By Leah Samuel Jan. 13, 2016 Reprints New federal guidelines about mammograms have sparked another round of questions about how best to detect and treat breast cancer, which kills about 40,000 women in the United States each year. We’ve combed through the research to round up five surprising — and important — facts about the disease.Physical breast exams aren’t helpfulThey’re a staple of the annual checkup. And many gynecologists still urge women to do monthly self-exams. (So do some women’s magazines.) But the evidence shows there’s no benefit to manual breast exams, whether they’re performed by a physician or by the woman herself.So the American Cancer Society doesn’t recommend regularly getting, or doing, such exams. Instead, the group urges women to “be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.”advertisement Tags breast cancerchemotherapymammograms HealthSelf-exams aren’t helpful, and other surprising facts about breast cancer Breast cancer kills about 40,000 women a year in the US. Chris Hondros/Getty Images If you have the earliest stage of breast cancer, your doctor may advise you to do nothing“Stage 0” cancer, formally called ductal carcinoma in situ, describes the early presence of cancerous or precancerous cells in milk ducts. It can indicate the possibility of a malignancy later in life, particularly for high-risk women, such as those with a strong family history of or genetic predisposition to breast cancer.DCIS can be treated with surgery or radiation. But some doctors are advising women at this stage to do nothing. A big study published last fall in JAMA Oncology looked at 100,000 women with DCIS. Most had lumpectomies or mastectomies — until recently, the standard treatment for “Stage 0” disease. Yet they still died of breast cancer at the same rate as women who were never diagnosed with DCIS.advertisement That evidence suggests “we should rethink our strategy,” Dr. Laura Esserman wrote in an editorial accompanying the study.The sit-and-wait approach is controversial, however. And doctors urge more vigilance, including the use of screening tests that are more sensitive than mammograms, in high-risk women.Magnetic resonance imaging “and ultrasound are important parts of the surveillance of these women,” said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. “They have to be watched very carefully.”For advanced cancer, surgery can sometimes be the first resortEven after cancer has spread, surgically removing the primary tumor appears to increase longevity in women with Stage IV breast cancer, according to a study of 21,000 women published last fall in the Journal of the American Medical Association.When cancer has spread, the conventional approach is chemotherapy, which reaches the whole body, or radiation. Going after the initial tumor with surgery “is a little counterintuitive,” said Mary Schroeder, assistant professor of health services research at the University of Iowa.But the study found that patients who underwent surgery in their first round of treatment had a median survival of 28 months, compared to 19 months for those who did not.Chemotherapy can discriminateFor certain aggressive types of breast cancer, the cure rates for African-American and Hispanic women are slightly lower than those for white or Asian women, according to an analysis published last fall in the Journal of Clinical Oncology.Researchers looked at outcomes for nearly 18,000 women with four types of aggressive, harder-to-treat forms of breast cancer. They all received chemotherapy prior to surgery.In the most dramatic example, a subgroup of nearly 6,000 women, the treatment eliminated tumors in 54 percent of the white women in the study, compared to 43 percent of the black women. No one seems to know why, said the study’s lead author, Dr. Brigid Killelea, a professor of surgery at Yale University.“That’s a difficult question,” she said. “The answer is probably multifactorial. And that’s why it’s so important to include black women and Hispanic women in clinical trials, and to encourage them to participate.”Breast cancer isn’t the most deadly cancer for women. But it is among the best funded.Lung cancer kills considerably more women in the United States than breast cancer each year.Nearly 72,000 women died last year from lung cancer and 40,000 died from breast cancer, according to the American Cancer Society.Breast cancer, however, still receives far more federal research funding than lung cancer. The National Institutes of Health spends about $685 million on breast cancer research, compared to $255 million on lung cancer.That works out to roughly $17,000 of research funding for every woman who dies from breast cancer in the United States, compared to less than $4,000 in research for every woman who dies from lung cancer.
In the LabZika-linked microcephaly was rare in early cases, but it’s only ‘tip of the iceberg’ Dispatch from Tahiti: Scientists on remote island unravel Zika’s mysteries “I personally thought that microcephaly was just the tip of the iceberg, that there was a whole host of conditions associated with this infection — which makes sense with all we know about congenital infections,” she said. “There’s never only one finding. There’s always a syndrome, you know? Many things.”Simon Cauchemez of the Institut Pasteur’s emerging diseases epidemiology unit, the lead author of the new study, acknowledged the finding of 1 in 100 women seems low, especially seen in the light of Nielsen-Saines’ recent paper. He suggested the variation in results probably relates to differences in the studies. Among them: Nielsen-Saines and her colleagues tracked the pregnancies of Brazilian women who were known to be infected with Zika. Link between Zika, birth defect getting stronger Senior Writer, Infectious Disease Helen covers issues broadly related to infectious diseases, including outbreaks, preparedness, research, and vaccine development. Six weeks pregnant, Daniela Rodriguez, 19, waits for test results in in Cucuta, Colombia, after being diagnosed with the Zika virus. Ricardo Mazalan/AP Although a 1-in-100 incidence seems rare, the researchers — from the Institut Pasteur in Paris and elsewhere — focused just on microcephaly, now seen as only part of the picture when it comes to the damage Zika can wreak in the womb. A recent study by American and Brazilian scientists reported that abnormalities were seen in 29 percent of fetuses carried by a group of women who were confirmed to have been infected with Zika during pregnancy.“Microcephaly seems to be the extreme,” said Dr. Karin Nielsen-Saines, the senior author of that paper, which was published in the New England Journal of Medicine in early March.advertisement Helen Branswell Related: A new study of one of the first known Zika outbreaks suggests that women infected with the virus during the first trimester of their pregnancies face a 1 in 100 chance of delivering a child with an abnormally small head, a condition known as microcephaly.Researchers combed the medical records from French Polynesia, which experienced an outbreak in 2013 and 2014, looking for cases of microcephaly. Using mathematical modeling, they determined that women there had only a 1 percent chance of giving birth to a microcephalic child, according to the study, which was published Tuesday in the journal the Lancet.The normal rate of microcephaly, though, is estimated at between 2 and 12 cases per 10,000. Extrapolating from the data in the new study would suggest 95 microcephaly cases among 10,000 women infected in the first trimester of pregnancy.advertisement @HelenBranswell Nielsen-Saines, who was not involved in Cauchemez’s study, suggested the microcephaly rate “looks low for what it is in Brazil.”“I think if you’re just looking at measurements in … a medical record, that’s very different from doing real-time imaging of the [fetal] brain, and then having the babies born and being able to assess,” said Nielsen-Saines, a professor of pediatric infectious diseases at the David Geffen UCLA School of Medicine.Her study is continuing to enroll pregnant women in Brazil who were infected with Zika; they hope to eventually follow 600. “And if the numbers aren’t as bad as we published originally … we’ll know.”Cauchemez told STAT he believes the risk may be greater for women who had symptomatic infections, versus those who were infected but had no symptoms. It is thought that 4 out of every 5 people infected with Zika show no signs of illness.“It’s still very noisy. But the kind of signal I get from the different studies is that there may be a real difference between risk in symptomatic women and those that are not symptomatic,” he suggested in an interview. About the Author Reprints Related: Tags global healthmicrocephalyZika Virus Related: By Helen Branswell March 15, 2016 Reprints Medical sleuths descend on Puerto Rico to unearth mysteries of Zika Laura Rodrigues, who has been working in Recife, Brazil on the Zika investigations there, said that might explain part of the difference, but she still thinks Cauchemez’s findings underestimate the problem.In a commentary Rodrigues wrote for the Lancet, she used Nielsen-Saines’ data to suggest that the risk of microcephaly after a first trimester infection might be as high as 22 percent. Rodrigues teaches at the London School of Hygiene and Tropical Medicine.She and Cauchemez agreed that the true picture is still coming into focus, and there will be more evidence on which to make such estimates soon. Nielsen-Saines and her group plan to issue an update on the women they are following — the cohort now has 300 pregnant women registered — in the next two months. Other groups in Brazil and Colombia will also be reporting results.Likewise, Cauchemez noted that, as Nielsen-Saines reported, there is a spectrum of neurological health problems in babies born to women who were infected with Zika during pregnancy. And problems are evident even when the women were infected in the second and third trimesters.“It’s not saying ‘If your child isn’t microcephalic, he’s fine.’ There could be other complications,” he noted.
Watch: Episode 3: Scientists are building mini-brains to understand the human mind Related: Watch: Episode 6: This is what happens to DNA in space Jessica Whited, a biologist at the Brigham Regenerative Medicine Center, is studying how salamanders are able to regrow amputated limbs, complete with bones, muscles and nerves. She hopes her findings will one day help humans regenerate their own limbs, too. Matthew Orr/STAT Related: By Carl Zimmer Aug. 25, 2016 Reprints Our bodies can heal themselves — at least up to a point. We can fuse bones back together again. We can clot a bleeding wound and close it with new skin.But the human body’s powers of regeneration have their limits. If you lose an arm in a car accident, you won’t grow it back in the days that follow.There are other species, however, that can regenerate an entire limb. Scientists have long marveled at the ability of salamanders to grow back a new leg that’s no different than the one they were born with. They can rebuild bones, muscles, nerves, and blood vessels, guiding them all into the correct position.advertisement Tags animalsregenerative medicine Science Happens!Episode 8: With some help from salamanders, will humans one day be able to regrow limbs? Watch: Episode 7: How flies might help us understand human circadian rhythm Watch: Episode 2: Peek inside a lab trying to create living medicine — from bugs in your gut Related: Related: Episode 8: With some help from salamanders, will humans one day be able to regrow limbs?Volume 0%Press shift question mark to access a list of keyboard shortcutsKeyboard ShortcutsEnabledDisabledPlay/PauseSPACEIncrease Volume↑Decrease Volume↓Seek Forward→Seek Backward←Captions On/OffcFullscreen/Exit FullscreenfMute/UnmutemSeek %0-9 facebook twitter Email Linkhttps://www.statnews.com/2016/08/25/limbs-regeneration-science-salamanders/?jwsource=clCopied EmbedCopiedLive00:0004:1004:10 Her research may help solve the evolutionary puzzle of why axolotls can regenerate so much more of their own bodies than we can. That puzzle is all the more intriguing because axolotls and we are kin. We share a common four-legged ancestor that crawled around on land around 350 million years ago.That shared history also means we inherited many of the same genes from that common ancestor. We just use them differently. Someday, scientists like Whited hope, axolotls may help us unlock our hidden healing powers. Watch: Episode 5: Everything you thought you knew about the shape of DNA is wrong Today, scientists are studying these salamanders — especially a Mexican species called the axolotl — with the tools of 21st-century biology. They can track the cells that produce new limbs, watching them perform their astonishing developmental dance.Jessica Whited, a faculty member of the orthopedic surgery department at Brigham and Women’s Hospital in Boston, is doing some of the most important research on the mysterious powers of axolotls. She and her colleagues are discovering key genes that axolotls switch on in order to create a limb from scratch.advertisement Related: Related: Watch: Episode 4: Can a worm’s lifespan hold the secrets to human aging? Related: Watch: Episode 1: Could playing a dolphin in a video game help stroke patients recover?
PharmalotPharmalot, Pharmalittle: Bernie Sanders stumps for controversial California drug pricing bill Good morning, everyone, and nice to see you again after our extended break to usher in a new year on our calendar. Quite a bit seems to have taken place while we were gone, so we are playing a game of catch-up today, which explains the lengthy list of tidbits below. Nonetheless, we hope you find them useful and, of course, that you have a productive day. And now, back to the coffee kettle for another cup of stimulation. To your health, as they say …Bernie Sanders appears in a new television ad to support a controversial ballot measure in California that would require the state to pay the same price of prescriptions drug as the US Department of Veterans Affairs, The Hill writes. “Proposition 61 is a very, very important step forward,” Sanders says in the ad. “It will be great for the taxpayers of California and it will be a real blow against this greedy industry that will reverberate all over America.”AstraZeneca’s Brilinta heart drug failed to help patients with serious circulatory problems in their legs, prompting the drug maker to scrap a $3.5 billion-a-year sales target for the medicine by 2023, Reuters writes. The drug did not show a benefit over Plavix, an older blood thinner, in treating peripheral artery disease. The setback follows similar disappointing results in March with the same AstraZeneca pill in another big trial in stroke patients.advertisement [email protected] About the Author Reprints Alex Hogan/STAT As Insys Therapeutics faces several government probes over the marketing of its Subsys opioid painkiller, chief executive John Kapoor disavows any managerial issues that have led to a growing number of salespeople charged with illegally promoting the treatment. “If something happened in the field, sometimes the company may not know about it,” he tells Forbes.A lobbying effort by three of Australia’s most powerful pharmaceutical trade groups to derail moves to make codeine drugs prescription-only has likely delayed a final decision until at least next year, the Sydney Morning Herald reports. A government committee last year issued an interim decision to remove products containing codeine from over-the-counter sales as of last June, citing growing evidence of codeine-related harm.advertisement @Pharmalot By Ed Silverman Oct. 5, 2016 Reprints Pharmalot Columnist, Senior Writer Ed covers the pharmaceutical industry. Ed Silverman The US Food and Drug Administration is requiring black box warnings on hepatitis C medicines because they may reactivate hepatitis B among patients. The agency said that cases of serious liver problems or death occurred in a few cases. Among the drugs for which labels will be required are Sovaldi and Harvoni, which are sold by Gilead Sciences, Merck’s Zepatier, and Viekira Pak from AbbVie.The Indian government is considering various measures, including heavy fines and imprisonment, in a draft version of its Drugs and Cosmetics Act to prevent drug makers from violating manufacturing norms, according to LiveMint. Currently, violations result in suspended manufacturing licenses and product recalls are voluntary, which would become mandatory if drugs fail to conform to standards of strength, quality or purity.Johnson & Johnson says a cyber security bug in its OneTouch Ping insulin pump could be hacked and cause diabetic patients to overdose with insulin, though the hacking risk is believed to be low, Reuters tells us. Last month, the health care giant wrote doctors and patients that a hacker could identify the specific frequency the device is using and then issue commands to the pump.The UK’s National Institute for Health and Care Excellence endorsed the use of AstraZeneca’s Tagrisso lung cancer drug after the company agreed to provide upcoming trial results and an undisclosed discount on the list price, Bloomberg News reports. The medicine becomes the first new cancer treatment to be introduced into the state-run National Health Service through such an agreement.Eli Lilly is buying Boehringer Ingelheim Vetmedica’s US pet vaccines portfolio for $885 million in a deal that includes a manufacturing and research site, the Wall Street Journal informs us.The UK’s NICE rejected Merck’s Keytruda as a second-line treatment for non-small cell lung cancer after determining its long-term benefits are unproven, PMLive reports.AstraZeneca licensed an experimental medicine for inflammatory diseases to Allergan for an upfront payment of $250 million and up to $1.27 billion in additional payments, Reuters says.Pfizer may begin making hundreds of layoffs this week at a Hospira manufacturing plant in North Carolina, according to WRAL Tech Wire.AstraZeneca laid off about 50 sales reps in India last week and the Federation of Medical and Sales Representatives of India has threatened a countrywide protest, the Economic Times writes.The FDA granted breakthrough status to Roche’s Actemra rheumatoid arthritis medication for giant cell arteritis, according to PMLive.Novartis is closing research facilities in China and Switzerland, and moving another from Singapore to California, Reuters writes. About 110 jobs will be lost. At the same time, the drug maker is creating new research hubs in Basel, Switzerland, and Cambridge, Mass., and up to 60 jobs may be transferred to those locations.Samsung BioLogics looks to raise as much as $2 billion in an initial public stock offering, according to the Wall Street Journal.The Global Health Innovative Technology Fund, a Japanese public-private partnership formed to battle infectious diseases, received investments totaling $11.4 million to be used for a single-dose antimalarial and other medicines.Concordia International is discussing alternatives to a leveraged buyout that include divesting a minority stake to a private equity firm in order to reduce $3 billion in debt, Reuters writes.Merrimack Pharmaceuticals chief executive officer Robert Mulroy resigned on Monday and cut 22 percent of its workforce as part of a restructuring, the Wall Street Journal says. Tags Bernie SandersFDAopioids
Leana S. Wen But the American Health Care Act, the proposed “repeal and replacement” plan, would eliminate the fund, putting the health, well-being, and security of Americans at immediate risk. When it comes to protecting our citizens, this so-called strategy is unscientific, irresponsible, and inhumane.There are three key areas that, if cut, would result in especially drastic consequences to our nation’s health.Outbreak preparedness and infectious disease preventionWith the recent emergence of diseases such as Ebola and Zika, local public health agencies have needed to put into place effective, agile strategies to address threats to public welfare. Local health departments were immediately on the front line of addressing the threat of Zika well before Congress answered the call for additional resources, which took 220 days.The Prevention and Public Health Fund currently provides nearly half of the funding for the Epidemiology and Laboratory Capacity program. It supports the efforts of state and local health departments to track outbreaks for conditions like meningitis and foodborne illness. It also helps develop rapid responses to evolving threats such as Ebola and the West Nile virus.The fund also supports more than 40 percent of the CDC’s immunization program, which protects Americans from contagious illnesses, including outbreaks of measles and the flu. As part of this funding, my state of Maryland received nearly $1 million to build a vaccine safety net for uninsured people to keep them and their communities healthier.Without these resources, the local capacity to provide emergency services to residents during times of extreme need will be decimated, putting all Americans at risk. Chronic disease preventionThe US spends more than three of every four health care dollars on treating chronic diseases such as heart disease, cancer, and lung disease, the top three causes of death in the US.In 2017, the Prevention and Public Health Fund will invest nearly $1 billion in programs across the country to support evidence-based prevention programs. During the last fiscal year, it provided Maryland with $3.5 million to fight obesity, smoking, and high blood pressure, risk factors that contribute to the leading causes of death.These resources reduce the short-term burden on the American health care system, limit the long-term personal and societal costs associated with these chronic conditions and, most important, save lives.The responsibility of providing these crucial services — and absorbing any potential cuts — would fall to the limited budgets of state and local health departments.Childhood lead poisoning preventionAs shown by the ongoing tragedy in Flint, Mich., lead poisoning remains an important health issue for communities across the country. Tags insurancepublic health About the Author Reprints By Leana S. Wen March 22, 2017 Reprints Related: Obamacare repeal and Trump’s spending plan put CDC budget in peril As a physician who has treated patients in the emergency department before and after the Affordable Care Act was instituted, I have seen firsthand how it has transformed the lives of many of my patients. And as the health commissioner for Baltimore city, I have seen how it has safeguarded the lives of more than 40,000 residents in my city, and millions more around the country, who would otherwise be uninsured.But there is more to the repeal of the ACA and its replacement with the American Health Care Act than the potential loss of health insurance by tens of millions of Americans. The act also includes a sustained mechanism to safeguard a healthier, more secure, and financially stable future for America: the Prevention and Public Health Fund.Created in 2010, this is the first federal funding source dedicated to public health. It directly empowers communities to prevent chronic conditions and helps local jurisdictions be more agile in responding to health crises while reducing long-term health costs.advertisement First OpinionThe ACA replacement would devastate America’s health Using Prevention and Public Health Fund resources, the CDC has given millions of dollars to support childhood lead poisoning prevention in nearly 30 states, including $17 million in fiscal year 2016. Such public health funds have enabled the city of Baltimore to reduce the number of children with elevated blood levels by 98 percent between 2002 and 2015. While we celebrate this immense progress, we acknowledge that our work is not done: Any level of lead in any of our children is unacceptable. Without these funds to monitor blood-lead levels or eliminate sources of lead, countless children will continue to suffer from this devastating and ultimately preventable disease.Those of us on the front line of health must remain vigilant in responding to both long-term challenges and emerging health threats.The proposed replacement for the ACA will roll back gains for millions of Americans and worsen the health of our nation. In addition to punishing many of our society’s most vulnerable individuals, its elimination of the Prevention and Public Health Fund without offering any replacement would endanger national security and raise long-term costs to the detriment of taxpayers and insurers.Approving the AHCA and losing the Prevention and Public Health Fund would put into jeopardy the safety of our country and that of generations to come.Leana Wen, MD, is the commissioner of health in Baltimore city. Related: Health workers don protective gear as they train for an Ebola outbreak. Eric Gay/AP ‘Kids don’t get a second chance’: EPA staff fear cuts to health programs under Trump Through the ACA, the Prevention and Public Health Fund accounts for nearly one-seventh of the budget for the Centers for Disease Control and Prevention — approximately $1 billion a year.advertisement @DrLeanaWen More specifically, these funds are used to prevent heart disease, cancer, diabetes, and other chronic conditions that are major causes of death in the United States. The fund also provides support for cities to prevent disease outbreaks, ensuring that our nation is prepared to face developing threats such as bioterrorism and Ebola and other infectious diseases.
HospitalsAnother health care deadline looms: Payments to safety net hospitals due to expire By Max Blau Sept. 22, 2017 Reprints Related: Drug makers will be fined for overcharging safety net hospitals and clinics ATLANTA — Drive around this city long enough, and you’ll see the billboards that have become a staple of the skyline. They read: Atlanta can’t live without Grady.For many here, that’s indeed the case. Grady Memorial Hospital, a safety net hospital with more than 950 beds, is where people go if they come down with the flu or if they suffer a gunshot wound, but can’t afford care anywhere else. In a state home to the third-highest percentage of uninsured residents, Georgia’s largest hospital last year spent $246 million treating patients who couldn’t afford their medical bills. The hospital was paid back for about third of those costs thanks to an overlooked-but-important federal program — but one that may abruptly end if Congress doesn’t take action before the end of the month.That possibility has hospitals across the country — especially those that treat low-income individuals — concerned.advertisement Delaying DSH payment cuts, VCU Health CEO Dr. Marsha Rappley said, would offer stability at a time when potential changes to CHIP and the 340B drug pricing program have also threatened to destabilize hospitals caring for residents of Richmond, Va. Rappley was one of 89 hospital administrators to sign a letter last week asking lawmakers to delay cuts to DSH payments for another two years.Still, Feldpush of America’s Essential Hospitals said, senators “aren’t talking about pending DSH cuts” because of the all-consuming focus on the Graham-Cassidy health care plan.If the deadline passes, lawmakers could potentially circle back to the issue of DSH payments. “It would be best for Congress to deal with the DSH delays before the deadline,” said Sean Brown, vice president of communications for the Federation of American Hospitals. “But if they don’t — it is our understanding that it can be done retroactively.”With the deadline looming, three congressmen circulated a letter on Thursday urging House leadership to delay cuts to DSH payment before it’s too late.“Our nation’s hospitals cannot sustain losses of this magnitude,” read the letter co-authored by Reps. Eliot Engel of New York, John Culberson of Texas, and Steven Palazzo of Mississippi. “Institutions will be forced to shutter, leaving our constituents without a safety net. We ask that you work swiftly to delay these cuts for at least two fiscal years, through 2020, or until a more sustainable, permanent solution is reached.”As of Friday, America’s Essential Hospitals said more than 150 members of Congress have signed onto the letter, making some hospital administrators cautiously optimistic that their concerns will be heard. Others, though, simply feel resigned to make do with whatever resources they have, even if it may soon be less than they had before.“Nobody else provides care for this group,” Rappley said. “People work in these institutions because they believe it’s the right to do. We’re determined to find a way to fulfill our mission.” Comparing the Covid-19 vaccines developed by Pfizer, Moderna, and Johnson & Johnson Since the ’80s, Disproportionate Share Hospitals payments — a part of Medicaid and Medicare — have offset a portion of the uncompensated care hospitals provide to patients every year. But because of a quirk of Obamacare’s implementation, the payments were slated to be gradually cut over an eight-year period. After temporary extensions over the past three years, the first of a total $43 billion in payment cuts are set to kick in on October 1.And safety net hospitals — which care for low-income patients as part of their mission — are poised to be hit hardest: They provide on average eight times more uncompensated care than other hospitals. If nothing happens, hospital administrators worry they may have to scale back or shutter departments, postpone plans for new treatment centers, or scrap preventive care programs intended to lower the total costs of care.advertisement Trending Now: “[The cuts] would be absolutely devastating,” said Beth Feldpush, senior vice president of policy and advocacy for America’s Essential Hospitals, which advocates for the interests of about 300 safety net hospitals. “If these cuts move forward, it’s be going to be very hard for safety net hospitals to continue to offer services to those in their communities who otherwise don’t have access to everything from primary care visits to emergency care services.”But amid senators’ legislative frenzy of a Sept. 30 deadline to pass a bill to repeal and replace Obamacare, the issue of DSH cuts has hardly been aired.“We don’t sleep well night,” said Dr. Michael Waldrum, CEO of Vidant Health in eastern North Carolina. “We are in the business of taking care of people. But it doesn’t help us run health care companies. It definitely leads to stress.”When the Affordable Care Act passed in 2009, the law originally required states to expand Medicaid and set a timeline to reduce annual DSH payments. The thinking was that, with more insured Americans, there would be less uncompensated care needed. But the U.S. Supreme Court tossed out the mandate for states to expand Medicaid in 2012. Eighteen states decided not to move forward with the key provision of the federal health law.The SCOTUS ruling therefore left safety net hospitals stuck in the middle of an unintended policy gap. Because Congress hasn’t fixed the underlying problem, administrators say these short-term delays have created an environment of constant uncertainty that forces them to be preoccupied with the business of staying open rather than the business of serving patients. “If you’re a private business, you couldn’t run like this,” said Katherine Yoder, vice president of government relations for the nonprofit Parkland Health and Hospital System in Dallas. “We don’t like this uncertainty. But we’re used to it.”For Medical University of South Carolina Health, Executive Director Dr. Patrick Cawley said the funding cuts, starting at $6 million for his health system in 2018, would potentially “put on hold” a new mental health crisis stabilization center. The center was planned to divert nearly two dozen patients from the emergency department each night toward specialized care that Cawley said would be better for patients and cheaper for the hospital.In southwest Florida, Lee Health’s plans to expand its facilities — in part to accommodate a state with a growing Medicaid population — would be hampered by DSH payment cuts. Dr. Larry Antonucci, president and CEO of Lee Health, said the company is considering delaying projects including a 250-bed expansion, clinics in underserved areas, and a cancer center.“We live and die by Medicaid and Medicare reimbursements,” Antonucci said. “Not only could [DSH cut delays] fall through the cracks, but there’s the specter of lawmakers letting the system fall apart, so they can rebuild it. Patients will be affected by it.”For its part, Grady Health System faces the prospect of at least $11 million in cuts in 2018 — growing to $45 million in 2024 — that would be a “major hit to Grady’s bottom line,” according to CEO John Haupert. In recent years, Haupert has warned that cuts to DSH payments may force his hospital to close either its OB-GYN clinic or mental health department — the latter being the second-largest provider of mental health services in Georgia. Billboards in Atlanta advertise Grady Memorial Hospital, a safety net hospital. Max Blau/STAT