their ability across the country to seek judicial relief from low Medicaid reimbursement rates.

The high court on Jan. 20 will hear a case from Idaho seeking to overturn a 2011 lower court order to increase payments to providers serving Medicaid enrollees with development disabilities. In the original case, five centers serving developmentally disabled adults and children argued that Idaho was unfairly keeping Medicaid reimbursement rates at 2006 levels despite studies showing that the cost of providing care had risen.

Idaho officials argue only the state and federal government should be able to set provider fees in Medicaid  and all other “private parties,” including patients and providers, should not be able to use the court system to gain higher rates. Twenty-seven states and the Obama administration are supporting Idaho’s appeal, along with the National Governors Association.

But providers and patient advocacy groups say they need to use the courts because states too often put their overall budgetary needs over the need of Medicaid patients to have adequate access to doctors and hospitals. Low rates inhibit doctors, dentists and other providers from participating in Medicaid, they say.

“Without recourse to the courts… hospitals and other providers will continue to bear losses that, for some, are unsustainable,” the American Hospital Association said in a brief filed in the Supreme Court case.

Although federal law says provider payments should be sufficient for Medicaid recipients to have the same access to services as those with private insurance, advocates say in court papers that the federal government is “a paper tiger”  when it comes to enforcement.

Battles over rates paid by Medicaid, the nation’s largest single health program, are nothing new. Access issues have gained more attention recently, however, because 27 states have expanded eligibility under the Affordable Care Act, resulting in enrollment of millions more people.

Matt Salo, executive director of the National Association of Medicaid Directors, said patients and providers already have the ability to lobby state and federal governments to raise reimbursement rates.

“These lawsuits result in a massive expenditure of states’ limited resources,” he said. “There are more appropriate avenues for them to get their concerns across than dragging state Medicaid agencies to court.”

If Idaho wins its appeal to the Supreme Court,  the decision could severely limit such suits, legal experts say.

“It would be beyond just a chilling effect,” said Sarah Somers, managing attorney for the National Health Law Program, a patient advocacy group.

The lawsuits are not frivolous, she said — they are an important tool. “The record of success in lawsuits …shows that courts found that Medicaid laws were being violated. If it costs money to enforce the law and to comply with it, that’s not a waste.”

Other lawyers for providers and patients agreed.

“These cases can be very effective in terms of increasing rates,” said Zenia Sanchez Fuentes, an attorney in Washington, D.C. Her firm helped argue a case that in 2006 led the District to increase fees to dentists, which led to more dentists seeing Medicaid patients. That lawsuit was initially filed in 1993.

“It can take a while, but it’s well worth taking on,” she said.

Somers pointed to the Florida case as one example of why providers and patients groups need the courts.

For years, Florida has been one of the lowest-paying states in reimbursing physicians, court documents show. The low pay has led many physicians either to not participate in Medicaid or severely limit how many recipients they are willing to see, the court ruled.

Florida’s own reports showed that in 2007 more than 380,000 children on Medicaid who should have received at least one checkup did not receive any preventive care. In the same year, the study showed just one in five children on Medicaid saw a dentist, the lowest rate in the country.

Such access problems are not unique to Florida.

A federal study in November found millions of low-income children were failing to get the free preventive exams and screenings guaranteed by Medicaid and the Obama administration is not doing enough to fix the problem.

The report, by the Department of Health and Human Services’ Office of Inspector General, found 63 percent of children on Medicaid received at least one medical screening in 2013, up from 56 percent in 2006, but the figure was still far below the department’s goal of 80 percent. Florida’s rate in 2013 was 57 percent.

Tommy Schechtman is a president of the Florida chapter of the American Academy of Pediatrics and a Palm Beach Gardens pediatrician who testified in the Florida case.

He said the pediatricians did not want to file the lawsuit, but the state gave them no other option.

“We were not making any progress in Florida in improving access and we had seen some success in other states with litigation,” he said.

U.S. District Judge Adalberto Jordan, ruling on a 10-year old case on New Year’s Eve, found Florida was violating federal Medicaid law by not ensuring that children have adequate access to providers.

Florida officials could appeal the decision, and plaintiffs’ attorney Stuart Singer said the Supreme Court decision in the Idaho case could complicate matters.

The Florida Medicaid agency harshly criticized the ruling.  “The Judge’s outdated observations pertain to a Medicaid program that no longer exists,” said a statement from the Florida Agency for Health Care Administration.

“Florida’s new statewide Medicaid managed care program is cost-effective and a working success.”

In Medicaid managed care, the state pays private health plans a monthly rate per member to coordinate coverage. Until last year, managed care was optional for most Florida Medicaid recipients.

For years, Florida health officials have said managed care companies help patients because the state can hold such plans accountable if they deliver poor care — a point often disputed by providers. Health plans often limit the number of providers to steer patients to those in their networks.

In his ruling, Judge Jordan said the care and access the Medicaid plans provided was no better than the state’s traditional system  in which it pays providers directly for each service provided.

“Children enrolled in Medicaid HMOs suffer from the same lack of access as children in …fee-for-service Medicaid,” his ruling said.

Jordan will hold a hearing later in January to determine a penalty and how the state should fix the problem.

For Rita Gorenflo, whose son Nathaniel is now 16, the Florida ruling is good news, though it’s uncertain what it will mean for her family because the case took so long to wind its way through the courts.

“I am thrilled that all of the kids on Medicaid will be able to access better care,” said Gorenflo,  an emergency room nurse for 18 years. “I can advocate for my kids fairly well, but there are some parents that can’t, and their kids deserve care.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

A sweeping rules package the House approved at the start of the 114th Congress includes a provision that has set off a war of words about the future of Social Security and benefits for disabled workers.

The measure would stop House lawmakers  from transferring money from Social Security’s Old-Age and Survivors Insurance Trust Fund to the program’s Disability Insurance Trust Fund unless lawmakers took steps to “improve the actuarial balance” of both funds.

To improve that balance, Congress would have to cut benefits, raise taxes, or find another way to put both the retirement and disability funds on firmer footing.  Lawmakers have in the past transferred funds from the retirement to the disability fund, and vice versa, nearly a dozen times.

Proponents of the change say it is needed to strengthen both the underlying Social Security program and its disability fund. Advocates for the poor and disabled say the move could harm millions of the nation’s most vulnerable Americans by reducing the level of benefits they now receive.

What follows are some frequently asked questions about Social Security’s Disability Insurance, also known as SSDI.

Q: What is Social Security Disability Insurance?

A: This part of the Social Security program provides cash payments to workers when they are disabled and off-the-job as a result. According to the Social Security Administration, the number of work credits you need to qualify for disability benefits depends on your age when you become disabled. Generally, though, you need 40 credits, 20 of which were earned in the last 10 years, ending with the year before the disability. Younger workers may qualify with fewer credits.

Q: How many people receive it?

A: Nationwide, approximately 11 million Social Security disability beneficiaries receive about $12 billion in monthly benefits, acting Social Security Administration Commissioner Carolyn W. Colvin told aHouse Ways and Means subcommittee last year.  Due to a variety of demographic trends — including overall population growth, more women in the workforce, the aging of the Baby Boom generation and the increase in the full retirement age for Social Security — the number of disabled workers has tripled since 1980 and doubled since 1995, according to the Center on Budget and Policy Priorities.

The typical beneficiary is in his or her late 50s and has a severe mental, musculoskeletal or other debilitating impairment. Program payments also went to family members – 160,000 spouses and 1.9 million children, according to the center. Disability beneficiaries receive an average of about $14,000 a year in payments.

Q: How is the program financed and is it running out of money?

A: The entire Social Security Program – including the Disability Insurance Trust Fund — is funded through a 12.4% payroll tax assessed on the first $118,500  of income.  Employees are taxed 6.2% of their income, and employers match the employee taxes by paying the other 6.2%. Individuals who are self-employed are responsible for paying the entire 12.4%.

Within the 6.2 percent, 5.3 percent finances the retirement and survivor programs and 0.9 percent funds the disability payments. Unless Congress takes action to bolster the disability trust fund, beneficiaries would see disability payments cut by about 20 percent in late 2016, according to program trustees.

According to Kathy Ruffing, a senior fellow at the Center on Budget and Policy Priorities, reallocating some taxes between the retirement and disability trust funds is a historically noncontroversial measure that Congress has taken 11 times in both directions, depending on which fund was running short. “Another reallocation to replenish the DI trust fund wouldn’t threaten seniors, contrary to the [House measure’s] implicit attempt to put retirement and disability beneficiaries against each other,” Ruffing wrote.

Reallocating taxes from the retirement fund to the disability fund to put both on equal financial footing would increase the solvency of the DI fund until 2033 while advancing the retirement fund’s depletion by one year, from 2034 to 2033. Since the retirement fund is much bigger than the disability fund, “a modest reallocation barely dents” the retirement fund, Ruffing added.

Q: Why do some lawmakers want to stop funds being transferred between the two programs?

A: Proponents of the House rules change say it’s necessary to preserve both the core Social Security program and the disability program.

“Anyone who cares about finding a fair solution for both the catastrophically disabled who depend on SSDI and senior citizens who depend on Social Security knows that we must find a long-term solution which protects both of them rather than a short term band aid which threatens them both,” said Rep. Tom Reed, R-N.Y., who co-sponsored the rules change along with Rep. Sam Johnson, R-Texas.  In July, Johnson, who chairs the House Ways and Means Social Security Subcommittee, sponsored legislation to deal with fraud in the disability program, noting that “recent scandals in Puerto Rico, West Virginia, and New York have highlighted the DI program’s growing vulnerability to sophisticated fraud rings.”

Others say the House rules change could cause harm.. In an open letter to Congress, Max Richtman, president and chief executive officer of the National Committee to Preserve Social Security & Medicare, said the shift would “cut benefits for Americans who have worked hard all their lives, paid into Social Security, and rely on their Social Security benefits, including Disability Insurance, in order to survive.” In a Jan. 6 letter to House lawmakers, AARP opposed the House measure as well, writing that it “undermines Congress’s ability to fully consider all potential legislative solutions – particularly options successfully considered many times in the past.”

Q: Does the House rules change mean that Congress cannot shift money between two funds?

A:  Since this is a House rules change, it does not apply to the Senate. While a House member could raise a point of order against any reallocation, that could be defeated if enough members wanted to shift funds between the two accounts.

But it’s clear that that the House measure fuels the politically explosive debate over Social Security, especially ahead of the 2016 presidential election. “It really is a very strong message from the House Republican leadership that this is on their radar screen and that they do not want to transfer money from the old age program to the disability program unless there are some significant changes in the way the disability program is run. I think that’s the message here,” said Howard Gleckman, a senior fellow at the Urban Institute and editor of the TaxVox blog.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Though they continue to be overshadowed by less expensive, less effective birth control methods, long-acting reversible contraceptives such as intrauterine devices are gaining ground, according to an analysis of recently released federal data.

Nearly 12 percent of women who used contraceptives between 2011 and 2013 used IUDs or hormonal implants, according to a Guttmacher Institute analysis of data from the federal National Survey of Family Growth.

That made these long-acting products the third most popular form of reversible contraception, behind birth control pills (26 percent) and condoms (15 percent).

The use of long-acting forms of contraception has been increasing steadily, from 2.4 percent in 2002 to 8.5 percent in 2009, according to Guttmacher.

Long-acting contraceptives don’t require women to remember to use birth control every day or whenever they have sex. That makes them one of the most effective forms of contraception, preventing pregnancy in more than 99 percent of cases. IUDs last for up to 12 years, depending on the type, while hormonal implants protect against pregnancy for up to three years.

In recent years, pharmaceutical companies have been marketing long-acting products directly to women, raising awareness among patients.

In addition, influential organizations such as the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have in recent years designated such  products as first-line choices for birth control.

Cost has always been one of the barriers. With a price tag for an IUD of several hundred dollars, many women opted instead for methods that didn’t require such high up-front spending, even though over time IUDs and implants may be less expensive than shorter term methods.

Cost should no longer be a barrier for most women. The health law requires that most health plans provide all FDA-approved contraceptives to women without requiring any out-of-pocket payments. The provision generally took effect in 2013, so the impact of the law’s requirements isn’t reflected to any large degree in the study’s figures, says Kavanaugh.

Over time, however, researchers expect the health law’s coverage requirements to boost the use of long-acting contraceptives, she says.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

mandrews4@nyc.rr.com

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Seattle Seahawks Stars Russell Wilson and Richard Sherman encourage Americans to visit HealthCare.gov and shop for coverage through the Health Insurance Marketplace

Dr. Michael Fratkin is getting a ride to work today from a friend.

“It’s an old plane. Her name’s ‘Thumper,’” says pilot Mark Harris, as he revs the engine of the tiny 1957 Cessna 182.

Fratkin is an internist and specialist in palliative medicine. He’s the guy who comes in when the cancer doctors first deliver a serious diagnosis.

He manages medications to control symptoms like pain, nausea and breathlessness. And he helps people manage their fears about dying, and make choices about what treatments they’re willing — and not willing — to undergo.

In rural Humboldt County, in the far northern reaches of California, Fratkin is essentially the only doctor in a 120-mile stretch who does what he does.

“There’s very little sophisticated understanding of the kinds of skills that really matter for people at the very end,” he says.

It takes 30 minutes to fly from Eureka, Calif., to the Hoopa Valley Indian Reservation. On this trip, Fratkin is going to visit a man named Paul James, who is dying of liver cancer.

“A good number of patients in my practice are cared for in communities that have no access to hospice services,” Fratkin says.

The plane touches down on a narrow landing strip. A loose horse runs next to the plane as we taxi down the runway.

Fratkin is here to make a rare house call. He met Paul and his wife, Cessie Abbott, at the hospital in Eureka. But the two-hour drive is too far for them to make often, so Fratkin comes to them.

It’s a visit that Cessie, in particular, has been waiting for. She and her husband know he’s dying. But it’s hard for them to talk to each other about it.

“Dr. Fratkin has kind of been my angel,” she says. Fratkin gets her husband to open up, she says, and reveal things he might not otherwise, because Paul’s “trying to be strong for us, I think.”

Cessie tells Fratkin that the pain in Paul’s belly has been getting worse.

“He’s moaning in his sleep now,” she says.

“Have you ever taken morphine tablets?” Fratkin asks Paul. Cessie explains that those tablets didn’t work for her husband. “Have you ever taken methadone?” Fratkin asks him. “We’re going to add a medicine that is long-acting.”

Fratkin believes there should be a spiritual component of these discussions, too.

“Yeah, Paul, there’s more to you than this body of yours, isn’t there?” he says, a refrain he repeats with almost all his patients.

“Oh yeah,” Paul says, and then goes quiet for a bit. He’s Yurok, and talks about how happy he is when he’s in the mountains, hunting with his grandsons.

Cessie says she can hear Paul praying when he’s alone in the bathroom. So Fratkin asks him to light some Indian root and say a prayer now.

“Great spirit, that created this earth …,” Paul begins, his eyes clenched shut.

By the time Fratkin leaves the Hoopa Valley, he’s spent half a day with one patient. This is something the hospital in Eureka just couldn’t afford to have him do.

Fratkin says he was under constant pressure to see patient after patient to meet the hospital’s billing quotas.

“It’s very hard for one doctor to manage the complexity of each individual patient and to crank it out in any way that generates productive revenue,” he says.

Fratkin decided he couldn’t, within the hospital system, easily provide the kind of palliative care he sees as his calling. So he decided to quit — and launch a startup.

“I had to sort out an out-of-the-box solution,” he says.

He calls his new company ResolutionCare. There’s no office, no clinic. Instead he wants to put the money for those resources into hiring a team of people who can travel and make house calls, so that very ill patients don’t have to get to the doctor’s office. When time is stretched, he plans to use video conferencing.

The key challenge is financing his big idea. Government programs like Medicare and Medicaid don’t pay for video sessions when the patient is at home. And they pay poorly for home visits.

So far, Fratkin has been cultivating private donors and is looking for foundation grants. He’s arranged an independent contract to sell his services back to the hospital he recently left. And he’s launched a crowdfunding campaign to back the training he’d like to do for other doctors of palliative medicine who practice in rural areas.

Down the line, Fratkin is even thinking of asking some of his more well-off patients to pay out-of-pocket for his services.

When he gets back to Eureka, after the visit with Paul James, Fratkin hops in his blue Prius and drives 30 minutes north to see Mary Maloney. She’s dying of esophageal cancer. She tried radiation and chemo for a while, but both made her feel awful. Fratkin was the one who told her it was OK to stop treatment.

“I mean, I love life,” Maloney says from the recliner in her home in Blue Lake. “I don’t want to let it go. But I don’t know if I’m willing enough to put myself through all the things I’d have to put myself through.”

Fratkin says he’s treated more than a thousand patients and, like other entrepreneurs with big ideas, thinks his startup could change the world. He knows he’s up against tough odds though — most startups don’t succeed.

Not long after Fratkin’s visit to the Hoopa Valley, Paul James passed away. We thank the family for sharing their story. This story is part of a reporting partnership that includes KQED, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.