NEW HAMPSHIRE: House considers defunding cutting from Medicaid

New Hampshire Public Radio
February 18, 2015

House Committee Hears Circumcision Bill

Today a house committee considered a bill that would prohibit Medicaid from funding circumcisions of newborn baby boys.

Bedford Republican Keith Murphy sponsored this bill. He firmly believes circumcision is dangerous – potentially, very dangerous.

"One hundred and seventeen children a year, on average, die from circumcision complications. In fact it’s one of the leading causes of neonatal male deaths," says Murphy.

Medical experts are highly skeptical of that number, which comes from a report by an anti-circumcision advocate. For the only year the Centers for Disease Control and Prevention tracked this data in 2010, there were no [reported] deaths from circumcisions.

Still, Murphy says New Hampshire should join the 18 states that have cut Medicaid payments for what he calls an elective procedure – including California, Florida and Maine. Circumcisions cost New Hampshire's Medicaid program about $212,000 every year.

But anti-circumcision activists didn’t talk much about the financial bottom line.

Ronald Goldman, Director of the Boston-based Circumcision Resource Center, painted a dark picture of circumcision’s impact on the male psyche.

"Anger, a sense of loss, sadness, and sexual anxieties....A recent study found a connection between circumcision and the risk of autism," said Goldman.

The bill’s opponents disputed these claims. A rabbi also warned it would discriminate against low-income Jews. [Since when did the taxpayer have to fund religious rituals?
 
Planned Parenthood of Northern New England, meanwhile, countered circumcision carries public health benefits, including lowered risk of urinary tract infections and some sexually transmitted diseases.

Jay Smith, a retired family physician, spoke on behalf of the New Hampshire Public Health Association.

"Basically, I think we just feel that it’s bad public policy to remove a procedure from Medicaid that is still approved for other insurance," said Smith. [And doubtless other insurance justifies funding it because it's covered by Medicaid.]

If passed, it’s worth noting this bill could impact a lot of people. The latest data from 2010 found Medicaid paid for nearly 30 percent of the babies born in New Hampshire.

[There were 12,352 live births in NH in 2012, some 6,000 of them boys, some 2000 of those covered by Medicaid. The circumcision rate was 75% in 2009, so some 1500 of them would be genitally cut - IF Medicaid pays for it .]

Earlier story

Bill Would Cut Circumcisions From Medicaid

New Hampshire Public Radio
December 26, 2014

Bill Would Cut Circumcisions From Medicaid Payments

By Jack Rodolico

A bill proposed in the state legislature would end Medicaid payments for circumcisions.

The bill’s sponsor, state representative Keith Murphy of Bedford, describes the practice as unethical.

"To me there’s something fundamentally wrong about strapping a baby boy to a board and amputating perfectly healthy, normal tissue," says Murphy.

Murphy adds trimming circumcisions from the state budget will save money, although how much will be determined by the legislature next year.

The American Academy of Pediatrics says the medical benefits of circumcisions outweigh the risks. Eighteen states deny Medicaid dollars for the procedure, including California, Maine and Florida.

Circumcisions are an important religious procedure for Muslims and Jews.

FLORIDA: Medicaid circumcision funding resumed by stealth

WUSF News
May 29, 2014

Medicaid Overhaul Message Trickles Out

by Mary Shedden
Adriana DeJesus doesn't remember getting a letter.

Her kids - 6-year-old Angel, and son, Christian – have been covered by Medicaid plans since birth. Her son’s asthma and ADHD keep her regularly connected to his doctors and make her diligent about understanding his health coverage.

But the St.Petersburg daycare worker says she missed seeing a notice that Florida is moving 3.5 million residents in its medical insurance program for the poor to a new managed care system.
She stumbled onto the news only after she looked for a dentist for a daughter, and a counselor filled her in on the changes.

“I didn’t even know,” she said.

She’s not alone. For months, the Agency for Health Care Administration has been asking 1.5 million Floridians with fee-for-service Medicaid medical coverage to pick a plan from thirteen pre-approved insurers.
...

Sunshine Health, like others involved in the managed care transition, are not new to Medicaid, Senior said. But in order to attract more business, the new managed care plans offer more options for treatment and a longer list of health providers accepting patients with Medicaid coverage.
...

The list of added benefits includes options never available before in Florida’s Medicaid system. Certain vaccines, adult dental, hearing and vision, newborn circumcisions and nutrition counseling are among the benefits offered. Paterson said the extras can attract business, but more importantly, they promote better health.

[Florida Medicaid funded infant male genital cutting until July 1, 2003. A cohort of healthy 11-year-olds is ready to be testimony that cutting the taxpayer funding did no harm.]

“Many of us felt like we needed to add this extra enhancement to the program to be competitive,” he said. “And it is true though that some of these benefits that we are offering could lead to reduction (in illness), because they are more preventative in nature.”

FLORIDA: "Boys not cut at birth may be later, so taxpayer should foot bill"

the Wall Street Journal
January 20, 2014

Circumcision Coverage Comes Into Focus

Revised Study on Procedure's Benefits Spurs Some States to Reconsider Ending Routine Medicaid Funding for Newborns
by Arian Campo-Flores
Saleem Islam, a pediatric surgeon in Gainesville, Fla., was surprised a few years ago when he started receiving a steady stream of referrals for older boys from low-income families to be circumcised.

"When we ask the parents, 'Why did you not get it done when the child was a baby and when it would have been safer?' they say, 'We couldn't afford it,' " Dr. Islam said recently.
[In other words, these babies never needed it, the parental whim had just overflowed. It is not safer as a newborn.]

Like a dozen other states, Florida ended Medicaid coverage of routine circumcisions for newborns after the American Academy of Pediatrics issued a lukewarm statement on the practice in 1999. While the organization concluded that removing the penis's foreskin has potential benefits, it found the data were insufficient to recommend it as a routine procedure. [If the data are insufficient to recommend it, how can the price make it recommendable?]

So Florida lawmakers justified their decision in part as a way to save money on what the AAP had deemed an unnecessary procedure.

Now, a revised policy statement by the AAP that takes a more favorable stance toward circumcision, along with a series of academic studies examining the impact of reduced coverage of the procedure, has cast a new spotlight on the decision by Florida and other states not to cover it under Medicaid.

In 2012, the AAP concluded that the benefits of circumcision outweigh the risks and justify "access to this procedure for families who choose it." The organization stopped short of recommending routine circumcision, however.

Public funding of routine circumcisions for newborns has been hotly debated in recent years. Supporters of the practice say it helps prevent urinary tract infections in babies and sexually transmitted infections, including HIV, later in life. But groups opposed to circumcision say the procedure is medically unnecessary and an unnatural, antiquated practice. [Also harmful, risky and a human rights violation.] In the case of the older boys referred to Dr. Islam, complaints ranged from inflammation to difficulty with the foreskin.

Ending Medicaid coverage of routine circumcisions may have stuck the state with a bigger bill instead, according to a group of University of Florida Health researchers that includes Dr. Islam. Costs for circumcisions more than doubled in the five years after the 2003 policy change, the study asserts. That was largely because families were opting to have the procedure done when boys were older—a more costly operation that Medicaid still covers if it is deemed medically necessary.

The number of boys ages 1 to 5 who were circumcised each quarter during the study period reached almost 1,000 in the third quarter of 2008, compared with a little over 500 in the fourth quarter of 2003. In every quarter, those figures exceeded the number of circumcisions for newborns.
[But raw numbers explain nothing withut context: birthrate and neonatal circumcision rate. If the neonatal rate is 100% the number of older boys available for circumcision is 0, so the only way it can go us up, whether there is any medical need or not.]

That helps explain why Medicaid costs for circumcisions in Florida climbed to $33.6 million in 2008 from $14.9 million in 2004, according to the study. [But so does inflation.] While the procedure costs as little as $250 for newborns, it can run more than $6,000 for older boys because they require general anesthesia and sometimes an operating room. Older kids also face a higher risk of complications, doctors say. [This is not true.]

"Given the costs to the state, it would make sense for the state to reverse" its decision, Dr. Islam said.
The Florida Agency for Health Care Administration, which administers Medicaid, said in a statement that the study "contains interesting points for discussion, but does not appear to provide conclusive medical evidence to allow for coverage of elective circumcisions."

Using a different database, the agency provided data showing circumcision costs under the traditional "fee-for-service" system in Medicaid dropped to $1.2 million last year from $2.3 million in 2002. But those figures don't include other ways Medicaid money pays for the procedure, such as through managed-care plans, Dr. Islam said.
[And his study doesn't include other costs of circumcision, such as the cost of repairing botches.]

Of the 18 states that no longer cover routine circumcisions, 12 made the decision in the wake of the AAP's 1999 policy statement. When the AAP came out with its revised position in 2012, some states weighed changing their policies. Medicaid officials in Utah recommended restoring circumcision coverage in 2013, but the legislature hasn't acted. Another effort by Colorado lawmakers to reinstate such funding failed last year, though the issue is likely to come up again this year.

Studies show the prevalence of circumcision has declined as more states have stopped paying for it. A 2009 paper published in the American Journal of Public Health found that hospitals in states where Medicaid covered the procedure had circumcision rates 24 percentage points higher than those in states that didn't, leading to potential health disparities.

Overall, newborn circumcision rates in the U.S. have been falling, to 58.3% in 2010 from 64.9% in 1981, according to the Centers for Disease Control and Prevention.

In preparing its 2012 statement, the AAP's task force on circumcision considered the fallout from the 1999 declaration, said Douglas Diekema, one of the members. The previous task force "had not foreseen that their statement would lead to a decrease in insurance coverage," he said.
[Yes, and it's all about the money.]
 
Around the same time, a team of Johns Hopkins University researchers published a study estimating that a 20-year decline in U.S. circumcision rates had resulted in $2 billion in health care costs to treat sexually transmitted infections and other illnesses in uncircumcised men and their female partners.
Anti-circumcision groups questioned the legitimacy of the Johns Hopkins analysis. And they cited a published response to the AAP statement by a group of mostly European doctors who said it reflected "cultural bias" in favor of the procedure.
[Not just any "group of mostly European doctors" but the heads or spokespeople for most of the paediatric associations of Europe.]

Dr. Islam said his stance on circumcision is neutral. "But if a family wants it done and we're going to fund it," he said, "it makes sense to fund it at the right time."
[Those are two big ifs, and why should they be connected?]

Earlier story

DENVER, COLORADO: Move to restore Medicaid circumcision funding fails

A lot of limp puns...

Colorado House Debate (audio)
April 4, 2013

Colorado house does not restore Medicaid circumcision funding

In the Colorado legislature, an amendment to restore Medicaid funding of circumcision was struck down on a technicality. It was moved by Rep Paul Rosenthal (D) who said "the AAP supports this amendment ... because they said that the benefits outweigh the risks...."

Rep Cheri Gerou (R) concentrated on making bad puns while asking for a No vote on the amendment.

Rep Claire Levy (D) said that the amendment is out of order because it would make substantive law via a footnote. That is how the chair ruled.

Earlier story

DENVER: Colorado Medicaid will not resume funding circumcision

Health Policy Solutions
May 5, 2012

Circumcision bill dies in Colorado House

By Katie Kerwin McCrimmon
A bill that would have restored Medicaid funding for circumcisions in Colorado died Friday.
The measure squeaked through a hearing in the House Health and Environment Committee on Thursday, then died in Appropriations Friday morning.

Opponents, who included health professionals, budget hawks and anti-circumcision activists told health committee members on Thursday that circumcision is cosmetic and potentially harmful, and taxpayers should not fund it.

Proponents for the bill argued that funding for circumcision for babies on Medicaid is a social justice issue. In general, insurance companies pay for the procedure for insured Colorado babies even though the American Academy of Pediatrics does not deem circumcisions to be “medically necessary.” Meanwhile, low-income parents who want their babies circumcised are being put on waiting lists for the procedure until parents can prove they’ve paid in advance.

Sen. Irene Aguilar, D-Denver, an internal medicine doctor for Denver Health, testified on behalf of restoring public funding for circumcision. Last year, Colorado lawmakers decided to save money and cut funding for Medicaid circumcisions. They were following the lead of 17 other states. Proponents wanted taxpayers to once again pay for the procedures for parents who choose to have their infants circumcised.

Fiscal analysts estimated that covering the procedures again would cost the state about $195,000 next year and $230,000 the year after that.

“As a physician, I don’t try to influence parents one way or the other,” Aguilar said. “People make this decision based on religious and cultural reasons.” [What business does a doctor have performing surgery based on religious or cultural reasons? (Answer: good business....)]
 
She said that there is some evidence that infant boys who don’t get circumcised have higher rates of urinary tract infections and that adult men who are uncircumcised and live in poverty tend to have increased rates of HPV, which can lead to higher rates of cervical cancer in female partners.

Only one other doctor testified on behalf of circumcision. The rest of the witnesses opposed public funding for the procedure for a variety of reasons.

They included Dr. Jennifer Johnson, a family physician who works with Medicaid and uninsured patients at Clinica Family Health Services.

“I’ve done at least 100 circumcisions and just recently decided to stop,” Johnson testified.

She said she and her husband, who is Jewish, decided not to circumcise their own son, who is now 4. She said she was concerned when she researched the issue and found that removing the foreskin from a boy’s penis damages numerous nerve endings. While circumcision is traditional in the Jewish community, Johnson said her husband was open to new research about the potential harms from circumcision.

If boys or men decide to remove the foreskin as adults, then they can make that decision, Johnson said. But she decided that as a physician, she should no longer do a procedure that is “potentially harmful.”

“This is not a necessary procedure,” Johnson said. “It’s a healthy, normal body part.”“There are a lot of medical needs in our population. We have no business using limited health care dollars on a medically unnecessary cosmetic procedure.”

One lawmaker, Rep. Sue Schafer, D-Wheat Ridge, elicited laughter in the hearing room when she asked Dr. Johnson if circumcision might help reduce teen pregnancy rates and teen sexual activity by reducing nerve sensation in boys’ penises.

“I’m wondering if there’s a risk of more sexual activity, more male irresponsibility” for uncircumcised boys, Schafer asked.

 [Rep. Janak Joshi, R-Colorado Springs, looks incredulous at Rep. Schafer's question.] Joshi, a retired doctor, voted against restoring circumcision funding, saying circumcision is uncommon in India and he's never seen infections due to lack of circumcision.

Johnson answered that teen pregnancy is certainly a problem, but said circumcision won’t halt teen sexual activity.

“Circumcision is not a cure for behavior. That’s about education,” she said.

...

While circumcision is an ancient tradition in some religions, circumcision opponents said it became popular in the U.S. as a method to prevent masturbation among boys. Later, fathers wanted their sons to look like them.

“Frankly that’s cosmetic surgery…and I strongly urge you to vote against it,” said Dr. Matt Mason, a physician from Telluride. He was skeptical about cost estimates and said circumcision is now rare in Western Europe, Canada and New Zealand. [Circumcision has always been rare in Western Europe.]
 
...

Earlier story

DENVER: Medicaid circumcision cover amendment moves forward

Health Policy Solutions
April 24, 2012

Lawmakers reconsider circumcision for babies on Medicaid

By Katie Kerwin McCrimmon
Circumcisions for low-income babies could once again be covered in Colorado after a bill seeking to restore funding moved forward Tuesday in the Senate.

Circumcision has become a polarizing issue in Colorado after the legislature last year voted to make Colorado the 18th state to ban Medicaid funding for the procedure. The state stopped paying for routine circumcisions last July.

Cost is not the primary point of contention. Circumcisions – which cost about $200 to $400 each – for low-income babies add up to a relatively small tab according to state fiscal analysts: about $195,000 next year and $230,000 the year after that.

Instead, activists on both sides are battling over whether the ancient practice of cutting an infant boy’s foreskin from the head of his penis is healthy. Opponents argue that the procedure is medically unnecessary, and elsewhere in the country, foes are trying to ban it altogether [No, to restrict it to consenting people] . Supporters believe circumcision should be a personal choice [No, the choice of another person] . They say it has health benefits including reduction of urinary tract infections in babies and prevention of HIV and AIDS among adults.

Debate over circumcision taps into deeply held personal and religious beliefs that often spark fights between new parents, medical professionals and lawmakers.

Sen. Joyce Foster, D-Denver, was alarmed to learn last summer that funding for circumcisions had been cut from Colorado’s Medicaid budget last year. So, this year, she introduced Senate Bill 12-90, which would restore the funding.
...
Foster also happens to be Jewish and her husband is the influential retired Temple Emanuel rabbi, Steven Foster. Ritual male circumcision is a fundamental tradition in Jewish culture.

Foster said her own religious views and those of her husband have nothing to do with her support for Medicaid funding of circumcision. She said traditional Jewish families typically don’t opt for circumcisions in a hospital. Rather a religious leader called a mohel performs the circumcision either at home or in a temple when the baby is about eight days old.

“This bill will have absolutely nothing to do with the Jewish community of Colorado,” she said.
[Oh really?]

Jewish Daily Forward February 27, 2012 Foster... said she believes that cutting Medicaid coverage for circumcision sent a message of support to anti-circumcision activists who want see the procedure outlawed nationwide. She is determined to push back against that effort. “Ultimately, I think when the anti-circumcision people begin to see so many states denying benefits,” Foster said, “it will be easier for them now to make their case that circumcision should be banned altogether.”

...
Foster said opponents of circumcision who are seeking to ban the procedure altogether would be abridging religious rights, not only for Jews, but also for others.

“Some people don’t want anybody to have it. That would be an attack not only on Jews, but on Christianity, which is based on Judaism, and on the Muslim community. ...
...
At an earlier hearing, Gillian Longley, a registered nurse from Louisville, was among those who testified against public funding for circumcision. She described routine circumcision of newborn boys as “elective, non-therapeutic, cosmetic surgery.

“It is neither medically necessary nor cost effective,” Longley said.

Lawmakers in the Senate last week nixed an amendment that would have added funding for Medicaid circumcisions to the budget bill, known as the long bill. But, on Tuesday, the Senate Appropriations Committee voted to move the bill forward. Now it goes to the full Senate; then if it passes, on to the House.
Earlier story

DENVER: Move to restore Medicaid circumcision funding fails

Denver Post
April 19, 2012

Colorado Senate's budget debate includes circumcisions, ATMs at strip clubs

By Tim Hoover
The Colorado Senate gave initial approval Wednesday night to a $19 billion state budget after a debate that touched on funding infant circumcisions for the poor and whether state welfare ATM cards can be used at strip clubs.
...
One of the most impassioned debates Wednesday was over infant circumcisions for Medicaid-eligible families. The state eliminated the funding last year, and Sen. Joyce Foster, D-Denver, wanted to restore the program at a cost of $194,986.
Emotional at times, Foster said low-income families that have to pay up to $400 for the procedure usually skip it.
"Because they're poor, they have no choice," she said. [So then the babies and later men do.]
Lambert said circumcision is an optional procedure that not everyone agrees is medically advisable.
"This is also one of those areas where private charities and private donations are possible," he said.
The amendment failed.
...
Earlier story

UPDATE:
 [Clarification: What the Colorado Senate refused to pass was an amendment to the annual appropriations bill to restore Medicaid funding for circumcision. This is a separate bill from SB12-090 which would require Colorado Medicaid to cover newborn circumcisions. SB12-090 is still on the table. The Senate Appropriations Committee hearing for SB12-090 is next Tuesday. If the Appropriations Committee passes the bill, it will go to the full Senate next and then to the House.]