It was July 30th when Atlanta’s Emory University Hospital got the first call. An American doctor who’d been treating Ebola in Liberia was now, himself, terribly sick with the virus. In just 72 hours, Dr. Kent Brantly came through Emory’s doors. Then, almost immediately, the staff learned a second Ebola patient was on the way. Dr. Jay Varkey’s first thought was, “What do we need today, in order to care for these patients tomorrow?”

In the three months since, Emory has treated four Ebola patients. All survived. Dallas nurse Amber Vinson spent more than a week at a special treatment unit at Emory before being discharged in good health and good spirits Tuesday.

“The general dogma in our industry in July was that if patients got so ill they required dialysis or ventilator support, there was no purpose in doing those interventions because they would invariably die,” Dr. Bruce Ribner, who heads Emory’s Ebola team, told reporters at a hospital press conference Tuesday.

But in this case, Emory proved otherwise, he said — aggressively treating the illness can be effective.

Emory’s plan to treat patients who have diseases like Ebola actually began 12 years ago. That’s when the Atlanta-based Centers for Disease Control and Prevention started working with the hospital to create a special isolation unit.

Since then, Varkey says, a core team of health workers has trained yearly. They’ve held practice drills every six months to stay sharp, ready for whatever infectious disease comes their way. Once, in 2005, the unit was used for a suspected SARS case that turned out to be negative.

But in July, with two patients on the way, it quickly became clear that Emory’s specially-trained team was too small, says Nancy Feistritzer, the hospital’s chief of nursing.

Critical care nurses volunteered to help fill in the gaps, but weren’t part of the core group that had long practiced for this day. The expanded team had to quickly train — and not everybody made the cut.

Once the team was in place, they focused on supportive care of these patients — administering IV fluids and preventing infections.

“The true cure for Ebola virus is keeping the patient alive long enough to develop the antibodies that will cause them to get over the infection,” Varkey says.

Emory learned lessons, big and small, from each patient, he says.

For example, just increasing the amount of working space around a patient sick with Ebola helped a lot, he says. So does “having a hand sanitizer dispenser available, [one] that wouldn’t require us to actually touch it with a gloved hand.”

In Emory’s experience, nurses on the Ebola unit who started out on 8-hour shifts preferred 12-hour rotations instead. And caring for the emotional health of patients in isolation is as important as promoting physical well-being, the staff learned.

Team members also worked hard to coordinate their efforts. From top administration to waste management crews, pharmacists to lab technicians — every department played a role.

“Every morning the team meets to discuss what worked well, what might be refined,” Feistritzer says, looking for lessons that might be put into practice the next shift, or the next day.

The Emory team doesn’t claim to have all the right answers, Varkey says. But what they do know, they’re sharing.

“Our entire 84-page document, in terms of our protocols,” he says, “is now available to any person who wants to access that on the web.”

Those protocols went live a week ago. So far, more than 11,300 people have registered to get access to them.

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

BERKELEY, Calif. — Again and again in the United States, anti-obesity crusaders have been stymied wherever they’ve tried to impose new laws on soda sales: in New York, ex-Mayor Michael Bloomberg’s plan to limit soda size was tossed out by the state’s highest court, proposed taxes in the northern California cities of El Monte and Richmond were voted down and the Washington, D.C. city council failed to pass an excise tax on soda.

Yet the successful enactment earlier this year of a nationwide tax on sugary drinks in Mexico has been a shot across the bow of Coca-Cola, Pepsi and other big soda makers, with Coca-Cola announcing a drop in profits, in part because of a decline in sales in its Latin American business.

Now, the soda industry is going to war in a pair of election battles in San Francisco and Berkeley, two of the most liberal cities in the U.S.

The measures, which voters will decide on Nov. 4, would impose a penny per ounce tax on sugary drinks in Berkeley and a two-cent per ounce tax in San Francisco. Citing the drinks’ impact on the nation’s obesity crisis, diabetes and other health problems, the money raised from the taxes would be directed, in San Francisco, toward childhood nutrition and recreation, and, in Berkeley, into the city’s general fund.

On a recent evening, soda tax supporter Pam Gray set off among the steep sidewalks in her north Berkeley neighborhood to convince voters here to support the measure. After knocking on doors, she finds a neighbor, Katy Wilson, being pulled on the end of a leash by a friendly dog. Wilson agrees kids eat too much sugar, and she is alarmed by the growing obesity rates, but she tells Gray she’s already made up her mind: She is going to vote no.

“I don’t think the measure gets to the root cause which is our attitudes toward eating, drinking and taking care of ourselves. It’s just, like, a penalty,” says Wilson.

The two neighbors debate the merits for some time, and Gray tries to make the case that Berkeley—where one out of three kids will develop diabetes, according to city officials— has to start somewhere: “The very initial steps around taxing tobacco started with some very small legislative steps,” Gray says, “This is really Berkeley’s attempt at beginning that process.”

The comparison to the declining tobacco industry is often cited. Vivien Azer, a stock analyst at Cowen and Company, covers the soda and tobacco industries and jokingly calls herself “The Sin Analyst.” She says the declines in soda volumes are eerily similar to those seen for cigarettes.

“If you look at the shape of the cigarette industry volumes, they were growing into the early 1980s, and they began to decline from there,” Azer says. “What we’ve seen in soda, is that volumes have been declining for about 10 years now, so I would argue that soda is about 20 years behind cigarettes.”

The early health concerns that led to a drop in cigarette purchases were followed by per-pack taxes and local and state smoking bans, and those measures have led to fewer teenagers and young adults taking up the habit. Soda drinkers, too, tend to start young, and if they haven’t established themselves as high volume consumers early in life, Azer says “the likelihood of them stepping up their consumption over time is relatively low.”

Along Berkeley’s main streets and in the underground subways here, advertisements blasting the proposed soda tax are everywhere. The American Beverage Association, the soda industry’s lobbying group, has spent about $1.7 million fighting the measure in Berkeley, and $7.7 million in San Francisco, according to state campaign filings. Roger Salazar, a spokesman for the ‘No’ campaigns, says these kinds of taxes have failed to pass in 30 cities and states across the country, and San Francisco and Berkeley will be no different.  “While they try to paint it as a launching pad, it’s more a last gasp,” he says.

Salazar says cities have more important priorities than deciding what their residents should be drinking. He adds that taxes don’t get at the root of the obesity epidemic. “Taxing beverages is not going to change behavior or teach people about healthy lifestyles,” he says.

But soda taxes are particularly worrisome to beverage companies, say economists, because soda drinkers are less tolerant of price increases than, say, cigarette smokers. And as a result, soda consumers do change their behavior. Matthew Harding, an economist at Duke University, recently analyzed more than 100 million supermarket purchases in the U.S., and he found Americans spend about 10 percent of their food budget on sugar sweetened beverages, including soda. But when supermarkets raised those drink prices, consumers, including low-income consumers, made more nutritious purchases. “Sugar intake dropped by almost 20 percent and calories by 8.5 percent,” Harding says.

Soda companies have come up with one response to the pressure to cut empty calories: make the cans smaller and charge more. For Coca-Cola’s so-called mini-cans, Azer says, the revenue per ounce is more than 100 percent higher than a regular can of Coke.

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

Starting Dec. 1, people with ALS – a disease that impairs motor function so people often can’t talk or even move – could lose access to technological advances that allow them to better communicate, thanks to a federal review of what Medicare is allowed to cover.

ALS, which stands for amyotrophic lateral sclerosis, hit the national spotlight this summer with the viral “Ice Bucket Challenge.” But while public awareness about the disease soared, Medicare changes that could curtail coverage of communication tools were – by “sheer dumb luck” – already in the works, said Kathleen Holt, associate director at the Center for Medicare Advocacy.

Now, though it’s difficult to say for certain if the summer’s attention has enhanced their efforts, one thing is clear: Patient advocates have begun shoring up arguments to push back against the impending change, Holt said.

Historically, Medicare has covered 80 percent of the cost for basic speech-generation devices – the machines many ALS patients use – while permitting patients to pay out of pocket for upgrades that allow the devices to connect to the internet and perform services such as opening doors. But in February, the Centers for Medicare & Medicaid Services posted a “coverage reminder” making clear that the program does not cover the cost of upgradable devices, based on a much earlier national coverage determination.

“We don’t see any reason why Medicare should turn the clock back to 2000, just because technology has evolved,” said Patrick Wildman, director of public policy at the ALS Association.

This notice is part of a review by Medicare contractors to make sure devices do in fact “comply with our coverage rules and the Medicare law,” CMS spokesperson Aaron Albright wrote in an email. This review, he added, has been “suspended” until December to address advocates’ concerns. ALS groups have said the change will effectively bar patients from the machines they have been able to obtain through Medicare for years. “Now all of a sudden the door is closing for them,” Holt said.

A basic speech-generation device costs around $4,000. But as patients purchase additions to the machine – such as eye-tracking technology, often used by patients who have lost movement in their limbs – the total price tag can end up reaching $15,000 or more. Typically, Medicare covers about 3,000 devices a year.

Following the new interpretation, ALS patients insured through Medicare can no longer use the program to buy devices that could potentially be connected to the internet – often the only way ALS patients communicate with people not in the room – or that perform basic functions such as turning on room lights, Wildman said.

That can endanger patients, Holt said. To illustrate, she told the story of an ALS patient who was sitting alone on his porch when a neighborhood boy started throwing rocks at him. The boy later said he wanted to see if the patient was really paralyzed. Because the patient “didn’t have the capability of the internet or ability to use the phone on his computer” he was unable to signal for help. “He sat there and was just barraged,” Holt added.

The reinterpretation comes on the heels of a federal rule change that took effect last April, reclassifying speech-generation devices so Medicare patients would have to rent them for 13 consecutive months before being allowed to own them. Also, advocates said, Medicare has in recent months begun denying claims to cover eye-tracking technology, which uses patients’ eye movements to input commands in speech devices. It is often the only way “locked-in” patients – that is, those who are conscious but can’t move or talk – can use their machines.

The rental requirement means ALS patients can temporarily lose access to the machine they have been using if they enter a hospital or hospice facility, since Medicare payments for the machines are suspended during that time, Wildman said. Those facilities generally are expected to provide speech devices, but devices often aren’t available or aren’t appropriately customized to match patients’ needs. If patients are released from the facility, the 13-month rental clock then restarts, and patients may not be able to reclaim their customized machines.

This scenario depends on whether manufacturers that stop receiving payments take the next step and take devices away from patients – so far it’s unclear whether or how often suppliers will do so, Wildman said, but the concern it could happen remains pressing.

And the trend of denying coverage for eye-tracking – which is usually reversed on appeal – also delays patients’ access to the technology, Holt said.

Two hundred members of Congress signed onto a “Dear Colleague” letter sent in September to CMS, asking the agency to address concerns about ALS patients’ access to speech generating devices.

CMS has not responded, despite legislators’ request to hear back by Oct. 1, wrote Riva Litman, a spokeswoman for Rep. Cathy McMorris Rodgers, R- Wash. McMorris Rodgers was one the letter’s original authors.

Meanwhile, Holt said CMS hasn’t indicated any immediate plan to address the issue.
The coverage reminder was originally scheduled to take effect Sept. 1.
But unless CMS somehow changes its interpretation by December, the delay doesn’t make much difference, Wildman said.

“Patients aren’t asking Medicare to cover their [devices’ extra] functionality,” Wildman said. “They’re just asking to allow functionality at their own expense – which CMS routinely allows for wheelchairs, for example.”

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

In the past year, new hepatitis C drugs that promise higher cure rates and fewer side effects have given hope to millions who are living with the disease. But many patients whose livers aren’t yet significantly damaged by the viral infection face a vexing reality: They’re not sick enough to qualify for the drugs that could prevent them from getting sicker.

An estimated 3 million people have hepatitis C. Faced with a cost per patient of roughly $95,000 or more for a 12-week course of treatment, many public and private insurers are restricting access to those who already have serious liver damage. Other strategies that limit access include restricting who can prescribe the drugs or requiring early proof the drug is working before continuing with treatment. In addition, many state Medicaid programs require that patients be drug and alcohol free for a period of months before they can get the hepatitis C drugs.

“Everybody is trying to figure out how best to deliver needed treatments without blowing out resources because of the cost,” says Brendan Buck, a spokesman for America’s Health Insurance Plans, a trade group. AHIP has been an outspoken critic of high prices for specialty drugs.

Insurers base their coverage decisions in part on practice guidelines issued by clinical groups such as the American Association for the Study of Liver Disease (AASLD). That organization recommends giving patients with advanced liver disease priority in treatment. “Limitations of workforce and societal resources may limit the feasibility of treating all patients within a short period of time,” the organization said in a press release announcing the recommendations.

Paul Walker is one of the healthy ones. For the first time in many years, the self-employed computer systems consultant has health insurance, a silver-level HMO from Blue Cross Blue Shield of Texas for which he pays $211 a month to cover himself and his wife. (Walker had earlier investigated getting insurance through Texas’ high-risk pool but balked at the $1,200 monthly premium for two people.)

Diagnosed with hepatitis C in 1998, the 53-year-old Tyler, Texas, resident was thrilled to learn that his liver is still basically healthy. A biopsy showed only slight evidence of the fibrous scar tissue that can cripple the liver, eventually resulting in cirrhosis or liver cancer.

Many baby boomers who have hepatitis C contracted it years ago from blood transfusions at a time when blood was not screened for the virus.

Walker’s doctor prescribed Sovaldi, a pill approved by the Food and Drug Administration in December that can cure the chronic infection in 12 weeks, significantly faster than the nearly year-long course of treatment often required under older drug regimens. Sovaldi must be taken with another hepatitis C drug such as interferon, which can cause flu-like symptoms, nausea and depression and which adds to the cost. Instead of interferon, Walker’s physician prescribed Olysio, another recently approved hepatitis C drug that is popular among physicians. But its use in combination with Sovaldi for cases like Walker’s hasn’t been approved by the Food and Drug Administration.

Walker’s insurer denied his physician’s request for the drug. Walker appealed the denial and was turned down again. The insurer cited the off-label use of Olysio in its denial, but Walker says he doesn’t think an approved combination of drugs would have changed the decision. The insurer generally doesn’t approve Sovaldi for patients like Walker, whose liver fibrosis is stage “F1” on scale of F0 to F4, he said. Only patients with more severe liver damage, stage F3 or F4, are typically approved for Sovaldi.

“We are committed to providing our members access to quality, cost-effective medications,” Dan McCoy, chief medical officer for Blue Cross Blue Shield of Texas, said in a statement. “Our coverage criteria is based on clinical trial data, published literature and recommendations from a wide variety of medical specialty societies. We constantly review and update our coverage criteria as new information becomes available or new specialty drugs or treatments come to market.” The insurer didn’t respond to a request for specific coverage criteria.

In October, the FDA approved another hepatitis C drug, Harvoni, a daily pill that doesn’t have to be taken with another drug. A typical 12-week course of treatment will generally cost about the same as for Sovaldi used with another drug (unless it’s Olysio, which can push the total treatment cost to $150,000 or more). Patients like Walker might be cured in as little as eight weeks using Harvoni, however, slashing the cost by a third.

Walker says he hopes he’ll be approved for Harvoni.

“The fact that I’m only F1, that’s good,” says Walker. “But until I actually get the medication and am cured there’s going to be a lot of anxiety.”

Many baby boomers who have hepatitis C contracted it years ago from blood transfusions at a time when blood was not screened for the virus. Walker believes he got it following a childhood accident that sent him to the hospital. Others got it from contaminated needles while experimenting with injection drugs. Now, hepatitis C infections are on the rise again as a new generation of prescription opioid abusers moves from pills to injection drugs.

According to the Centers for Disease Control and Prevention, up to 70 percent of people infected with the hepatitis C virus will develop chronic liver disease and up to 20 percent will eventually develop cirrhosis, a severe scarring of the liver. Up to 5 percent will develop liver cancer.

Patient advocates say that in addition to helping individual patients avoid health problems down the road or infecting others, the new drugs present an enormous public health opportunity.

“We can address hepatitis C and eradicate it,” says Ryan Clary, executive director of the National Viral Hepatitis Roundtable, an advocacy group.

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

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

RENO, Nev. – For Carolyn Oatman, enrolling in Medicaid this year was “a dream come true.”

Uninsured since she lost her job five years ago in this desert gambling city, Oatman, 57, often couldn’t afford the drugs to control her asthma and high blood pressure. She would sell her blood plasma to scrape together enough money to see a doctor.

Since she signed up for Medicaid, though, her care is free, including her medicines. But there’s a downside: It can take two months to get a doctor’s appointment at a local community health center, or an all-day wait if she just shows up.

Such delays are a result of the surge in newly insured patients seeking care as Nevada became one of 26 states to expand Medicaid under the Affordable Care Act in 2014. The Reno area has seen its Medicaid enrollment nearly double this year — one of the biggest jumps of any metro area nationwide.

In many ways, the experience of this self-proclaimed “Biggest Little City in the World,” where glitzy hotels abut gritty neighborhoods of pawn shops and strip clubs, illustrates the promise and pitfalls of expanding Medicaid, the federal-state insurance program for the poor.

Though happy to have coverage, many new enrollees are frustrated by the lack of providers willing to see them, which can mean long waits for care, according to interviews with patients, doctors and local health officials.

Sometimes, when Oatman needs to see a doctor in a hurry, she drives to the nearest emergency room – getting care where it costs taxpayers the most.

“I love it on Medicaid because now I can go the emergency room when I need to and don’t have to worry about the bill,” said Oatman, whose only income is her husband’s $1,200 monthly disability check.

Physicians and clinics that treat the poor say they’ve been overwhelmed by new patients, many of whom suffer from multiple chronic conditions.

“We are struggling to keep up with demand for care,” said Chuck Duarte, executive director of Community Health Alliance, the region’s largest federally funded community health center.

Duarte, the state’s former Medicaid director, said he’s worried the problems will escalate when the second Obamacare enrollment period begins Nov. 15.

Nevada Signed On Early

Nevada Gov. Brian Sandoval was the first Republican governor to embrace Medicaid expansion after the Supreme Court in 2012 made that provision of Obamacare optional for states. In December 2012, Sandoval estimated about 78,000 Nevadans would gain Medicaid coverage starting in 2014.

In fact, Medicaid enrollment statewide grew from 330,000 people in September 2013 to more than 601,000 in August 2014— an 82 percent increase, according to the Nevada Department of Health and Human Services. That compares to average enrollment growth of about 20 percent in the states that expanded the program.

Among the reasons for the rapid take-up in Nevada were its high uninsured rate and previously stingy Medicaid eligibility guidelines, which excluded childless adults altogether and covered jobless parents with dependent children only if they made below 24 percent of the federal poverty level, or about $5,700 for a family of four.

In Washoe County, the state’s second largest county where Reno sits at the base of the Sierra Nevada mountains, enrollment increased from 50,000 to over 90,000 members this year.

Many of those new enrollees have far greater health needs than the mothers and children who dominated the Medicaid rolls in the past, said Eric Lloyd, chief executive of Amerigroup of Nevada.

Amerigroup has seen more cases of advanced heart disease, lung disease, diabetic complications and advanced cancers. Mental illness and substance abuse problems are also way up. The rate of members getting hospital care doubled this year, he said.

Duarte said the influx of Medicaid patients seeking services has exacerbated the longstanding shortage of doctors and other health providers. “It’s a combination of lack of providers and doctors unwilling to take these patients,” he said.

Without enough exam space and providers to keep up with demand, the health center, which saw 26,000 patients last year, turns away hundreds of patients a week seeking immediate care, he said. While existing patients may wait a month or more for appointments, new patients may not be able to get appointments for two months.

“We’ve been told by our Medicaid managed care organizations that we have several thousands of their members waiting for their first appointment,” Duarte said.

‘My Life Is Back On Track’

Still, there are individual success stories.

Karen Silverman, 61, is one of those. In the past, working as a parking lot attendant without health coverage, she often could not afford the drugs to treat her high blood pressure and diabetes.

“I would forgo my cholesterol or blood pressure medicine so I could afford my insulin,” she said. “It was scary but I had no choice.”

In February, she enrolled in Medicaid. Now she pays nothing for doctor visits or prescription drugs. After several months of taking her medications regularly, her diabetes and blood pressure are better controlled and she has started walking again.

“I feel as if my life is back on track,” she said.

And she is not the only one.  In the past year, Duarte says that more of the health center’s patients are controlling chronic health problems as more became insured.  For example, about 73 percent of hypertension patients have their blood pressure under control now, compared to 64 percent a year ago.

Amerigroup and UnitedHealthcare, the managed care plans the state pays to take care of most Medicaid enrollees, point to many such stories, even as they acknowledge the challenges of meeting increased demand for care.

The plans say they are working to add providers, but are limited by the shortage of specialists and by how much they can pay based on their state funding.

“We are doing the best we can with the available provider network,” said Amerigroup’s Lloyd. In addition to more doctors, he said the health plan needs case managers to help patients with complex illnesses and clinicians to provide mental health and substance abuse services.

Nevada Ranks 48th For Docs Per Capita

Such physician shortages are not confined to Nevada, but the issue is particularly bad here. The state ranks 48th in the nation for its number of active physicians per capita — largely the result of big population growth, having just two medical schools and relatively few medical training slots.

The shortage has meant doctors focus on treating higher-paying patients with private insurance or Medicare. In addition to Medicaid’s lower pay, doctors often avoid enrollees because of their higher no-show rates.

Duarte said situation worsened because the state cut Medicaid payments to providers several times in the past decade to help balance its budget.

“Cardiology, orthopedics, name the specialty and we can’t get it,” he said.  Mental health needs among new Medicaid enrollees are huge, yet he “can count on two fingers the number of psychiatrists willing to take Medicaid recipients.”

To entice more providers, the health law increased Medicaid pay for primary care doctors in 2013 and 2014 to the same levels paid by Medicare. In Nevada, that has meant a nearly 30 percent pay hike. But federal money runs out at year’s end.

Nevada Medicaid Director Laurie Squartsoff said the state may step in to maintain the higher pay rates next year. The state is also trying to add residency training slots and expand the use of telemedicine.

“The size of our health system and number of providers has not changed prior to Medicaid expansion and what we are seeing are more people who need services,” she said.

Andrew Pasternak, a family physician who works in a more upscale part of Reno, says he likely will stop seeing new Medicaid patients in January if the payments drop. “It’s a huge worry,” he said, noting his reimbursement will go from $75 for a basic office visit to about $44.  His practice now sees 400 Medicaid enrollees, up from 20 the previous year.

Sitting in Pasternak’s exam room recently, Hannah Zuniga talked about different worries.  When her husband, Paul, lost his job as an assistant manager at Home Depot in January, Zuniga was relieved when she found her family would qualify for Medicaid.  Yet while their three children could keep their pediatrician, the parents had to find new doctors.

They were given a list of providers, but several they called were no longer taking new patients. Pasternak was the fifth primary care doctor she tried seeking help for a urinary tract infection.

When she needed a hand surgeon to remove a cyst on her wrist, two physicians she called were not taking new patients and a third was backed up for three months. “It’s been very frustrating to not know where you can get care,” she said.

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