Michelle Andrews, Kaiser Health News

The U.S. has made great progress treating people who are infected with HIV, but if they get cancer they’re less likely to get the care they need, a recent study found.

Researchers examined treatment for a variety of cancers, including upper gastrointestinal tract, colorectal, prostate, lung, head and neck, cervix, breast, anal, and two blood cancers. With the exception of anal cancer, treatment rates differed significantly between HIV-infected people and those who weren’t infected, according to the study.

Trish233/Thinkstock

For example, 33% of patients with HIV and lung cancer failed to receive any treatment for the cancer, compared with 14% of those who weren’t infected. Similarly, 44% of people who were HIV positive didn’t receive treatment for upper GI cancer versus 18% of those who weren’t infected with HIV. Twenty-four percent of men with prostate cancer who were HIV positive didn’t get treatment, compared with 7% of non–HIV-infected men.

Cancer treatment was defined as radiation, chemotherapy, and/or surgery.

“To have made such great strides with treating HIV only to have them succumb to cancer is devastating,” said Dr. Gita Suneja, a radiation oncologist at the University of Utah’s Huntsman Cancer Institute in Salt Lake City and the lead author of the study. It was published online this month in the journal Cancer.

The study used the National Cancer Data Base to analyze treatment for adults younger than 65 who were diagnosed with any of the 10 most common cancers to affect HIV patients between 2003 and 2011. The study included 10,265 HIV-infected adults and 2.2 million without HIV.

The data base, which is sponsored by the American Cancer Society and the American College of Surgeons, captures roughly 70% of newly diagnosed cancer cases in the United States.

The study noted that more than a third of the patients with HIV had stage 4 cancer – cancer that has metastasized – when they were diagnosed, while only 19% of those without HIV did.

Improvements in antiretroviral therapy to treat HIV have helped reduce the incidence of cancers such as Kaposi sarcoma that are closely linked to AIDS, but rates for other cancers often associated with normal aging have increased among HIV patients. In addition, people with HIV have a higher incidence of some lifestyle-related cancers, such as lung cancer, which could be linked to higher rates of smoking. Cancer is now the second most common cause of death among HIV-infected people, behind AIDS-related causes.

HIV patients are more likely to be uninsured or underinsured, and lack of coverage can affect access to cancer care. But having insurance didn’t eliminate the problem: Privately insured people with HIV were significantly more likely to be untreated for many cancers than were privately insured people without HIV, the study found.

“We know that people with Medicaid or who are uninsured receive subpar cancer treatment, and that’s a big public health issue,” said Dr. Suneja. “But even factoring that in, HIV-infected people are still less likely to receive cancer treatment. That means there are other drivers that we couldn’t measure in the study.”

Disparities in cancer treatment could exist for several reasons. For one thing, for most cancers there are no national treatment guidelines for HIV-infected patients, Dr. Suneja said. One of the few exceptions is anal cancer, the only cancer for which the study found little discrepancy in treatment among HIV-infected and noninfected patients. According to the research, the difference among those not receiving treatment was 4.8% for HIV patients versus 3.1% for others.

For other cancers, “the oncologist may pause and ask, ‘Does the HIV infection mean they shouldn’t get standard cancer treatment?’ ” Dr. Suneja added.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

The U.S. has made great progress treating people who are infected with HIV, but if they get cancer they’re less likely to get the care they need, a recent study found.

Researchers examined treatment for a variety of cancers, including upper gastrointestinal tract, colorectal, prostate, lung, head and neck, cervix, breast, anal, and two blood cancers. With the exception of anal cancer, treatment rates differed significantly between HIV-infected people and those who weren’t infected, according to the study.

Trish233/Thinkstock

For example, 33% of patients with HIV and lung cancer failed to receive any treatment for the cancer, compared with 14% of those who weren’t infected. Similarly, 44% of people who were HIV positive didn’t receive treatment for upper GI cancer versus 18% of those who weren’t infected with HIV. Twenty-four percent of men with prostate cancer who were HIV positive didn’t get treatment, compared with 7% of non–HIV-infected men.

Cancer treatment was defined as radiation, chemotherapy, and/or surgery.

“To have made such great strides with treating HIV only to have them succumb to cancer is devastating,” said Dr. Gita Suneja, a radiation oncologist at the University of Utah’s Huntsman Cancer Institute in Salt Lake City and the lead author of the study. It was published online this month in the journal Cancer.

The study used the National Cancer Data Base to analyze treatment for adults younger than 65 who were diagnosed with any of the 10 most common cancers to affect HIV patients between 2003 and 2011. The study included 10,265 HIV-infected adults and 2.2 million without HIV.

The data base, which is sponsored by the American Cancer Society and the American College of Surgeons, captures roughly 70% of newly diagnosed cancer cases in the United States.

The study noted that more than a third of the patients with HIV had stage 4 cancer – cancer that has metastasized – when they were diagnosed, while only 19% of those without HIV did.

Improvements in antiretroviral therapy to treat HIV have helped reduce the incidence of cancers such as Kaposi sarcoma that are closely linked to AIDS, but rates for other cancers often associated with normal aging have increased among HIV patients. In addition, people with HIV have a higher incidence of some lifestyle-related cancers, such as lung cancer, which could be linked to higher rates of smoking. Cancer is now the second most common cause of death among HIV-infected people, behind AIDS-related causes.

HIV patients are more likely to be uninsured or underinsured, and lack of coverage can affect access to cancer care. But having insurance didn’t eliminate the problem: Privately insured people with HIV were significantly more likely to be untreated for many cancers than were privately insured people without HIV, the study found.

“We know that people with Medicaid or who are uninsured receive subpar cancer treatment, and that’s a big public health issue,” said Dr. Suneja. “But even factoring that in, HIV-infected people are still less likely to receive cancer treatment. That means there are other drivers that we couldn’t measure in the study.”

Disparities in cancer treatment could exist for several reasons. For one thing, for most cancers there are no national treatment guidelines for HIV-infected patients, Dr. Suneja said. One of the few exceptions is anal cancer, the only cancer for which the study found little discrepancy in treatment among HIV-infected and noninfected patients. According to the research, the difference among those not receiving treatment was 4.8% for HIV patients versus 3.1% for others.

For other cancers, “the oncologist may pause and ask, ‘Does the HIV infection mean they shouldn’t get standard cancer treatment?’ ” Dr. Suneja added.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

The U.S. has made great progress treating people who are infected with HIV, but if they get cancer they’re less likely to get the care they need, a recent study found.

Researchers examined treatment for a variety of cancers, including upper gastrointestinal tract, colorectal, prostate, lung, head and neck, cervix, breast, anal, and two blood cancers. With the exception of anal cancer, treatment rates differed significantly between HIV-infected people and those who weren’t infected, according to the study.

Trish233/Thinkstock

For example, 33% of patients with HIV and lung cancer failed to receive any treatment for the cancer, compared with 14% of those who weren’t infected. Similarly, 44% of people who were HIV positive didn’t receive treatment for upper GI cancer versus 18% of those who weren’t infected with HIV. Twenty-four percent of men with prostate cancer who were HIV positive didn’t get treatment, compared with 7% of non–HIV-infected men.

Cancer treatment was defined as radiation, chemotherapy, and/or surgery.

“To have made such great strides with treating HIV only to have them succumb to cancer is devastating,” said Dr. Gita Suneja, a radiation oncologist at the University of Utah’s Huntsman Cancer Institute in Salt Lake City and the lead author of the study. It was published online this month in the journal Cancer.

The study used the National Cancer Data Base to analyze treatment for adults younger than 65 who were diagnosed with any of the 10 most common cancers to affect HIV patients between 2003 and 2011. The study included 10,265 HIV-infected adults and 2.2 million without HIV.

The data base, which is sponsored by the American Cancer Society and the American College of Surgeons, captures roughly 70% of newly diagnosed cancer cases in the United States.

The study noted that more than a third of the patients with HIV had stage 4 cancer – cancer that has metastasized – when they were diagnosed, while only 19% of those without HIV did.

Improvements in antiretroviral therapy to treat HIV have helped reduce the incidence of cancers such as Kaposi sarcoma that are closely linked to AIDS, but rates for other cancers often associated with normal aging have increased among HIV patients. In addition, people with HIV have a higher incidence of some lifestyle-related cancers, such as lung cancer, which could be linked to higher rates of smoking. Cancer is now the second most common cause of death among HIV-infected people, behind AIDS-related causes.

HIV patients are more likely to be uninsured or underinsured, and lack of coverage can affect access to cancer care. But having insurance didn’t eliminate the problem: Privately insured people with HIV were significantly more likely to be untreated for many cancers than were privately insured people without HIV, the study found.

“We know that people with Medicaid or who are uninsured receive subpar cancer treatment, and that’s a big public health issue,” said Dr. Suneja. “But even factoring that in, HIV-infected people are still less likely to receive cancer treatment. That means there are other drivers that we couldn’t measure in the study.”

Disparities in cancer treatment could exist for several reasons. For one thing, for most cancers there are no national treatment guidelines for HIV-infected patients, Dr. Suneja said. One of the few exceptions is anal cancer, the only cancer for which the study found little discrepancy in treatment among HIV-infected and noninfected patients. According to the research, the difference among those not receiving treatment was 4.8% for HIV patients versus 3.1% for others.

For other cancers, “the oncologist may pause and ask, ‘Does the HIV infection mean they shouldn’t get standard cancer treatment?’ ” Dr. Suneja added.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

In most states, consumers with HIV or AIDS who buy silver-level plans on the insurance marketplaces find limited coverage of common drug regimens they may need and high out-of-pocket costs, according to a new analysis.

In 31 states and the District of Columbia, silver-level plans cover fewer than seven of the 10 most common drug treatment options or charge consumers more than $200 a month in cost sharing, according to an analysis of 2015 silver plans by consultant group Avalere Health. Only 16 percent of those marketplace plans cover all 10 of the top HIV/AIDS drug regimens and charge less than $100 a month.

Silver plans are the most popular on the insurance marketplaces set up by the health law. They cover 70 percent of medical charges, on average, while consumers are responsible for 30 percent.

“It’s just more ammunition showing that many plans are engaging in discriminatory plan designs,” says Carl Schmid, deputy executive director at The AIDS Institute, an advocacy group based in Tampa, Fla. “It’s not just Florida. It’s happening around the country as well.”

Last year, The AIDS Institute and the National Health Law Program filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that four Florida insurers — CoventryOne (which is owned by Aetna), Cigna, Humana and Preferred Medical — were violating the anti-discrimination provisions of the health law by structuring their prescription drug plans so that they discouraged people with HIV/AIDS from applying. The four insurers placed all HIV medications, including generics, on the highest cost-sharing tiers, the groups alleged.

The Florida Office of Insurance Regulation eventually reached agreements with the four plans to move HIV/AIDS drugs from specialty to generic tiers and reduce cost sharing in 2015.

Coverage for HIV/AIDS drugs can vary widely, says Caroline Pearson, a senior vice president at Avalere who authored the analysis. “Typically plans have a relatively unified formulary state to state, but HIV is the exception,” she says. “If you happen to be in a state that covers them well, you’re well off.”

For 2016, Pearson doesn’t expect any big changes in drug coverage for people with HIV and AIDS.

“As consumers consider their options for 2016, it’s likely the same barriers will remain,” she says. “Consumers need to be thoughtful about plan selection.”

Kaiser Health News is a nonprofit national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

In most states, consumers with HIV or AIDS who buy silver-level plans on the insurance marketplaces find limited coverage of common drug regimens they may need and high out-of-pocket costs, according to a new analysis.

In 31 states and the District of Columbia, silver-level plans cover fewer than seven of the 10 most common drug treatment options or charge consumers more than $200 a month in cost sharing, according to an analysis of 2015 silver plans by consultant group Avalere Health. Only 16 percent of those marketplace plans cover all 10 of the top HIV/AIDS drug regimens and charge less than $100 a month.

Silver plans are the most popular on the insurance marketplaces set up by the health law. They cover 70 percent of medical charges, on average, while consumers are responsible for 30 percent.

“It’s just more ammunition showing that many plans are engaging in discriminatory plan designs,” says Carl Schmid, deputy executive director at The AIDS Institute, an advocacy group based in Tampa, Fla. “It’s not just Florida. It’s happening around the country as well.”

Last year, The AIDS Institute and the National Health Law Program filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that four Florida insurers — CoventryOne (which is owned by Aetna), Cigna, Humana and Preferred Medical — were violating the anti-discrimination provisions of the health law by structuring their prescription drug plans so that they discouraged people with HIV/AIDS from applying. The four insurers placed all HIV medications, including generics, on the highest cost-sharing tiers, the groups alleged.

The Florida Office of Insurance Regulation eventually reached agreements with the four plans to move HIV/AIDS drugs from specialty to generic tiers and reduce cost sharing in 2015.

Coverage for HIV/AIDS drugs can vary widely, says Caroline Pearson, a senior vice president at Avalere who authored the analysis. “Typically plans have a relatively unified formulary state to state, but HIV is the exception,” she says. “If you happen to be in a state that covers them well, you’re well off.”

For 2016, Pearson doesn’t expect any big changes in drug coverage for people with HIV and AIDS.

“As consumers consider their options for 2016, it’s likely the same barriers will remain,” she says. “Consumers need to be thoughtful about plan selection.”

Kaiser Health News is a nonprofit national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

In most states, consumers with HIV or AIDS who buy silver-level plans on the insurance marketplaces find limited coverage of common drug regimens they may need and high out-of-pocket costs, according to a new analysis.

In 31 states and the District of Columbia, silver-level plans cover fewer than seven of the 10 most common drug treatment options or charge consumers more than $200 a month in cost sharing, according to an analysis of 2015 silver plans by consultant group Avalere Health. Only 16 percent of those marketplace plans cover all 10 of the top HIV/AIDS drug regimens and charge less than $100 a month.

Silver plans are the most popular on the insurance marketplaces set up by the health law. They cover 70 percent of medical charges, on average, while consumers are responsible for 30 percent.

“It’s just more ammunition showing that many plans are engaging in discriminatory plan designs,” says Carl Schmid, deputy executive director at The AIDS Institute, an advocacy group based in Tampa, Fla. “It’s not just Florida. It’s happening around the country as well.”

Last year, The AIDS Institute and the National Health Law Program filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that four Florida insurers — CoventryOne (which is owned by Aetna), Cigna, Humana and Preferred Medical — were violating the anti-discrimination provisions of the health law by structuring their prescription drug plans so that they discouraged people with HIV/AIDS from applying. The four insurers placed all HIV medications, including generics, on the highest cost-sharing tiers, the groups alleged.

The Florida Office of Insurance Regulation eventually reached agreements with the four plans to move HIV/AIDS drugs from specialty to generic tiers and reduce cost sharing in 2015.

Coverage for HIV/AIDS drugs can vary widely, says Caroline Pearson, a senior vice president at Avalere who authored the analysis. “Typically plans have a relatively unified formulary state to state, but HIV is the exception,” she says. “If you happen to be in a state that covers them well, you’re well off.”

For 2016, Pearson doesn’t expect any big changes in drug coverage for people with HIV and AIDS.

“As consumers consider their options for 2016, it’s likely the same barriers will remain,” she says. “Consumers need to be thoughtful about plan selection.”

Kaiser Health News is a nonprofit national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

When kids start school this fall, it’s a sure bet that some won’t have had their recommended vaccines because their parents have claimed exemptions from school requirements for medical, religious, or philosophical reasons. Following the much publicized outbreak of measles that started in Disneyland in California in December, these exemptions have drawn increased scrutiny.

That outbreak, which eventually infected 147 people in seven states, was a wake-up call for many parents, who may not have realized how contagious or serious the disease can be, and for states as well, public health officials said.

©Yarinca/istockphoto.com

“States are beginning to realize that they have effective measures to combat these outbreaks, and philosophical exemptions are eroding these protections and resulting in significant costs to states,” said Dr. Carrie Byington, professor of pediatrics at the University of Utah and chairwoman of the American Academy of Pediatrics Committee on Infectious Diseases.

In addition, research shows that eliminating vaccine exemptions or making them harder to get can improve vaccination rates and reduce disease outbreaks.

California and Vermont passed laws this year eliminating exemptions in 2016 for philosophical reasons; California’s law eliminates religious exemptions as well.

The Centers for Disease Control and Prevention provides recommended vaccination schedules for children and adults, but there’s no federal requirement that parents vaccinate their children. All states, however, have laws or policies requiring that children be up-to-date on recommended vaccines in order to attend school or day care. Unvaccinated children can generally attend only if their parents have obtained a vaccination exemption approved by the states.

Every state allows medical exemptions for children whose immune systems are compromised because of congenital problems or cancer treatment, for example. Nearly all states allow exemptions from vaccinations because of religious beliefs; excluding California and Vermont, 18 permit exemptions because of parents’ personal or philosophical convictions, according to the National Conference of State Legislatures.

Just three states – West Virginia, Mississippi, and now, California – allow vaccine exemptions only for medical reasons.

In recent years, exemption rates for children have soared, but they vary. On the low end, New Mexico’s rate was less than 0.5% in 2012, while the top state rate was Oregon’s at 6.5%, according to a study in the journal Health Affairs.

Local rates may be much higher, though. There are pockets in California and Colorado, for example, where the exemption rates top 30%, said L.J. Tan, chief strategy officer at the Immunization Action Coalition, an advocacy group that works to increase immunization rates.

But since in most places the percentage of children getting the recommended vaccines tops 90% for most diseases, many parents have never seen someone with measles, for example, or whooping cough and may not understand their dangers.

“In the absence of disease the alleged risks of the vaccine become easier to sell,” Mr. Tan said.

Those risks are real, said Barbara Loe Fisher, cofounder and president of the National Vaccine Information Center, a group that advocates that people be able to decline mandatory vaccines based on their philosophical or personal beliefs. Fisher testified before the California State Assembly against the new law, which takes effect next July.

“Some people are more susceptible than others to injury or death from vaccines,” Ms. Fisher said. “But it’s not clear who is at higher risk.”

For the vast majority of people, however, vaccines are very safe, and studies have failed to show a link to autism, a common concern of parents who don’t vaccinate their kids. “The risk of getting the disease is higher than the risk of getting a vaccine,” said Dr. Mark H. Sawyer, a pediatric infectious disease specialist at the University of California, San Diego.

The Health Affairs study analyzed the different elements of state rules to tease out the extent to which they affected vaccine exemptions. It found, for example, that policies that required the state health department to approve nonmedical exemptions or permitted exemptions only for specific vaccines rather than all vaccines had a significant effect on reducing vaccine exemptions. So too did laws that imposed civil or criminal punishments such as expulsion from school (for the child) or criminal negligence charges (for parents) for not complying with vaccination rules.

The threat of penalties alone may be enough to deter parents from refusing vaccinations, said study coauthor W. David Bradford, Ph.D., professor of public policy at the University of Georgia.

The more restrictive policies were reflected in lower rates of whooping cough. States with the most effective exemption policies had an average incidence of 7.3 pertussis cases per 100,000 people from 2002 to 2012, while states with the least effective policies had an incident rate more than twice as high at 16.06 cases, the study reported.

More broadly, the study showed that there are tools that work. “There is room for lots of states to improve their policies in ways that encourage people to get their kids vaccinated,” said Dr. Bradford. “I take that as encouraging.”

Kaiser Health News (KHN) is a nonprofit national health policy news service.

When kids start school this fall, it’s a sure bet that some won’t have had their recommended vaccines because their parents have claimed exemptions from school requirements for medical, religious, or philosophical reasons. Following the much publicized outbreak of measles that started in Disneyland in California in December, these exemptions have drawn increased scrutiny.

That outbreak, which eventually infected 147 people in seven states, was a wake-up call for many parents, who may not have realized how contagious or serious the disease can be, and for states as well, public health officials said.

©Yarinca/istockphoto.com

“States are beginning to realize that they have effective measures to combat these outbreaks, and philosophical exemptions are eroding these protections and resulting in significant costs to states,” said Dr. Carrie Byington, professor of pediatrics at the University of Utah and chairwoman of the American Academy of Pediatrics Committee on Infectious Diseases.

In addition, research shows that eliminating vaccine exemptions or making them harder to get can improve vaccination rates and reduce disease outbreaks.

California and Vermont passed laws this year eliminating exemptions in 2016 for philosophical reasons; California’s law eliminates religious exemptions as well.

The Centers for Disease Control and Prevention provides recommended vaccination schedules for children and adults, but there’s no federal requirement that parents vaccinate their children. All states, however, have laws or policies requiring that children be up-to-date on recommended vaccines in order to attend school or day care. Unvaccinated children can generally attend only if their parents have obtained a vaccination exemption approved by the states.

Every state allows medical exemptions for children whose immune systems are compromised because of congenital problems or cancer treatment, for example. Nearly all states allow exemptions from vaccinations because of religious beliefs; excluding California and Vermont, 18 permit exemptions because of parents’ personal or philosophical convictions, according to the National Conference of State Legislatures.

Just three states – West Virginia, Mississippi, and now, California – allow vaccine exemptions only for medical reasons.

In recent years, exemption rates for children have soared, but they vary. On the low end, New Mexico’s rate was less than 0.5% in 2012, while the top state rate was Oregon’s at 6.5%, according to a study in the journal Health Affairs.

Local rates may be much higher, though. There are pockets in California and Colorado, for example, where the exemption rates top 30%, said L.J. Tan, chief strategy officer at the Immunization Action Coalition, an advocacy group that works to increase immunization rates.

But since in most places the percentage of children getting the recommended vaccines tops 90% for most diseases, many parents have never seen someone with measles, for example, or whooping cough and may not understand their dangers.

“In the absence of disease the alleged risks of the vaccine become easier to sell,” Mr. Tan said.

Those risks are real, said Barbara Loe Fisher, cofounder and president of the National Vaccine Information Center, a group that advocates that people be able to decline mandatory vaccines based on their philosophical or personal beliefs. Fisher testified before the California State Assembly against the new law, which takes effect next July.

“Some people are more susceptible than others to injury or death from vaccines,” Ms. Fisher said. “But it’s not clear who is at higher risk.”

For the vast majority of people, however, vaccines are very safe, and studies have failed to show a link to autism, a common concern of parents who don’t vaccinate their kids. “The risk of getting the disease is higher than the risk of getting a vaccine,” said Dr. Mark H. Sawyer, a pediatric infectious disease specialist at the University of California, San Diego.

The Health Affairs study analyzed the different elements of state rules to tease out the extent to which they affected vaccine exemptions. It found, for example, that policies that required the state health department to approve nonmedical exemptions or permitted exemptions only for specific vaccines rather than all vaccines had a significant effect on reducing vaccine exemptions. So too did laws that imposed civil or criminal punishments such as expulsion from school (for the child) or criminal negligence charges (for parents) for not complying with vaccination rules.

The threat of penalties alone may be enough to deter parents from refusing vaccinations, said study coauthor W. David Bradford, Ph.D., professor of public policy at the University of Georgia.

The more restrictive policies were reflected in lower rates of whooping cough. States with the most effective exemption policies had an average incidence of 7.3 pertussis cases per 100,000 people from 2002 to 2012, while states with the least effective policies had an incident rate more than twice as high at 16.06 cases, the study reported.

More broadly, the study showed that there are tools that work. “There is room for lots of states to improve their policies in ways that encourage people to get their kids vaccinated,” said Dr. Bradford. “I take that as encouraging.”

Kaiser Health News (KHN) is a nonprofit national health policy news service.

When kids start school this fall, it’s a sure bet that some won’t have had their recommended vaccines because their parents have claimed exemptions from school requirements for medical, religious, or philosophical reasons. Following the much publicized outbreak of measles that started in Disneyland in California in December, these exemptions have drawn increased scrutiny.

That outbreak, which eventually infected 147 people in seven states, was a wake-up call for many parents, who may not have realized how contagious or serious the disease can be, and for states as well, public health officials said.

©Yarinca/istockphoto.com

“States are beginning to realize that they have effective measures to combat these outbreaks, and philosophical exemptions are eroding these protections and resulting in significant costs to states,” said Dr. Carrie Byington, professor of pediatrics at the University of Utah and chairwoman of the American Academy of Pediatrics Committee on Infectious Diseases.

In addition, research shows that eliminating vaccine exemptions or making them harder to get can improve vaccination rates and reduce disease outbreaks.

California and Vermont passed laws this year eliminating exemptions in 2016 for philosophical reasons; California’s law eliminates religious exemptions as well.

The Centers for Disease Control and Prevention provides recommended vaccination schedules for children and adults, but there’s no federal requirement that parents vaccinate their children. All states, however, have laws or policies requiring that children be up-to-date on recommended vaccines in order to attend school or day care. Unvaccinated children can generally attend only if their parents have obtained a vaccination exemption approved by the states.

Every state allows medical exemptions for children whose immune systems are compromised because of congenital problems or cancer treatment, for example. Nearly all states allow exemptions from vaccinations because of religious beliefs; excluding California and Vermont, 18 permit exemptions because of parents’ personal or philosophical convictions, according to the National Conference of State Legislatures.

Just three states – West Virginia, Mississippi, and now, California – allow vaccine exemptions only for medical reasons.

In recent years, exemption rates for children have soared, but they vary. On the low end, New Mexico’s rate was less than 0.5% in 2012, while the top state rate was Oregon’s at 6.5%, according to a study in the journal Health Affairs.

Local rates may be much higher, though. There are pockets in California and Colorado, for example, where the exemption rates top 30%, said L.J. Tan, chief strategy officer at the Immunization Action Coalition, an advocacy group that works to increase immunization rates.

But since in most places the percentage of children getting the recommended vaccines tops 90% for most diseases, many parents have never seen someone with measles, for example, or whooping cough and may not understand their dangers.

“In the absence of disease the alleged risks of the vaccine become easier to sell,” Mr. Tan said.

Those risks are real, said Barbara Loe Fisher, cofounder and president of the National Vaccine Information Center, a group that advocates that people be able to decline mandatory vaccines based on their philosophical or personal beliefs. Fisher testified before the California State Assembly against the new law, which takes effect next July.

“Some people are more susceptible than others to injury or death from vaccines,” Ms. Fisher said. “But it’s not clear who is at higher risk.”

For the vast majority of people, however, vaccines are very safe, and studies have failed to show a link to autism, a common concern of parents who don’t vaccinate their kids. “The risk of getting the disease is higher than the risk of getting a vaccine,” said Dr. Mark H. Sawyer, a pediatric infectious disease specialist at the University of California, San Diego.

The Health Affairs study analyzed the different elements of state rules to tease out the extent to which they affected vaccine exemptions. It found, for example, that policies that required the state health department to approve nonmedical exemptions or permitted exemptions only for specific vaccines rather than all vaccines had a significant effect on reducing vaccine exemptions. So too did laws that imposed civil or criminal punishments such as expulsion from school (for the child) or criminal negligence charges (for parents) for not complying with vaccination rules.

The threat of penalties alone may be enough to deter parents from refusing vaccinations, said study coauthor W. David Bradford, Ph.D., professor of public policy at the University of Georgia.

The more restrictive policies were reflected in lower rates of whooping cough. States with the most effective exemption policies had an average incidence of 7.3 pertussis cases per 100,000 people from 2002 to 2012, while states with the least effective policies had an incident rate more than twice as high at 16.06 cases, the study reported.

More broadly, the study showed that there are tools that work. “There is room for lots of states to improve their policies in ways that encourage people to get their kids vaccinated,” said Dr. Bradford. “I take that as encouraging.”

Kaiser Health News (KHN) is a nonprofit national health policy news service.

Earlier this week the federal government clarified that insurers can’t charge people for anesthesia administered during a free colonoscopy to screen for colorectal cancer. That’s good news for consumers, some of whom have been charged hundreds of dollars for anesthesia after undergoing what they thought would be a free test. But the government guidance leaves important questions unanswered.

Under the health law, most health plans have to provide care that’s recommended by the U.S. Preventive Services Task Force without charging members anything out of pocket. The only exception is for plans that have grandfathered status under the law.

That task force, a nonpartisan group of medical experts, recommends that starting at age 50 people periodically receive either a colonoscopy, sigmoidoscopy, or fecal occult blood test to screen for colorectal cancer.

Although the health law made it clear that the colonoscopy itself must be free for patients, it didn’t spell out how anesthesia or other charges should be handled.

That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn’t be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure.

With this week’s guidance, the government has made it clear that consumers also don’t have to pick up the tab for anesthesia during a colonoscopy.

But other questions remain. Consumers may still find themselves on the hook for facility or pathology charges related to a screening colonoscopy, according to an e-mail from Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable.

In addition, cost sharing rules are unclear for consumers who get a positive result on a blood stool test and need to follow up with a colonoscopy. The federal government hasn’t clarified whether that procedure is considered part of the free screening process or whether insurers can charge for it as a diagnostic procedure, according to Ms. Howard and Ms. Doroshenk.

In a 2012 study, researchers found that four insurers imposed patient cost sharing for colonoscopies after a positive blood stool test and three did not.

As for consumers who paid for anesthesia and now learn that they shouldn’t have been charged, it’s unclear if they can get their money back.

“Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years,” said Ms. Howard and Ms. Doroshenk.

The Department of Health and Human Services didn’t respond to a request for clarification.

Kaiser Health News is a nonprofit national health policy news service.

Earlier this week the federal government clarified that insurers can’t charge people for anesthesia administered during a free colonoscopy to screen for colorectal cancer. That’s good news for consumers, some of whom have been charged hundreds of dollars for anesthesia after undergoing what they thought would be a free test. But the government guidance leaves important questions unanswered.

Under the health law, most health plans have to provide care that’s recommended by the U.S. Preventive Services Task Force without charging members anything out of pocket. The only exception is for plans that have grandfathered status under the law.

That task force, a nonpartisan group of medical experts, recommends that starting at age 50 people periodically receive either a colonoscopy, sigmoidoscopy, or fecal occult blood test to screen for colorectal cancer.

Although the health law made it clear that the colonoscopy itself must be free for patients, it didn’t spell out how anesthesia or other charges should be handled.

That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn’t be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure.

With this week’s guidance, the government has made it clear that consumers also don’t have to pick up the tab for anesthesia during a colonoscopy.

But other questions remain. Consumers may still find themselves on the hook for facility or pathology charges related to a screening colonoscopy, according to an e-mail from Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable.

In addition, cost sharing rules are unclear for consumers who get a positive result on a blood stool test and need to follow up with a colonoscopy. The federal government hasn’t clarified whether that procedure is considered part of the free screening process or whether insurers can charge for it as a diagnostic procedure, according to Ms. Howard and Ms. Doroshenk.

In a 2012 study, researchers found that four insurers imposed patient cost sharing for colonoscopies after a positive blood stool test and three did not.

As for consumers who paid for anesthesia and now learn that they shouldn’t have been charged, it’s unclear if they can get their money back.

“Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years,” said Ms. Howard and Ms. Doroshenk.

The Department of Health and Human Services didn’t respond to a request for clarification.

Kaiser Health News is a nonprofit national health policy news service.

Earlier this week the federal government clarified that insurers can’t charge people for anesthesia administered during a free colonoscopy to screen for colorectal cancer. That’s good news for consumers, some of whom have been charged hundreds of dollars for anesthesia after undergoing what they thought would be a free test. But the government guidance leaves important questions unanswered.

Under the health law, most health plans have to provide care that’s recommended by the U.S. Preventive Services Task Force without charging members anything out of pocket. The only exception is for plans that have grandfathered status under the law.

That task force, a nonpartisan group of medical experts, recommends that starting at age 50 people periodically receive either a colonoscopy, sigmoidoscopy, or fecal occult blood test to screen for colorectal cancer.

Although the health law made it clear that the colonoscopy itself must be free for patients, it didn’t spell out how anesthesia or other charges should be handled.

That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn’t be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure.

With this week’s guidance, the government has made it clear that consumers also don’t have to pick up the tab for anesthesia during a colonoscopy.

But other questions remain. Consumers may still find themselves on the hook for facility or pathology charges related to a screening colonoscopy, according to an e-mail from Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable.

In addition, cost sharing rules are unclear for consumers who get a positive result on a blood stool test and need to follow up with a colonoscopy. The federal government hasn’t clarified whether that procedure is considered part of the free screening process or whether insurers can charge for it as a diagnostic procedure, according to Ms. Howard and Ms. Doroshenk.

In a 2012 study, researchers found that four insurers imposed patient cost sharing for colonoscopies after a positive blood stool test and three did not.

As for consumers who paid for anesthesia and now learn that they shouldn’t have been charged, it’s unclear if they can get their money back.

“Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years,” said Ms. Howard and Ms. Doroshenk.

The Department of Health and Human Services didn’t respond to a request for clarification.

Kaiser Health News is a nonprofit national health policy news service.