Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity and require full names.
Kaiser Health News’ June 20 scoop on the exact number of children under age 13 who had been detained at the border under the Trump administration’s “zero tolerance” immigration policy got wide attention, including from investigative news outlet ProPublica and Hollywood legend Mia Farrow:

What about the 2322 children under 12 years old, who are currently being detained by Trump administration? When will they be united with their parents? What is the process? https://t.co/j6VyXjMgNS
— Mia Farrow (@MiaFarrow) June 20, 2018

In walking back into the past, we are now in the year 1941! https://t.co/qXrAjKFS6M
— Andrej Mrevlje (@andrejmrevlje) June 21, 2018

— Andrej Mrevlje, founder and editor of Yonder, Washington, D.C.
‘Pain Pills’ Or Intoxicants?
A thought on Julie Appleby’s article about opioid duration (“Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass,” June 22): Our words form our ideas. A “pain pill” stops pain from occurring. Opioids do not do this. Intoxicants stop us from perceiving pain. Opioid meds do this.
What would happen if we called opioids “intoxicants”?
There are times when an intoxicant is appropriate. I had knee surgery, and it’s best to be intoxicated to endure that. Afterward, I took half a narcotic. Of course, my knee hurt. But the pain had meaning: that I was healing and things would get better.
I have been an ER doctor for 33 years, since before the so-called opioid epidemic began. I now tell patients to whom I’m giving opioids that I’m giving them permission to be drunk when that is what they need — and not when they don’t.
— Dr. Tom Benzoni, Des Moines
A Kentucky surgeon voices his concern that the patients’ needs could get lost amid prescriptive formulas for how many opioids are needed post-surgery.

“no one should be given more than five or 10 opioid tablets after a cesarean section.” Seriously? This “research” is beneath the level expected of @HopkinsMedicine -Someone should tell these surgeons that they treat patients – not procedures. @AAPSonline https://t.co/fluBCOqrms
— Confluential Truth (@jamespmurphymd) June 25, 2018

— Dr. James Murphy, Louisville
One D.C. source hopes to put readers wise to the teenage black market of pain pills following wisdom teeth extractions.

I know teens who get a 10 day supply for wisdom teeth. Then they stash about 50% of them (day 5) for distribution later to friends.
— Lucia Savage (@SavageLucia) June 22, 2018

— Lucia Savage, Washington, D.C.
Extra Pointer On Poison Ivy
Very good article on poison ivy (“Poison Ivy, A ‘Familiar Stranger’ That Could Ruin Your Summer,” June 11). Something you might want to add in future discussions, though, is that the sap of the tropical mango tree has the same oil that causes a reaction from poison ivy contact. Few people realize this, but even when buying fresh mangoes in the store, this sticky sap that is around the broken stem can give the same kind of painful rash as poison ivy does.
— Keith Cheshire, East Palatka, Fla.
Opening Up About Stigma
I wish Kate Spade’s family would come forth and share their true experiences surrounding her illness (“Kate Spade’s Death Ignites Concern About Rising Suicide Rate,” June 7). Substance abuse and mental illness need to be openly discussed to take away the stigma, so those who need help aren’t judged and receive proper care.
— Debbie Strobl, St. Louis
Concerning bipolar disorder, otherwise known as manic-depressive illness: Bipolar II is not “milder” than bipolar I. It’s different. The degree of mania is less extreme, but the periods of depression tend to be much longer. Misdiagnosis as merely depression is likely, which can lead to ineffective medication. The point I would have liked Liz Szabo’s story to emphasize about Ms. Spade is that while her treatment did not prevent her suicide, it may well have delayed it. Treatment is not always successful, but not treating serious mental illness guarantees poor outcomes.
— Candy Clouston, Plainfield, Ill.
My Own Private ‘A-Ha’ Moment
Your reporting on Montana’s state health plan (‘Holy Cow’ Moment Changes How Montana’s State Health Plan Does Business,” June 20) is right-on … kinda sorta. A long time ago, I worked for six different small to medium rural hospitals in several states and sections of the country from the late 1970s until 2008. What Montana has done is crude but useful.
I had often thought that Medicare’s “cost-based” system needed improvement. The introduction of the diagnosis-based reimbursement was a step in the right direction: rewarding hospitals able to provide specific services economically (comparatively) without subsidy for other services that cannot be provided at a reasonable cost. I thought that paying average costs was a way to shift funds away from the most expensive hospitals to small and rural hospitals, which have much lower costs. But, alas, these strategies were bastardized and manipulated.
I finally quit financial management of hospitals when I realized I had reached a point where I had to cut back on nursing to be able to pay for clerks and systems to maximize coding of the billing. I applaud Montana for its relatively simple system. But I reserve my enthusiasm for the fact that a smarter man than most, W. Edwards Deming, described the health care system as the most complex industry in the U.S.
I think his 60-year-old observation holds up. My belief is that there is no really good method of health care financial design. But, obviously, all others are better than what we have in this country.
— Mike Thomas, Kalama, Wash.
Back-And-Forth On Nursing Homes
As a former nursing home administrator and an attorney representing skilled nursing facilities, I found that this article (“Neglect Unchecked: Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients,” June 13) incorrectly argued that skilled nursing facilities are financially incentivized to transfer patients to the hospital and that financial considerations increase transfer rates.
First, the examples of financial burdens are incorrect: Physicians directly bill the residents’ insurance for examinations and “stat” lab tests are simply not a significant cost much less one that would be alleviated by a hospital transfer. Second, Medicaid residents do not usually return with up to 100 days of higher Medicare reimbursement because: (1) residents don’t often stay in the hospital long enough for the three-midnight qualifying stay; (2) residents may have already used their 100 days; and (3) long-term residents may not meet Medicare’s criteria to be a “skilled” patient (e.g. making enough progress with physical therapy).
The issue of hospital readmission requires a balancing act of minimizing unnecessary transfers to the hospital without creating a chilling effect that would discourage appropriate transfers.  However, the tendency to sensationalize articles about skilled nursing facilities with unrelated allegations of poor patient care leaves little room for a discussion regarding hospital readmissions or other important topics involving skilled nursing facilities and/or the provision of care to elderly patients with complex, chronic and progressive diseases.
— Tara Murray, Sausalito, Calif.

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