KHN’s ‘What the Health?’: The Biden Health Agenda

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President Joe Biden wasted no time getting down to work. Among the raft of executive orders he signed on Inauguration Day were several aimed at curtailing the covid crisis, including one requiring mask-wearing by federal employees and anyone on federal property for the next 100 days.

Meanwhile, with the inauguration of Vice President Kamala Harris and the swearing-in of two new Democratic senators from Georgia, Democrats took over the majority in the Senate, albeit with a 50-50 tie. That leaves Democrats in charge of both the legislative and executive branches for the first time since 2010, but with such narrow majorities it could be difficult to advance many of Biden’s top health agenda items, starting with an expansion of the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

  • Although Biden can make certain changes to the federal policies in the fight against covid-19, much of what he has detailed in his plan will require congressional action, and Senate Republicans do not appear willing to support a major legislative package just yet.
  • Many of the efforts against covid that Biden has said he wants to put in place are initiatives that have been recommended by public health officials over the past year and not acted upon. But the discovery of new, more contagious variants of the coronavirus may necessitate faster efforts to distribute vaccine and other actions.
  • Wearing masks and other simple public health practices can have a big impact on slowing the spread of covid, but much of the public is looking to a vaccine for help. Those supplies remain limited and it’s not clear whether Biden’s interest in using the Defense Production Act to force industry to help will increase vaccine production.
  • Vaccination success is hampered by unreliable estimates of the amount of supplies states can expect to receive and a patchwork of sign-up methods and eligibility criteria.
  • Among the actions Biden and a Democratic Congress could take to reverse policies instituted by the Trump administration are ramping up workplace enforcement of covid rules to help keep employees from spreading the disease, restoring a penalty for not having insurance so that the lawsuit threatening the Affordable Care Act would become moot, and overturning rules requiring reviews of federal scientists.
  • The Senate has not yet scheduled a confirmation hearing for Xavier Becerra, Biden’s choice for Health and Human Services secretary. Before a mob stormed the U.S. Capitol this month, it was thought that establishing a new federal health team would be the president’s priority, but national security took precedence after the violence.
  • Controlling drug prices is an issue with huge popular support, but Congress is divided over how to do it. The broad measure that passed the House in 2019 is again unlikely to fly in the Senate, but senators may try to produce a more modest proposal along the lines of a bipartisan measure offered previously by Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore).
  • Drugmakers have generally fought most efforts to implement price controls, but there may be growing interest within the industry to work out a bipartisan deal that they have a hand in, rather than waiting to see what Democrats can push through.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Atlantic’s “Pramila Jayapal Is ‘Next-Level’ Angry,” by Elaine Godfrey

Alice Miranda Ollstein: The New York Times’ “Emerging Coronavirus Variants May Pose Challenges to Vaccines,” by Apoorva Mandavilli

Sarah Karlin-Smith: Vanity Fair’s “A Tsunami of Randoms”: How Trump’s COVID Chaos Drowned the FDA in Junk Science,” by Katherine Eban

Tami Luhby: KHN’s “Black Americans Are Getting Vaccinated at Lower Rates Than White Americans,” by Hannah Recht and Lauren Weber

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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After a Decade of Lobbying, ALS Patients Gain Faster Access to Disability Payments

Anita Baron first noticed something was wrong in August 2018, when she began to drool. Her dentist chalked it up to a problem with her jaw. Then her speech became slurred. She managed to keep her company, which offers financing to small businesses, going, but work became increasingly difficult as her speech worsened. Finally, nine months, four neurologists and countless tests later, Baron, now 66, got a diagnosis: amyotrophic lateral sclerosis.

ALS, often called Lou Gehrig’s disease after the New York Yankees first baseman who died of it in 1941, destroys motor neurons, causing people to lose control of their limbs, their speech and, ultimately, their ability to breathe. It’s usually fatal in two to five years.

People with ALS often must quit their jobs and sometimes their spouses do, too, to provide care, leaving families in financial distress. A decade-long campaign by advocates highlighting this predicament notched a victory last month when Congress passed a bill opening key support programs earlier for ALS patients.

In late December, then-President Donald Trump signed the bill into law. It eliminates for ALS patients the required five-month waiting period to begin receiving benefits under the Social Security Disability Insurance program, which replaces at least part of a disabled worker’s income. Gaining SSDI also gives these patients immediate access to Medicare health coverage.

Advocacy groups note that the Social Security Administration still will need to set up procedures for implementing the law, before patients will see the benefits.

The Muscular Dystrophy Association, an umbrella organization for people with 43 neuromuscular conditions, partnered with other ALS groups to support the bill to eliminate the SSDI waiting period.

“We’re hopeful that it can serve as a model for other conditions that may be similarly situated,” said Brittany Johnson Hernandez, senior director of policy and advocacy at MDA.

In the weeks leading up to the passage of the bill, Sen. Mike Lee (R-Utah) sought to broaden the scope of the legislation to include other conditions. He pledged to continue to work on legislation to eliminate the SSDI waiting period for additional diseases that meet certain criteria, including those with no known cure and a life expectancy of less than five years.

Eliminating the SSDI waiting period has been a top priority for ALS advocates. There is no simple, single test or scan to confirm that someone has ALS, though symptoms can escalate rapidly. By the time people finally get the diagnosis, they are often already seriously disabled and unable to work. Waiting five months longer for financial aid can be a burden, according to patients and families.

“Five months may seem like a short period of time, but for someone with ALS it matters,” said Danielle Carnival, CEO of I Am ALS, an advocacy group. “It’s a huge win and will make a huge difference for people right away.”

Eligibility for SSDI benefits generally requires people to have worked for about a quarter of their adult lives at jobs through which they paid Social Security taxes. Benefits are based on lifetime earnings; the average monthly SSDI benefit was $1,259 in June 2020, according to the Social Security Administration. (The average retirement benefit was $1,514 that month.)

The SSDI waiting period was intended to make sure the program served only people expected to have claims that would last at least a year, said Ted Norwood, chief legal officer at Integrated Benefits Inc. in Jefferson City, Missouri, who represents SSDI applicants. But it isn’t necessary, he added, because disability rules now require that people have a condition that will keep them out of work at least a year or result in death.

“The five-month waiting period serves no purpose as far as weeding out cases,” Norwood said.

Existing federal law also made special health provisions for people with ALS and end-stage renal disease. Most people with disabilities must wait two years to be eligible for Medicare, but people with either of those two diseases can qualify sooner. ALS patients are eligible as soon as SSDI benefits start.

The new law could have made a big difference for Baron, who lives in Pikesville, Maryland. She and her husband, who works part time at a funeral parlor, didn’t have comprehensive health insurance when she got sick. They were enrolled only in a supplemental medical plan that paid out limited cash benefits.

By the time she was diagnosed and her SSDI and Medicare came through, Baron and her husband had maxed out their credit cards, raided $10,000 from their IRA and gone to their family for money. They were $13,000 in debt. They sold their house and moved into a condo to save on expenses.

“It is imperative that as [people] become more and more debilitated and cannot work, that they have immediate access to SSDI,” Baron said.

Like Sen. Lee, some patient advocates say the accommodations on disability benefits and Medicare made for patients with ALS should be extended to others with similarly intractable conditions.

The Social Security Administration has identified 242 conditions that meet the agency’s standards for qualifying for disability benefits and are fast-tracked for benefit approval.

Once approved, people with these conditions still must wait five months before they receive any money. Now, under the new law, people with ALS can skip the waiting period, though no one else on the “compassionate allowances” list can.

Breast cancer advocates are hoping for similar accommodations for people with metastatic breast cancer. Legislation introduced in the House and Senate in 2019 would have eliminated the SSDI waiting period for this group, but it did not pass.

Tackling the problem one condition at a time doesn’t make sense, others argue.

“Can you imagine, one by one, people with these conditions trying to find people in the House and in the Senate to champion the bill?” said Carol Harnett, president of the Council for Disability Awareness, which represents disability insurers.

Deb McQueen-Quinn thinks it would be good if the new law sets a precedent for eliminating the SSDI waiting period. At 55, McQueen-Quinn has lived with ALS since 2009, far longer than most.

A former convenience store manager, she uses a wheelchair full time now. She knows all too well the toll of the disease. ALS runs in her family, and she’s watched several family members, including her sister, brother and a cousin die of it.

Her sister, a former quality control engineer, was diagnosed in 2006 and died the following year, a week before she would have received her first SSDI payment.

McQueen-Quinn, who lives in Wellsville, New York, with her husband, has two children in their 30s. Her son, 33, carries the familial genetic mutation that leads to ALS. So far he hasn’t developed symptoms. But it’s for people like her son and other family members that she fought for the new law.

“Now that we’ve set the precedent, I’m sure you’ll see a lot of other diseases go after this,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Patients Fend for Themselves to Access Highly Touted Covid Antibody Treatments

By the time he tested positive for covid-19 on Jan. 12, Gary Herritz was feeling pretty sick. He suspects he was infected a week earlier, during a medical appointment in which he saw health workers who were wearing masks beneath their noses or who had removed them entirely.

His scratchy throat had turned to a dry cough, headache, joint pain and fever — all warning signs to Herritz, who underwent liver transplant surgery in 2012, followed by a rejection scare in 2018. He knew his compromised immune system left him especially vulnerable to a potentially deadly case of covid.

“The thing with transplant patients is we can crash in a heartbeat,” said Herritz, 39. “The outcome for transplant patients [with covid] is not good.”

On Twitter, Herritz had read about monoclonal antibody therapy, the treatment famously given to President Donald Trump and other high-profile politicians and authorized by the Food and Drug Administration for emergency use in high-risk covid patients. But as his symptoms worsened, Herritz found himself very much on his own as he scrambled for access.

His primary care doctor wasn’t sure he qualified for treatment. His transplant team in Wisconsin, where he’d had the liver surgery, wasn’t calling back. No one was sure exactly where he should go to get it. From bed in Pascagoula, Mississippi, he spent two days punching in phone numbers, reaching out to health officials in four states, before he finally landed an appointment to receive a treatment aimed at keeping patients like him out of the hospital — and, perhaps, the morgue.

“I am not rich, I am not special, I am not a political figure,” Herritz, a former community service officer, wrote on Twitter. “I just called until someone would listen.”

Months after Trump emphatically credited an experimental antibody therapy for his quick recovery from covid and even as drugmakers ramp up supplies, only a trickle of the product has found its way into regular people. While hundreds of thousands of vials sit unused, sick patients who, research indicates, could benefit from early treatment — available for free — have largely been fending for themselves.

Federal officials have allocated more than 785,000 doses of two antibody treatments authorized for emergency use during the pandemic, and more than 550,000 doses have been delivered to sites across the nation. The federal government has contracted for nearly 2.5 million doses of the products from drugmakers Eli Lilly and Co. and Regeneron Pharmaceuticals at a cost of more than $4.4 billion.

So far, however, only about 30% of the available doses have been administered to patients, federal Department of Health and Human Services officials said.

Scores of high-risk covid patients who are eligible remain unaware or have not been offered the option. Research has shown the therapy is most effective if given early in the illness, within 10 days of a positive covid test. But many would-be recipients have missed this crucial window because of a patchwork system in the U.S. that can delay testing and diagnosis.

“The bottleneck here in the funnel is administration, not availability of the product,” said Dr. Janet Woodcock, a veteran FDA official in charge of therapeutics for the federal Operation Warp Speed effort.

Among the daunting hurdles: Until this week, there has been no nationwide system to tell people where they could obtain the drugs, which are delivered through IV infusions that require hours to administer and monitor. Finding space to keep covid-infected patients separate from others has been difficult in some health centers slammed by the pandemic.

“The health care system is crashing,” Woodcock told reporters. “What we’ve heard around the country is the No. 1 barrier is staffing.”

At the same time, many hospitals have refused to offer the therapy because doctors were unimpressed with the research federal officials used to justify its use.

Monoclonal antibodies are lab-produced molecules that act as substitutes for the body’s own antibodies that fight infection. The covid treatments are designed to block the SARS-CoV-2 virus that causes infection from attaching to and entering human cells. Such treatments are usually prohibitively expensive, but for the time being the federal government is footing the bulk of the bill, though patients likely will be charged administrative fees.

Nationwide, nearly 4,000 sites offer the infusion therapies. But for patients and families of people most at risk — those 65 and older or with underlying health conditions — finding the sites and gaining access has been almost impossible, said Brian Nyquist, chief executive officer of the National Infusion Center Association, which is tracking supplies of the antibody products. Like Herritz, many seeking information about monoclonals find themselves on a lone crusade.

“If they’re not hammering the phones and advocating for access for their loved ones, others often won’t,” he said. “Tenacity is critical.”

Regeneron officials said they’re fielding calls about covid treatments daily to the company’s medical information line. More than 3,500 people have flooded Eli Lilly’s covid hotline with questions about access.

As of this week, all states are required to list on a federal locator map sites that have received the monoclonal antibody products, HHS officials said. The updated map shows wide distribution, but a listing doesn’t guarantee availability or access; patients still need to check. It’s best to confer with a primary care provider before reaching out to the centers. For best results, treatment should occur as soon as possible after a positive covid test.

Some health systems have refused to offer the monoclonal antibody therapies because of doubts about the data used to authorize them. Early studies suggested that Lilly’s therapy, bamlanivimab, reduced the need for hospitalization or emergency treatment in outpatient covid cases by about 70%, while Regeneron’s antibody cocktail of casirivimab plus imdevimab reduced the need by about 50%.

But those studies were small, just a few hundred subjects, and the results were limited. “A lot of doctors, actually, they’re not impressed with the data,” said Dr. Daniel Griffin, an infectious disease expert at Columbia University who co-hosts the podcast “This Week in Virology.” “There really is still that question of, ‘Does this stuff really work?’”

As more patients are treated, however, there’s growing evidence that the therapies can keep high-risk patients out of the hospital, not only easing their recovery but also decreasing the burden on health systems struggling with record numbers of patients.

Dr. Raymund Razonable, an infectious disease expert at the Mayo Clinic in Minnesota, said he has treated more than 2,500 covid patients with monoclonal antibody therapy with promising results. “It’s looking good,” he said, declining to provide details because they’re embargoed for publication. “We are seeing reductions in hospitalizations; we’re seeing reductions in ICU care; we’re also seeing reductions in mortality.”

Banking on observations from Mayo experts and others, federal officials have been pushing for wider use of antibody therapies. HHS officials have partnered with hospitals in three hard-hit states — California, Arizona and Nevada — to set up infusion centers that are treating dozens of covid patients each day.

One of those sites went up in late December at El Centro Regional Medical Center in California’s Imperial County, an impoverished farming region on the state’s southern border that has recorded among the highest covid infection rates in the state. For months, the medical center strained to absorb the overwhelming influx of patients, but chief executive Dr. Adolphe Edward said a new walk-up infusion site has already put a dent in the covid load.

More than 130 people have been treated, all patients who were able to get the two-hour infusions and then recuperate at home. “If those folks would not have had the treatment, they would have come through the emergency department and we would have had to admit the lion’s share of them,” he said.

It’s important to make sure people in high-risk groups know to seek out the therapy and to get it early, Edward said. He and his staff have been working with area doctors’ offices and nonprofit groups and relying on word-of-mouth.

“On multiple levels, we’re saying, ‘If you’ve tested positive for the virus, come and let us see if you are eligible,’” Edward said.

Greater awareness is a goal of the HHS effort, said Dr. John Redd, chief medical officer for the assistant secretary for preparedness and response. “These antibodies are meant for everyone,” he said. “Everyone across the country should have equal access to these products.”

For now, patients like Herritz, the Mississippi liver transplant recipient, say reality is falling well short of that goal. If he hadn’t continued to call in search of a referral, he wouldn’t have been treated. And without the therapy, Herritz believes, he was just days away from hospitalization.

“I think it’s horrible that if I didn’t have Twitter, I wouldn’t know anything about this,” he said. “I think about all the people who have died not knowing this was an option for high-risk individuals.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Host Dan Weissmann Talks Price Transparency on ‘Axios Today’

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As we settle into the new year, we have two small doses of good news.

First, a new federal rule could help cut through one health care issue. Host Dan Weissmann talked about the rule — which requires hospitals to make public the prices they negotiate with insurers — in a short conversation with his former public-radio colleague, Niala Boodhoo, for the daily-news podcast “Axios Today.”

You’ll find more detail on that rule in this story from reporter Celia Llopis-Jepsen, whose reporting about a $50,000 “air ambulance” ride formed the core of a recent episode about how consumers get squeezed by insurers on one side and providers on the other.

Later in the episode, a listener describes how he used what he learned from “An Arm and a Leg” to head off an insurance nightmare.

Here’s a transcript for this episode.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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California Budget Reflects ‘Pandemic-Induced Reality,’ Governor Says

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SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.

But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.

Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.

However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.

Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”

But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.

And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.

“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”

Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.

Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.

“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.

Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.

The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.

Covid Relief

Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.

He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.

Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.

Transforming Medi-Cal

Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.

In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.

State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.

Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.

Controlling Health Care Costs

Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.

Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.

Newsom acknowledged Friday the task would be “tough.”

Battling Homelessness and Food Insecurity

Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.

Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.

Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.

Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.

“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”

Expanding Health Coverage

Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.

Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.

“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Aunque controlen el Senado, demócratas necesitarán apoyo republicano en temas clave de salud

Ante la pandemia, los demócratas han abogado por ayudas más generosas, más presión sobre las farmacéuticas para que bajen los precios y más atención al racismo sistémico en la atención de salud.

El 20 de enero, con el control del Senado y la Cámara de Representantes, tendrán el poder de elegir qué propuestas de salud se votarán en el Congreso.

Las victorias del reverendo Raphael Warnock y Jon Ossoff en Georgia dieron a los demócratas dos escaños más en el Senado y la ventaja en un Senado dividido 50-50. Cuando la vicepresidenta electa, Kamala Harris, jure el cargo, su voto servirá como desempate, convirtiéndose así en el voto 51 de los demócratas.

Pero este estrecho margen de votos no eliminará el “filibusteo” (discursos obstruccionistas y dilatorios), lo que significa que los demócratas no tendrán suficientes votos para aprobar muchos de sus planes sin los republicanos.

Eso pondrá en peligro muchas propuestas demócratas de salud, como la de ofrecer a los estadounidenses una opción de seguro público patrocinada por el gobierno, y complicará los esfuerzos para aprobar más ayudas para la pandemia.

Queda por ver si los legisladores serán más proclives al compromiso después que una turba pro-Trump invadiera el Capitolio, el 6 de enero, atacando a la policía y dañando propiedad federal. Hubo cinco muertos.

Los estrechos márgenes de los demócratas en el Senado y en la Cámara de Representantes — donde pueden permitirse perder cuatro votos y aun así aprobar una legislación— también darán más influencia a algunos legisladores que, al no estar de acuerdo con los líderes de sus partidos, tendrán un incentivo para impulsar sus propias agendas a cambio de sus votos.

Habrá poco espacio para los desacuerdos intrapartidarios; y los demócratas dejaron claro, durante las primarias presidenciales, que no están todos de acuerdo sobre cómo lograr sus objetivos de salud pública.

En menos de dos semanas, los demócratas dirigirán los comités encargados de establecer la legislación sobre salud y de examinar a los nominados de Biden en esta área.

El control del Comité de Salud, Educación, Trabajo y Pensiones del Senado pasará a la senadora Patty Murray, demócrata de Washington, quien negoció el acuerdo de 2013 con el entonces presidente de la Cámara de Representantes, Paul Ryan, que puso fin a un largo cierre del gobierno, entre otros acuerdos bipartidistas.

En 2019, Murray y el presidente republicano del comité, el senador Lamar Alexander, de Tennessee, introdujeron un amplio paquete legislativo para reducir los costos de salud. Entre sus propuestas se encontraba una iniciativa para bajar los precios de los medicamentos recetados, mediante la eliminación de las lagunas legales que permiten a los fabricantes de medicamentos de marca bloquear a la competencia.

Durante una entrevista, antes de que los demócratas se aseguren el Senado, Murray dijo que el trabajo de su comité se centrará en los problemas que impiden a los estadounidenses recibir un tratamiento médico equitativo y asequible.

La prioridad, dijo, serán las disparidades raciales, evidenciadas por los desproporcionados índices de mortalidad entre las madres de raza negras, y entre las comunidades de color, que sufren los peores impactos de la pandemia de covid-19.

“No todos los que acuden al médico reciben la misma atención, sienten el mismo nivel de comodidad y muchas veces no se les cree”, dijo Murray.

Murray aseguró que presionará a los senadores para que consideren el impacto en las comunidades de color de cada pieza legislativa. “Esa será la cuestión en cada paso que demos”, añadió.

El miércoles 6, pidió a los republicanos que se incorporen a la lucha contra la pandemia “con políticas que ayuden directamente a los que más sufren y que nos ayuden a salir de esta crisis con más fortaleza y justicia”.

“Con una administración Biden-Harris y una mayoría demócrata en el Senado, los desafíos que enfrentamos no serán menores, pero finalmente tenemos la oportunidad de enfrentarlos y comenzar a tomar medidas”, declaró Murray. “Estoy deseando ponerme manos a la obra”.

El Comité de Finanzas del Senado, que supervisa Medicare, Medicaid y las políticas fiscales relacionadas con la salud, estará encabezado por el senador Ron Wyden, demócrata de Oregon.

Si bien el comité HELP también celebrará una audiencia de confirmación para Xavier Becerra, el candidato de Biden a la Secretaría del Departamento de Salud y Servicios Humanos; es el Comité de Finanzas el que votará para avanzar su confirmación.

En diciembre, los republicanos del Senado amenazaron con retrasar la nominación de Becerra antes de que Biden lo anunciara oficialmente. Los republicanos le reprochan a Becerra su falta de experiencia en el campo de la salud, cuestionan su apoyo a un sistema de salud de un solo pagador y se oponen a su defensa del derecho al aborto.

Como fiscal general de California, Becerra se enfrentó a las demandas presentadas por los funcionarios estatales republicanos contra la Ley de Cuidado de Salud A Bajo Precio (ACA).

Pero se espera que la escasa ventaja de los demócratas en el Senado sea suficiente para rechazar las objeciones de los republicanos a la nominación.

El mes pasado, Wyden alabó el compromiso de Becerra para responder a la pandemia, proteger la cobertura de los cuidados de salud y abordar las disparidades raciales; y dijo que esperaba con interés la audiencia de Becerra “para que pueda ponerse a trabajar y empezar a ayudar a la gente durante esta crisis sin precedentes”.

Además, después de meses de denunciar los fracasos de la administración Trump en el manejo de la pandemia, los demócratas controlarán qué proyectos de ley de ayuda se votarán.

El paquete del mes pasado no incluyó sus demandas de más fondos para los gobiernos estatales y locales, y los republicanos de la Cámara de Representantes bloquearon una iniciativa demócrata que pretendía aumentar los cheques de estímulo de $600 a $2,000.

Los demócratas se han unido en sus demandas de más ayuda, aunque a veces han estado en desacuerdo sobre cómo llevarla a cabo.

En el otoño, con las elecciones cerca y sin ningún acuerdo a la vista, los demócratas moderados, que buscaban ganar su propia elección, presionaron a la presidenta de la Cámara de Representantes, Nancy Pelosi, para que abandonara las negociaciones por un paquete de ayuda de $2,2 billones, que los republicanos calificaron como un fracaso, y aprobara una ayuda más modesta pero desesperadamente necesaria.

“Tanto el liderazgo demócrata, como el republicano, ha metido la pata. Todos son responsables”, declaró a Politico el representante Max Rose, demócrata de Nueva York. “Hagan algo ¡Hagan algo!” Rose perdió la reelección.

Voces más progresistas, como la de la representante Alexandria Ocasio-Cortez, demócrata de Nueva York, y el senador Bernie Sanders, independiente de Vermont, han presionado a favor de una ayuda más generosa, con mayores cheques de estímulo.

Más allá de la pandemia, el liderazgo demócrata ha mencionado el precio de los medicamentos como otra área de acción. Pero una de sus propuestas más populares, que autorizaría al gobierno federal a negociar los precios de los medicamentos para quienes están en Medicare, es poco probable que atraiga los votos republicanos que necesitaría.

Cuando los demócratas de la Cámara de Representantes aprobaron una de estas propuestas en 2019, los senadores republicanos aseguraron que ellos nunca la aprobarían.

Los miembros del ala más progresista de los demócratas, por su parte, argumentaron que la propuesta no era suficientemente agresiva.

Sin embargo, después de años de esfuerzos republicanos por socavar ACA, parece probable que la estabilización de la ley pueda cobrar fuerza en un Congreso controlado por los demócratas.

La Cámara de Representantes aprobó, el verano pasado, una legislación destinada a aumentar la cobertura y la asequibilidad, incluyendo la limitación de los costos de los seguros a no más del 8,5% de los ingresos y la ampliación de los subsidios.

Legisladores como Murray y Wyden se han apresurado a señalar que las consecuencias devastadoras de la pandemia, la pérdida de puestos de trabajo y la pérdida de cobertura del seguro, por nombrar sólo dos, han puesto de relieve la necesidad de fortalecer el sistema de salud.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm And a Leg’: How a Former Health Care Executive Became a Health Care Whistleblower

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Former health care executive Wendell Potter spent part of 2020 publishing high-profile apologies for the work he used to do — the lies he said he told the American people for his old employers. These days, he said, he’s also trying to debunk myths he once sold.

“What I used to do for a living was mislead people into thinking that we had the best health care system in the world,” Potter said.

In this episode, Potter talks about his transformation from health care executive to health care whistleblower. His is also a story about the long, messy process of change — whether that’s changing your own life or trying to change a bigger system.

Here’s a transcript of the episode.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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Even With Senate Control, Democrats Will Need Buy-In From GOP on Key Health Priorities

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Democrats have argued for more generous pandemic relief, more pressure on drugmakers to lower prices and more attention to systemic racism in health care. On Jan. 20, with control of the Senate and the House of Representatives, they’ll have the power to choose which health care proposals get a vote in Congress.

The victories of the Rev. Raphael Warnock and Jon Ossoff in Georgia last week gave Democrats two more Senate seats and the upper hand in the Senate’s now 50-50 split. After Vice President-elect Kamala Harris takes the oath of office, she will serve as the tiebreaker as needed — in effect, Democrats’ 51st vote.

But that vote count is too small to eliminate the filibuster, meaning Democrats will not have enough votes to pass many of their plans without Republicans. That will likely doom many Democratic health care proposals, like offering Americans a government-sponsored public insurance option, and complicate efforts to pass further pandemic relief.

It remains to be seen how willing lawmakers are to compromise with one another in the aftermath of a pro-Trump mob’s breach of the Capitol on Wednesday. Thursday, Democrats demanded the president’s removal for inciting rioters who disrupted the certification of President-elect Joe Biden’s victory, assaulted Capitol Police officers and damaged federal property. One demonstrator and a police officer were killed, and three demonstrators died of medical emergencies.

Democrats’ slim margins in the Senate and the House — where they can afford to lose only four votes and still pass legislation — will also give individual lawmakers more leverage, handing those who disagree with party leaders an incentive to push their own priorities in exchange for their votes. There will be little room for intraparty disagreements, and Democrats made it clear during the presidential primaries that they disagree about how to achieve their health care goals.

In less than two weeks, Democrats will lead the committees charged with marking up health care legislation and vetting Biden’s health nominees.

The change will hand control of the Senate Health, Education, Labor and Pensions Committee to Sen. Patty Murray (D-Wash.), who brokered the 2013 agreement with then-House Speaker Paul Ryan that ended a long government shutdown, among other bipartisan deals.

In 2019, Murray and the committee’s Republican chairman, Sen. Lamar Alexander of Tennessee, introduced a wide-ranging package to lower health costs for consumers. Among its proposals was an initiative to lower prescription drug prices by eliminating loopholes that allow brand-name drugmakers to block competition.

In an interview before Democrats secured the Senate, Murray said her committee work will be focused on the problems that prevent all Americans from receiving equitable, affordable treatment in health care. Racial disparities, evidenced by disproportionate mortality rates among Black mothers and among communities of color suffering the worst impacts of the pandemic, will be a priority, she said.

“Not everybody goes into the doctor and gets the same advice, feels the same comfort level and is believed,” Murray said.

Murray said she will press for senators to consider how any piece of legislation will affect communities of color. “It will be the question I ask about every step we take,” she said.

On Wednesday, she called out Republicans for standing in the way of fighting the pandemic “with policies that would directly help those struggling the most and would help us build back from this crisis stronger and fairer.”

“With a Biden-Harris Administration and a Senate Democratic majority, the challenges we face won’t get any less tough — but we’ve finally got the opportunity to face them head on and start taking action,” Murray said in a statement. “I can’t wait to start getting things done.”

The Senate Finance Committee, which oversees Medicare, Medicaid and health-related tax policies, will be run by Sen. Ron Wyden (D-Ore.). While the HELP committee will also hold a confirmation hearing for Biden’s nominee for secretary of the Department of Health and Human Services, Xavier Becerra, it is the Finance Committee that will vote to advance his confirmation.

Senate Republicans signaled they would delay considering Becerra’s nomination before Biden officially announced his name last month. Calling him unqualified due to his lack of a health care background, they questioned his support for a single-payer health care system and opposed his efforts to preserve abortion rights. As California’s attorney general, Becerra led efforts to fight lawsuits brought by Republican state officials against the Affordable Care Act.

But Democrats’ slim edge in the Senate is expected to be enough to drown out Republicans’ objections to the nomination. Last month, praising Becerra’s commitment to responding to the pandemic, protecting health care coverage and addressing racial disparities, Wyden said he looked forward to Becerra’s hearing “so he can get on the job and start helping people during this unprecedented crisis.”

Also, after months of decrying the Trump administration’s failures managing the pandemic, Democrats will control which relief bills get a vote.

Last month’s package did not include their demands for more funding for state and local governments, and House Republicans blocked a Democratic effort to increase stimulus checks to $2,000, from $600.

Democrats have been united in their calls for more assistance, though they have disagreed at times about how to push for it.

In the fall, with the election approaching and no deal in sight, moderate Democrats in tough races pushed for House Speaker Nancy Pelosi to abandon negotiations for a $2.2 trillion relief package that Republicans called a nonstarter in favor of passing more modest but desperately needed relief.

“Every member of the leadership team, Democrats and Republicans, have messed up. Everyone is accountable,” Rep. Max Rose (D-N.Y.) told Politico. “Get something done. Get something done!” He lost his bid for reelection.

More progressive voices like Rep. Alexandria Ocasio-Cortez (D-N.Y.) and Sen. Bernie Sanders (I-Vt.) have been a force for more generous aid, particularly larger stimulus checks.

Beyond the pandemic, top Democrats have mentioned drug pricing as another area ripe for action. But one of their most popular proposals, which would authorize the federal government to negotiate drug prices for those on Medicare, is unlikely to attract the Republican votes it would need. When House Democrats passed one such proposal in 2019, Senate Republicans vowed it would never pass.

Members of Democrats’ more progressive wing, for their part, argued the proposal may not go far enough.

After years of Republican efforts to undermine the Affordable Care Act, though, it looks likely that efforts to stabilize the law could gain more traction under a Democratic-controlled Congress. The House passed legislation last summer aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income and expanding subsidies.

Lawmakers like Murray and Wyden have been quick to point out that the pandemic’s devastating consequences — lost jobs and lost insurance coverage, to name just a couple — have only underscored the need to strengthen the health care system.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: A Look Back at 2020 — What We Learned and Where We’re Headed

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This episode turns the tables: Host Dan Weissmann gets interviewed about what he learned in 2020 and what’s ahead for the show — with T.K. Dutes, a radio host and podcast-maker who is also a former nurse, so she knows a thing or two about the health care system. She chronicled her career transition in an episode of NPR’s “Life Kit.”

During their conversation, Dutes shared stories about life before and after health insurance. She coins what could be a new tagline for “An Arm and a Leg”: “Where there’s money, there’ll be scams.”

Here’s a transcript of the episode.

For more of Dutes’ work, check out “Open World,” a podcast she published recently with Rose Eveleth. The first episode features a reading by and discussion with the writer N.K. Jemisin, who won a MacArthur “genius” award the day after the show came out. (Clearly, the MacArthur folks were listening.)

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Seniors Face Crushing Drug Costs as Congress Stalls on Capping Medicare Out-Of-Pockets


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Sharon Clark is able to get her life-sustaining cancer drug, Pomalyst — priced at more than $18,000 for a 28-day supply — only because of the generosity of patient assistance foundations.

Clark, 57, a former insurance agent who lives in Bixby, Oklahoma, had to stop working in 2015 and go on Social Security disability and Medicare after being diagnosed with multiple myeloma, a blood cancer. Without the foundation grants, mostly financed by the drugmakers, she couldn’t afford the nearly $1,000 a month it would cost her for the drug, since her Medicare Part D drug plan requires her to pay 5% of the list price.

Every year, however, Clark has to find new grants to cover her expensive cancer drug.

“It’s shameful that people should have to scramble to find funding for medical care,” she said. “I count my blessings, because other patients have stories that are a lot worse than mine.”

Many Americans with cancer or other serious medical conditions face similar prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending this year (rising from $6,350 in 2020), except for very low-income beneficiaries.

President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.

That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.

Growing Expense of Specialty, Cancer Medicines

Nearly 70% of seniors want Congress to pass an annual limit on out-of-pocket drug spending for Medicare beneficiaries, according to a KFF survey in 2019. (KHN is an editorially independent program of KFF.)

The affordability problem is worsened by soaring list prices for many specialty drugs used to treat cancer and other serious diseases. The out-of-pocket cost for Medicare and private insurance patients is often set as a percentage of the list price, as opposed to the lower rate negotiated by insurers.

For instance, prices for 54 orally administered cancer drugs shot up 40% from 2010 to 2018, averaging $167,904 for one year of treatment, according to a 2019 JAMA study. Bristol Myers Squibb, the manufacturer of Clark’s drug, Pomalyst, has raised the price 75% since it was approved in 2013, to about $237,000 a year. The company believes “pricing should be put in the context of the value, or benefit, the medicine delivers to patients, health care systems and society overall,” a spokesperson for Bristol Myers Squibb said via email.

As a result of rising prices, 1 million of the 46.5 million Part D drug plan enrollees spend above the program’s catastrophic coverage threshold and face $3,200 in average annual out-of-pocket costs, according to KFF. The hit is particularly heavy on cancer patients. In 2019, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to the JAMA study.

The median annual income for Medicare beneficiaries is $26,000.

Medicare patients face modest out-of-pocket costs if their drugs are administered in the hospital or a doctor’s office and they have a Medigap or Medicare Advantage plan, which caps those expenses.

But during the past several years, dozens of effective drugs for cancer and other serious conditions have become available in oral form at the pharmacy. That means Medicare patients increasingly pay the Part D out-of-pocket costs with no set maximum.

“With the high cost of drugs today, that 5% can be a third or more of a patient’s Social Security check,” said Brian Connell, federal affairs director for the Leukemia & Lymphoma Society.

This has forced some older Americans to keep working, rather than retiring and going on Medicare, because their employer plan covers more of their drug costs. That way, they also can keep receiving financial help directly from drugmakers to pay for the costs not covered by their private plan, which isn’t allowed by Medicare.

‘This Is a Little Nuts’

All this has caused financial and emotional turmoil for people who face a life-threatening disease.

Marilyn Rose, who was diagnosed with chronic myeloid leukemia three years ago, until recently was paying nothing out-of-pocket for her cancer drug, Sprycel, which has a list price of $176,500 a year. That’s because Bristol Myers Squibb, the manufacturer, paid her insurance deductible and copays for the drug.

But the self-employed artist and designer, who lives in West Caldwell, New Jersey, recently turned 65 and went on Medicare. The Part D plan offering the best deal on Sprycel charges more than $10,000 a year in coinsurance for the drug.

Rose asked her oncologist if she could switch to an alternative medication, Gleevec, for which she’d pay just $445 a year. But she ultimately decided to stick with Sprycel, which her doctor said is a longer-lasting treatment. She hopes to qualify for financial aid from a foundation to cover the coinsurance but won’t know until sometime this month.

“It’s just strange you have to make a decision about your treatment based on your finances rather than what’s the right drug for you,” she said. “I always thought that when I get to Medicare age I’ll be able to breathe a sigh of relief. This is a little nuts.”

Given the sticker shock, many other patients choose not to fill a needed prescription, or delay filling it. Nearly half of patients who face a price of $2,000 or more for a cancer drug walk away from the pharmacy without it, according to a 2017 study. Fewer than half of Medicare patients with blood cancer received treatment within 90 days of their diagnosis, according to a 2019 study commissioned by the Leukemia & Lymphoma Society.

“If I didn’t do really well at scrounging free drugs and getting copay foundations to work with us, my patients wouldn’t get the drug, which is awful,” said Dr. Barbara McAneny, an oncologist in Albuquerque, New Mexico, and past president of the American Medical Association. “Patients would just say, ‘I can’t afford it. I’ll just die.’”

The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation.

But Daniel Klein, CEO of the PAN Foundation, which provides drug copay assistance to more than 100,000 people a year, said there are more patients in need than his foundation and others like it can help.

“If you are a normal consumer, you don’t know much about any of this until you get sick and all of a sudden you find out you can’t afford your medication,” he said. Patients are lucky, he added, if their doctor knows how to navigate the charitable assistance maze.

Yet many don’t. Daniel Sherman, who trains hospital staff members to navigate financial issues for patients, estimates that fewer than 5% of U.S. cancer centers have experts on staff to help patients with problems paying for their care.

Sharon Clark, who struggles to cover her cancer drugs, works with the Leukemia & Lymphoma Society counseling other patients on how to access helping resources. “People tell me they haven’t started treatment because they don’t have money to pay,” she said. “No one in this country should have to choose between housing, food or medicine. It should never be that way, never.”

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: 2020 in Review — It Wasn’t All COVID

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COVID-19 was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?” podcast, panelists look back at some of the biggest non-coronavirus stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet.

Among the takeaways from this week’s podcast:

  • The coronavirus pandemic strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the virus.
  • Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.
  • The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year. Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy. Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.
  • Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent. That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.
  • The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021. But the effort could have a hidden consequence: higher insurance premiums.
  • Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.
  • President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court. Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.
  • The gigantic spending and COVID relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network. The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums.

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Retiree Living the RV Dream Fights $12,387 Nightmare Lab Fee

Lorraine Rogge and her husband, Michael Rogge, travel the country in a recreational vehicle, a well-earned adventure in retirement. This spring found them parked in Artesia, New Mexico, for several months.


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In May, Rogge, 60, began to feel pelvic pain and cramping. But she had had a total hysterectomy in 2006, so the pain seemed unusual, especially because it lasted for days. She looked for a local gynecologist and found one who took her insurance at the Carlsbad Medical Center in Carlsbad, New Mexico, about a 20-mile drive from the RV lot.

The doctor asked if Rogge was sexually active, and she responded yes and that she had been married to Michael for 26 years. Rogge felt she made it clear that she is in a monogamous relationship. The doctor then did a gynecological examination and took a vaginal swab sample for laboratory testing.

The only lab test Rogge remembered discussing with the doctor was to see whether she had a yeast infection. She wasn’t given any medication to treat the pelvic pain and eventually it disappeared after a few days.

Then the bill came.

The Patient: Lorraine Rogge, 60. Her insurance coverage was an Anthem Blue Cross retiree plan through her husband’s former employer, with a deductible of $2,000 and out-of-pocket maximum of $6,750 for in-network providers.

Total Bill: Carlsbad Medical Center billed $12,386.93 to Anthem Blue Cross for a vaginosis, vaginitis and sexually transmitted infections (STI) testing panel. The insurer paid $4,161.58 on a negotiated rate of $7,172.05. That left Rogge responsible for $1,970 of her deductible and $1,040.36 coinsurance. Her total owed for the lab bill was $3,010.47. Rogge also paid $93.85 for the visit to the doctor.

Service Provider: Carlsbad Medical Center in Carlsbad, New Mexico. It is owned by Community Health Systems, a large for-profit chain of hospital systems based in Franklin, Tennessee, outside Nashville. The doctor Rogge saw works for Carlsbad Medical Center and its lab processed her test.

Medical Service: A bundled testing panel that looked for bacterial and yeast infections as well as common STIs, including chlamydia, gonorrhea and trichomoniasis.

What Gives: There were two things Rogge didn’t know as she sought care. First, Carlsbad Medical Center is notorious for its high prices and aggressive billing practices and, second, she wasn’t aware she would be tested for a wide range of sexually transmitted infections.

The latter bothered her a lot since she has been sexually active only with her husband. She doesn’t remember being advised about the STI testing at all. Nor was she questioned about whether she or her husband might have been sexually active with other people, which could have justified broader testing. They have been on the road together for five years.

“I was incensed that they ran these tests, when they just said they were going to run a yeast infection test,” said Rogge. “They ran all these tests that one would run on a very young person who had a lot of boyfriends, not a 60-year-old grandmother that’s been married for 26 years.”

Although a doctor doesn’t need a patient’s authorization to run tests, it’s not good practice to do so without informing the patient, said Dr. Ina Park, an associate professor of family community medicine at the University of California-San Francisco School of Medicine. That is particularly true with tests of a sensitive nature, like STIs. It is doubly true when the tests are going to costs thousands of dollars.

Park, an expert in sexually transmitted infections, also questioned the necessity of the full panel of tests for a patient who had a hysterectomy.

Beyond that, the pricing for these tests was extremely high. “It should not cost $12,000 to get an evaluation for vaginitis,” said Park.

Charles Root, an expert in lab billing, agreed.

“Quite frankly, the retail prices on [the bill] are ridiculous, they make no sense at all,” said Root. “Those are tests that cost about $10 to run.”

In fall 2019, The New York Times and CNN investigated Carlsbad Medical Center and found the facility had taken thousands of patients to court for unpaid hospital bills. Carlsbad Medical Center also has higher prices than many other facilities — a 2019 Rand Corp. study found that private insurance companies paid Carlsbad Medical Center 505% of what Medicare would pay for the same procedures.

The bundled testing panel run on Rogge’s sample was a Quest Diagnostics SureSwab Vaginosis Panel Plus. It included six types of tests. Quest Diagnostics didn’t provide the cost for the bundled tests, but Kim Gorode, a company spokesperson, said if the tests had been ordered directly through Quest rather than through the hospital, it was likely “the patient responsibility would have been substantially less.”

According to Medicare’s Clinical Laboratory Fee Schedule, Medicare would have reimbursed labs only about $40 for each test run on Rogge’s sample. And Medicaid would reimburse hospitals in New Mexico similarly, according to figures provided by Russell Toal, superintendent of New Mexico’s insurance department.

But hospitals and clinics can — and do — add substantial markups to clinical tests sent out to commercial labs.

Although private health insurance doesn’t typically reimburse hospitals at Medicare or Medicaid rates, Root said, private insurance reimbursement rates are rarely much more than 200% to 300% of Medicare’s rates. Assuming a 300% reimbursement rate, the total private insurance would have reimbursed for the six tests would have been $720.

That $720 is less than what Carlsbad Medical Center charged Rogge for her chlamydia test alone: $1,045. And for several of the tests, the medical center charged multiple quantities — presumably corresponding to how many species were tested for — elevating the cost of the yeast infection test to over $4,000.

Toal, who reviewed Rogge’s bill, called the prices “outrageous.”

Resolution: Rogge contacted Anthem Blue Cross and talked to a customer service representative, who submitted a fraud-and-waste claim and an appeal contending the charges were excessive.

The appeal was denied. Anthem Blue Cross told Rogge that under her plan the insurance company had paid the amount it was responsible for, and that based on her deductible and coinsurance amounts, she was responsible for the remainder.

Anthem Blue Cross said in a statement to KHN all the tests run on Rogge were approved and “paid for in accordance with Anthem’s pre-determined contracted rate with Carlsbad Medical Center.”

By the time Rogge’s appeal was denied, she had researched Carlsbad Medical Center and read the stories of patients being brought to court for medical bills they couldn’t pay. She had also gotten a notice from the hospital that her account would be sent to a collection agency if she didn’t pay the $3,000 balance.

Fearing the possibility of getting sued or ruining her credit, Rogge agreed to a plan to pay the bill over three years. She made three payments of $83.63 each in September, October and November, totaling $250.89.

After a Nov. 18 call and email from KHN, Carlsbad Medical Center called Rogge on Nov. 20 and said the remainder of her account balance would be waived.

Rogge was thrilled. We “aren’t the kind of people who have payment plans hanging over our heads,” she said, adding: “This is a relief.”

“I’m going to go on a bike ride now” to celebrate, she said.

The Takeaway: Particularly when visiting a doctor with whom you don’t have a long-standing trusted relationship, don’t be afraid to ask: How much is this test going to cost? Also ask for what, exactly, are you being tested? Do not be comforted by the facility’s in-network status. With coinsurance and deductibles, you can still be out a lot.

If it’s a blood test that will be sent out to a commercial lab like Quest Diagnostics anyway, ask the physician to just give you a requisition to have the blood drawn at the commercial lab. That way you avoid the markup. This advice is obviously not possible for a vaginal swab gathered in a doctor’s office.

Patients should always fight bills they believe are excessively high and escalate the matter if necessary.

Rogge started with her insurer and the provider, as should most patients with a billing question. But, as she learned: In American medicine, what’s legal and in accordance with an insurance contract can seem logically absurd. Still, if you get no satisfaction from your initial inquiries, be aware of options for taking your complaints further.

Every state and U.S. territory has a department that regulates the insurance industry. In New Mexico, that’s the Office of the Superintendent of Insurance. Consumers can look up their state’s department on the National Association of Insurance Commissioners website.

Toal, the insurance superintendent in New Mexico, said his office doesn’t (and no office in the state does that he’s aware of) have the authority to tell a hospital its prices are too high. But he can look into a bill like Rogge’s if a complaint is filed with his office.

“If the patient wants, they can request an independent review, so the bill would go to an independent organization that could see if it was medically necessary,” Toal said.

That wasn’t needed in this case because Rogge’s bill was waived. And after being contacted by KHN, Melissa Suggs, a spokesperson with Carlsbad Medical Center, said the facility is revising their lab charges.

“Pricing for these services will be lower in the future,” Suggs said in a statement.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Surprise! Congress Takes Steps to Curb Unexpected Medical Bills

Most Americans tell pollsters they’re worried about being able to afford an unexpected medical bill.

Late Monday, Congress passed a bill to allay some of those fears. The measure is included in a nearly 5,600-page package providing coronavirus economic relief and government funding for the rest of the fiscal year.

Specifically, the legislation addresses those charges that result from a long-running practice in which out-of-network medical providers — from doctors to air ambulance companies — send insured Americans “surprise bills,” sometimes for tens of thousands of dollars.

The legislation itself was a bit of a surprise, coming after two years of debate that featured high-stakes lobbying by all who stood to gain or lose: hospitals, insurers, patient advocacy groups, physicians, air ambulance companies and private equity firms, which own a growing number of doctor practices. A similar effort failed at the last minute a year ago after intense pressure from a range of interests, including those private equity groups.

This time around, no group got everything it wanted. Lawmakers compromised — mainly over how to determine how much providers will ultimately be paid for their services.

“No law is perfect,” said Zack Cooper, an associate professor of public health and economics at Yale who studies health care pricing. “But it fundamentally protects patients from being balance-billed,” he said, referring to out-of-network medical providers billing patients for amounts their insurer did not cover. “That’s a remarkable achievement.”

The bottom line: Patients may still be surprised by the high cost of health care overall. But they will now be protected against unexpected bills from out-of-network providers.

Here’s a rundown on what this legislation means for consumers:

Fewer Surprise Bills

Starting in 2022, when the law goes into effect, consumers won’t get balance bills when they seek emergency care, when they are transported by an air ambulance, or when they receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.

Patients will pay only the deductibles and copayment amounts that they would under the in-network terms of their insurance plans.

Medical providers won’t be allowed to hold patients responsible for the difference between those amounts and the higher fees they might like to charge. Instead, those providers will have to work out with insurers acceptable payments. For the uninsured, for whom everything is out of network, the bill requires the secretary of Health and Human Services to create a provider-patient bill dispute resolution process.

The measure takes aim at situations in which patients have little choice about whether they are in network, including emergencies. A recent survey found 18% of emergency room visits, on average, resulted in at least one surprise bill. (A growing number of emergency rooms are staffed by private equity-owned agencies that sign few in-network agreements.)

The legislative agreement also applies to nonemergency care provided at in-network facilities, where patients receive care and services from out-of-network providers, such as anesthesiologists and laboratories.

Also included in the bar on balance billing is air ambulance transportation, which is among the most expensive medical services, often costing tens of thousands of dollars.

Still, the bill does not extend its consumer protections to the far more commonly used ground ambulance services. But it does call for an advisory committee to recommend how to take this step.

An Option for Consumers to Agree to Balance Billing

In some cases, physicians can balance-bill their patients, but they must get consent in advance.

This part of the bill is aimed at patients who want to see an out-of-network physician, perhaps a surgeon or obstetrician recommended by a friend.

In those cases, physicians must provide a cost estimate and get patient consent at least 72 hours before treatment. For shorter-turnaround situations, the bill requires that patients receive the consent information the day the appointment is made.

In a sense, though, this provision allows consumers to forfeit protection.

Health providers “have to give you a good-faith cost estimate. If you sign that, then you can be billed whatever that physician wants to bill you,” said Jack Hoadley, research professor emeritus in the Health Policy Institute at Georgetown University.

The legislation allows this only in nonemergency circumstances and bars many types of physicians from the practice. Anesthesiologists, for example, can’t seek consent to balance-bill for their services, nor can radiologists, pathologists, neonatologists, assistant surgeons or laboratories.

Payment Will Be Sorted Out in Negotiations

While lawmakers agreed that patients will be held harmless, the real fight was over how to decide what amounts providers would be paid by insurers.

Some groups — including hospitals and physicians — opposed any kind of benchmark or standard to which all bills would be held. On the other side, insurers, employers and consumer groups argued for a benchmark, warning that, without one, providers would angle for much higher payments.

The legislation carves out some middle ground.

It gives insurers and providers 30 days to try to negotiate payment of out-of-network bills. If that fails, the claims would go through an independent dispute resolution process with an arbitrator, who would have the final say.

The bill does not specify a benchmark, but it bars physicians and hospitals from using their “billed charges” during arbitration. Such charges are generally far higher than negotiated rates and bear little or no relation to the actual cost of providing the care.

That was considered a win for insurers, employers and consumer advocates, who argued that allowing billed charges would mean higher prices — potentially driving up premiums — in cases sent to arbitration.

Billed charges “are totally made up” by providers, said Cooper, at Yale. “So, the big deal is that arbitrators are not considering charges.”

But hospitals and doctors won a limit they sought, too.

In last-minute changes over the weekend, they succeeded in barring consideration of Medicare or Medicaid prices during arbitration. Those government payments are often far lower than the negotiated rates paid by insurers and self-insured employers.

Instead, the bill says negotiators can consider the median in-network prices paid by each insurer for the services in dispute. Other factors, too, can come into play, including whether the medical provider tried to join the insurers’ network, and how sick the patient was compared with others. It also allows consideration of network rates a provider may have agreed to during the previous four years, which might help some high-priced services, such as air ambulances, remain costly even in arbitration.

Overall, the legislation “did include some wins for provider groups,” said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy.

Even so, he expects the legislation will help insurers contain some prices and provide “some downward pressure on premiums, even if relatively minor at the end of the day.”

State Laws May Change

More than 30 states have enacted some type of surprise billing protections, but only 17 are considered comprehensive, according to the Commonwealth Fund.

Comprehensive states — California, New York and New Mexico, for example — extend protections to cover nonemergency situations at in-network hospitals, but that isn’t the case in less comprehensive states, the fund noted.

And state laws have another limitation: They apply only to certain types of insurance, and often do not cover Americans who get their health insurance through self-insured employers, which tend to be midsize to large companies because they fall under federal rules.

But the new federal rules will cover most types of insurance plans, including those offered by self-insured employers.

“States can’t fully deal with these situations, but this covers it,” said Hoadley, at Georgetown.

Still, some provisions in state law, such as how to determine a payment, differ from the federal law. In such cases, the federal law defers to states.

Statehouse lawmakers may eventually alter their legislation or adopt new proposals to avoid confusion, said policy experts. If they don’t, they could be left with rules that affect people differently depending on whether their insurance comes through a large self-insured employer or directly from an insurance plan subject to state law. “I would be surprised if, over time, states don’t just glom onto the federal law,” said Adler.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: All I Want for Christmas Is a COVID Relief Bill

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Congress appears to be inching ever closer to agreement on a long-delayed COVID-19 relief bill, which would extend unemployment insurance and other emergency programs set to expire in the next several days. That bill, however, apparently will not include the top-priority items for both political parties: business liability protections supported by Republicans and aid to states and localities sought by Democrats.

The bill is likely to be part of a giant spending bill to keep the federal government funded for the rest of the fiscal year. And it might include a last-minute surprise: legislation to put an end to “surprise” medical bills sent to patients who inadvertently obtain care outside their insurance network.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rebecca Adams of CQ Roll Call and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Congress has essentially agreed on a federal spending bill for the rest of the fiscal year — which began in October. But it will likely wait as lawmakers continue squabbling over the COVID relief package, with negotiations now centering on small details.
  • Republicans for months have been hesitant to move forward on a bill that would provide more relief for consumers affected by the pandemic because party leaders did not like Democrats’ insistence that it include more state and local aid. But that provision has been jettisoned, so Republicans are less opposed to the measure. Plus, they see a political downside to holding up the bill: Their two Georgia candidates for Senate — facing Democratic opponents in a special runoff election — are being hammered on the issue.
  • The compromise on surprise medical bills came after supporters secured agreement among Democrats who had favored varying remedies and all the committees in the House and Senate on the bill, a consensus that was forged with major concessions by progressives.
  • But doctors’ groups and other industry critics are still attacking the surprise billing proposal — even though many observers see the bill as tilted in their favor over insurers — so its passage is not guaranteed. Supporters are banking on the looming end of the congressional session to move the measure over the finish line.
  • Vice President Mike Pence announced he will get vaccinated against COVID-19 in public this week in hopes of convincing anyone skeptical about the shots that they are safe. President-elect Joe Biden is planning to do the same soon. But this is a difficult stance for politicians. They don’t want to look as if they are pushing themselves ahead in line, but they also want to normalize the use of the vaccine.
  • About 200 state and local public health leaders have quit or been fired because of public opposition to measures to curb the coronavirus. Although President Donald Trump has reined in his criticism of some of these officials and their efforts, the opposition is still strong. Those critics may be buttressed by fears that new restrictions imposed to control the surging virus will hurt the economy.

Also this week, Rovner interviews Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, about the future of employer-provided health insurance.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Texas Monthly’s “Texas Wedding Photographers Have Seen Some $#!+,” by Emily McCullar

Alice Miranda Ollstein: The New York Times’ “‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C.,” by Noah Weiland

Mary Agnes Carey: NPR’s “How Do We Grieve 300,000 Lives Lost?” by Will Stone

Rebecca Adams: Bloomberg News’ “White House Official Recovers From Severe Covid-19, Friend Says,” by Jennifer Jacobs

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As Congress Bickers Over Pandemic Relief, Flight Attendant’s Life Is in a Holding Pattern

Troy Muenzer has seen the damage that COVID can do. A flight attendant who was diagnosed with a “suspected” case of the deadly virus, Muenzer, 32, endured months of lingering breathing problems; hefty, unexpected medical bills; lost wages, then furlough; and, earlier this month, the loss of his health insurance.

Last week, his bank account was hacked, causing him to lie awake one night worrying he wouldn’t be able to get back all that 2020 has taken. “From everything that’s happened this year, it just seems like it’s never-ending,” he said.

At the beginning of the pandemic, Congress passed several relief bills to help the country’s companies and its workforce: business grants and loans, paycheck protection for furloughed workers, one-time stimulus checks for taxpayers, expanded unemployment benefits. Much of the aid is set to expire by year’s end, if it hasn’t already.

This week, Muenzer’s furlough checks will stop coming. His monthly unemployment check is not enough to cover food and rent. He gave up his health insurance earlier this month because he could no longer afford the premium.

A little over two months ago, just before cutting his hours from few to none, his employer — a major airline — told him Congress could save his job. But lawmakers have shown they can’t, or won’t, put partisan politics aside to help the millions of Americans like Muenzer suffering the devastating impacts of the pandemic.

The chances for another round of pandemic relief before the end of the year look grim. Senate Majority Leader Mitch McConnell has signaled that Republicans could not accept a $908 billion bipartisan compromise written by moderates. Last spring, House Democrats introduced a proposal more than three times larger that they said was necessary to tackle the pandemic. Congress approved its last substantial relief bill nearly eight months ago.

Muenzer first got blindsided by COVID-19 in March. He was on a business trip, and as he got ready for bed in his hotel room, he began having trouble breathing. A former college football player who normally ran near his home by Lake Michigan, he lay awake, short of breath and terrified he would die in his sleep.

When the pandemic first gripped the nation, he had taken what precautions he could but was not permitted to wear a mask while working crowded flights. The Centers for Disease Control and Prevention did not recommend that Americans wear masks in public until April 3, but Muenzer was already sick.

Muenzer notified his employer that he had COVID symptoms and isolated himself at home. A telehealth doctor told him he needed in-person medical attention, but he was afraid he couldn’t afford it. He was already burning through his sick days.

Meanwhile, on April 14, with COVID cases exploding in cities like New York and San Francisco and among close-quartered groups like nursing homes and prisons, McConnell announced the Senate would extend its already weeks-long recess on the advice of public health officials. The day before, Democratic leaders said the House would do the same.

Congress had just passed a record $2 trillion stimulus package, its third relief measure. With House Democrats calling for more, including worker protections and medical leave, Rep. Kevin McCarthy of California, the House Republican minority leader, said it was too soon to talk about more aid. “I wouldn’t be so quick to say you have to write something else,” he said, according to NPR. “Let’s let this bill work.”

Muenzer did benefit from those early interventions. He received the one-time $1,200 stimulus check. But it barely made a dent in the wages he had lost being out sick, let alone once passenger demand cratered and the airline reduced his hours.

His employer was one of many companies that accepted help from the government on the condition they would temporarily hold off on furloughing employees. Muenzer was furloughed Oct. 1.

Muenzer has been receiving unemployment since then. But the extra $600 Congress gave the unemployed early in the pandemic expired long before that, and his monthly $1,200 unemployment check is not enough to cover his rent in Chicago, let alone food or medical care.

The relief legislation also required Muenzer’s private insurance plan to cover testing to detect or diagnose COVID-19 without Muenzer being required to pay anything. But that didn’t work.

The day the Senate extended its recess, Muenzer was so short of breath that he went to Northwestern Memorial Hospital’s emergency room. There, health care workers in full protective suits examined him and administered a chest X-ray. Diagnosed as “suspected COVID” and sent home to quarantine for 14 days, he did not get a COVID test.

With those critical diagnostic tests in short supply across the country at that time, they were reserved for seniors or patients with serious health conditions.

Muenzer received a bill for $108.59 for that emergency room visit, which he paid. Then another arrived, this one for $806.85 for the chest X-ray and other emergency room charges. Such billing problems were not unusual in the early days of the pandemic. Because COVID tests were not administered widely, patients like Muenzer lacked the official COVID diagnosis that required the medical system to zero out patient charges.

“I went to the COVID testing sign,” Muenzer said. “Then I didn’t even get tested and still got billed all that money.”

Muenzer was fortunate: A local television reporter heard about his problems and called the billing department herself. Though he had been fighting the bills for weeks, that day, the hospital returned Muenzer’s calls, blaming the problem on a coding error and assuring him his bills would be covered. But the hospital never returned his first payment.

When the payroll protection program’s conditions expired on Oct. 1, thousands of pilots, flight attendants like Muenzer and other airline employees — whose hours had already been trimmed — were furloughed. Muenzer said they were told the airline may be able to hold onto them a little longer, if Congress could pass another relief bill.

Indeed, Congress had considered legislation that would specifically bail out the airline industry. Muenzer watched as lawmakers debated bills that could have saved his job. But he did not overtly root for the legislation to pass. “It felt almost selfish,” he said. “Everybody’s hurting.”

Muenzer’s employer will stop sending him furlough pay on Dec. 15. Because it was calculated by averaging his pay for the past year, and his pay is based on flight hours, it wasn’t much. And given he has barely worked since he began feeling sick in March, his average work hours dropped significantly. He has tried to find a new job, but no luck yet.

But he feels lucky because he received furlough pay at all. He feels lucky because the hospital reduced his COVID testing bill to just $109. He feels lucky because he has family who can help him.

His company has assured its furloughed employees that they hope to bring them back in waves next year, if a vaccine is successful, if customer demand goes up again and if Congress can pass a relief bill.

That’s a lot of ifs at the moment — especially that last one, with Congress at a partisan logjam over a new COVID stimulus bill as it also tries to close out business for the year. Republicans are pushing for broader protections for businesses that could be sued if workers or customers become infected with the coronavirus. Democrats are pushing for funding for state and local governments battling the pandemic. Some lawmakers are also pushing for another round of one-time, $1,200 stimulus checks.

Even the bipartisan compromise would boost unemployment by only $300 a week through April. But it also includes support for the transportation sector, including airlines.

When he isn’t drowning out his anxieties watching Netflix, he keeps a close eye on Congress, “praying for something to happen.” It has been “very stressful, to say the least,” he said, “to feel like your life depends on the decisions of people in political power.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Shopping for Health Insurance? Here’s How One Family Tried to Pick a Plan

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When host Dan Weissmann and his wife set out to pick a health insurance plan for next year, they realized that keeping the plan they have means paying $200 a month more. But would a “cheaper” plan cost them more in the long run?  It depends. And the COVID pandemic makes their choice a lot more complicated.

After trying to puzzle it out, Weissmann debriefs with Karen Pollitz, a health insurance expert at KFF, who knows about the angst of medical bills from personal experience.

Health insurance can be painful, but the alternative ― not having health insurance ― is so much worse. If you want to go deeper on health insurance, you might want to check out these episodes from the first season of the podcast:

  • In “Why You (and I) Will Likely Pick the Wrong Health Insurance,” we learn: Smart economists have proved it’s actually super hard — even they aren’t sure they’ll pick correctly.
  • In an episode inspired by KHN reporter Jenny Gold, we learn about insurance companies’ price-gouging. And often we end up paying the price.
  • In the first-ever episode of this show, Weissmann’s family confronts the big puzzle: Can we even get insurance that’ll work for us?
  • In “A ‘Deal’ on Health Insurance Comes With Troubling Strings,” we go on a journey with a kinda-famous “financial therapist” who says she gets rattled when it comes to picking health insurance. And she’s pretty uncomfortable — morally, personally — with some of the choices she’s made. (Also, Weissmann’s family makes another cameo.)

And here are some other helpful big-picture takes:

Want to go a lot deeper? Especially if you’re actually looking at buying health insurance, maybe on the Obamacare exchange?

Weissmann found healthcare.gov to be super usable this year, way better than the last time he checked.

“I punched in the answers to a few questions, and got to quickly tell it which doctors our family sees (and what meds we take) … and it provided a clear list that showed which plans cover our docs, how much they would cost us, etc.,” he said.

  • Subsidies are available for Affordable Care Act plans. KFF has this explanation of how they work. It’s a slog, but thorough. Print it out, grab a snack and settle in. This bit of research explains that a lot of people qualify for a plan with no premium. (KHN, which co-produces “An Arm and a Leg,” is an editorially independent program of KFF.)
  • KFF has a whole database of frequently asked questions about the ACA. Hundreds of Q’s and A’s, including 180-plus in Spanish.
  • Also great, also very thorough: The Georgetown University Center on Health Insurance Reforms has a whole site full of resources for navigating the ACA. (It’s actually for “navigators” — folks who help civilians understand the sign-up process.)

That’s a lot, right? Picking a plan can be overwhelming. But don’t let it get you down.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Obamacare Alum Andy Slavitt Takes Stock of the COVID Pandemic — So Far

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Andy Slavitt has spent much of 2020 talking with almost everybody who knows anything about the COVID-19 pandemic — and sharing what he learns in real time, first on Twitter, then on his pandemic podcast, “In the Bubble.

To do our own podcast episode about what we’ve learned so far and what we might expect next, Slavitt was the person to speak with.

He is a former head of the Centers for Medicare & Medicaid Services during the final years of the Obama administration.

Slavitt shared some of the cost-side realities of vaccines and testing. Then there was an uncomfortable guest-host moment about the characterization of his role as founder of a venture capital firm — before the conversation got back on track and he shared thoughts on the role of profit and health care.

“We’ve created some of the worst excesses, and we’re not getting the basic job done. Health care is not affordable to people,” Slavitt said.

Given the choice, he said, he would pick a health system that covers everybody even if it were a little worse than the current system, versus one that is very expensive and leaves many people without health care. 

“I’d be, ‘I’m all over the socialist side,’” he said. “If you asked me, though, what do I think are the ingredients to a successful health care system? I would say it includes innovation.”

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Think Your Health Care Is Covered? Beware of the ‘Junk’ Insurance Plan

Looking back, Sam Bloechl knows that when the health insurance broker who was helping him find a plan asked whether he’d ever been diagnosed with a major illness, that should have been a red flag. Preexisting medical conditions don’t matter when you buy a comprehensive individual plan that complies with the Affordable Care Act. Insurers can’t turn people down or charge them more based on their medical history.

But Bloechl, now 31, didn’t know much about health insurance. So when the broker told him a UnitedHealthcare Golden Rule plan would cover him for a year for less than his marketplace plan — “Unless you like throwing money away, this is the plan you should buy,” he recalls the agent saying — he signed up.

That was December 2016. A month later Bloechl was diagnosed with stage 4 non-Hodgkin’s lymphoma after an MRI showed tumors on his spine.

To Bloechl’s dismay, he soon learned that none of the expensive care he needed would be covered by his health plan. Instead of a comprehensive plan that complied with the ACA, he had purchased a bundle of four short-term plans with three-month terms that provided only limited benefits and didn’t cover preexisting conditions.

Because they tend to be less expensive, short-term plans continue to find buyers, and they have been championed by the Trump administration, which has loosened restrictions on them, as an alternative for consumers.

With this year’s open enrollment period well underway, millions of people are looking for coverage on the federal and state marketplaces. Sometimes it’s hard to tell the difference between comprehensive plans sold there and “junk” plans with limited benefits and coverage restrictions.

“These plans continue to proliferate,” said Cheryl Fish-Parcham, director of access initiatives at Families USA, a consumer health care advocacy organization. “People need to be careful, whether they’re buying by phone or on a website.”

Bloechl assumed he was buying a comprehensive plan that would cover him for a life-threatening illness, although at the time he had no inkling he was sick. But when doctors said Bloechl needed a stem cell transplant, Golden Rule denied the request.

The reason: He had visited a chiropractor for back pain before he bought the plan. Bloechl had blamed the pain on the heavy lifting that came with running his Chicago landscaping business. But Golden Rule argued that he had sought medical treatment for a preexisting condition — cancer — so the plan didn’t have to cover it. It didn’t matter that he hadn’t been diagnosed when he purchased it.

The insurer didn’t cover any of his other bills for chemo and radiation either. Bloechl appealed the decision, but his appeals failed. He had more than $800,000 in bills for care — and that’s before the stem cell transplant he desperately needed.

“It’s just disgusting that these companies expect Joe Schmo or a guy like me to interpret [these policies] and then get screwed in the end,” Bloechl said.

UnitedHealthcare refused to discuss this case with KHN unless Bloechl signed a statement waiving his right to privacy. But he told KHN he did not feel comfortable signing a legal document provided by the insurer.

“Our agents work with individuals to help them understand their health insurance options and select a plan that best meets their needs,” said UnitedHealthcare’s communications director, Maria Gordon Shydlo, in an email. “We inform each individual of their coverage options, including associated costs, network size and if the selected plan covers pre-existing conditions. We adhere to a stringent application process that helps ensure consumers understand the plan they are purchasing before they make a final decision.”

Consumer advocates have long sounded alarm bells about short-term and other plans that don’t comply with the Affordable Care Act rules that require plans to provide comprehensive benefits to all comers, regardless of their health, and prohibit placing annual or lifetime dollar limits on coverage. ACA-compliant plans can also be purchased outside the marketplace, however, and that’s where shoppers may run into trouble, thinking they’re buying comprehensive coverage when they’re actually buying something much more limited.

“It’s a little bit of the Wild West out there,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “We often get calls about these products, and sometimes it can be challenging to figure out what they even are.”

Short-term plans have garnered much attention in recent years. In 2017, the Obama administration limited their duration to less than three months to discourage people from relying on these limited plans for primary coverage rather than as a temporary coverage bridge for people switching plans, as intended. But these plans were championed by the Trump administration as a cheaper option for consumers, and it issued a rule in 2018 that permitted short-term plans with terms of up to 364 days, with an option to renew for up to 36 months. The rule requires short-term plan materials to explain that the plans are not comprehensive insurance and may not cover some medical costs.

Such plans can be appealing to healthy people who don’t expect to need medical care. But as Bloechl’s experience shows, life can throw curveballs.

“Our patients are often young and healthy,” said Ryan Holeywell, senior director of advocacy communications at the Leukemia & Lymphoma Society.

Some states restrict or even prohibit the sale of short-term plans on the individual market.

But these short-term plans are just the tip of the iceberg.

There are fixed indemnity plans that pay out a certain amount — $100 a day for a limited hospital stay or $150 for an OB-GYN visit, for example — that may not come close to covering the actual costs.

Accident and critical illness plans provide lump-sum cash benefits when people experience medical emergencies like a heart attack or stroke under certain circumstances.

Cancer-only plans may provide hospitalization coverage but not cover other services. “You may be treated with chemo and radiation but never go to the hospital,” said Anna Howard, a policy principal at the American Cancer Society’s Cancer Action Network. “So, the policy may never pay out.”

Then there are bundled plans that combine options, such as a short-term plan along with a prescription drug discount card and cancer coverage.

Unfortunately, consumers can’t always rely on insurance brokers to give them accurate information or steer them to comprehensive coverage, as Sam Bloechl discovered.

In August, the federal Government Accountability Office published a report about the experiences of “secret shoppers” who called 31 health insurance sales representatives and asked about plans, saying they had preexisting conditions such as diabetes and heart disease. In more than a quarter of cases, the sales reps “engaged in potentially deceptive marketing practices,” the report found, including falsely claiming that drugs such as insulin were covered, or offering a plan that didn’t cover preexisting conditions.

One reason brokers might encourage consumers to buy non-ACA plans: higher commissions.

“In our survey of brokers, they do report they pay higher commissions than ACA plans,” Corlette said. Some brokers reported they avoid noncompliant plans, however, because they pose risks for consumers.

The National Association of Health Underwriters, an organization for health insurance and employee benefits professionals, did not respond to a request for information and comment.

Consumers can be sure they’re getting a comprehensive, ACA-compliant plan if they buy it from marketplaces set up by that health law, Howard said.

Brokers can help people understand their options and buy a plan, including plans that comply with the ACA, but picking a broker can be challenging.

“Ideally go to someone in a brick-and-mortar building who has to bump into you in the grocery store,” Corlette said.

After his experience with Golden Rule, Sam Bloechl decided his best option was to offer a group plan to workers at his small landscaping company that he could also enroll in. He worked with a different broker, and he had lawyers look over the policies he was considering. He wanted to be sure that whatever plan he bought would cover his stem cell transplant.

The new plan did cover it. And by the time he went to work out payment on his $800,000-plus bill, his income had declined so much because of his illness that he qualified for charity care. The hospital wrote off his bill.

His cancer is in remission.

But the experience with the short-term policy still rankles. “Charity care picked up the one bill and [UnitedHealthcare Golden Rule’s] competitor paid for the transplant,” he said. “They got off the hook without paying a dime.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: Who Will Run the Biden Health Effort?

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The quadrennial guessing game about who will get what health job in a new presidential administration has taken on a new urgency in 2020 as the COVID-19 pandemic continues to rage.

Meanwhile, as two promising vaccine candidates inch closer to approval, the federal government is gearing up for the immense effort of delivering two shots to as many Americans as they can.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • After naming his national security and economic teams, President-elect Joe Biden is expected to focus next on his health care officials. Those names likely will be unveiled by next week. But even without a full list of appointees, it’s clear Biden will have strong health experience in the White House with his choice of Ron Klain as chief of staff and Neera Tanden to head the Office of Management and Budget. Klain was the Ebola response coordinator for President Barack Obama, and Tanden worked on the Affordable Care Act negotiations.
  • The departure of Dr. Scott Atlas from the list of President Donald Trump’s key advisers does not mean his influence is over. His advocacy for policies that opened the economy — even if they caused wider spread of the coronavirus — and an acceptance of attempting to achieve herd immunity by letting the virus spread have gained traction in some states and among conservatives.
  • Democratic House and Senate leaders endorsed efforts by a bipartisan group of lawmakers for a $900 billion COVID relief bill. But Senate Majority Leader Mitch McConnell has not yet said he will sign on to the effort, nor has Trump.
  • Public health officials are concerned that many people will be hesitant to get a coronavirus vaccine, if one is approved by the Food and Drug Administration, because the effort has been so politicized. Trump’s hard press to get the vaccine out before the election alarmed some consumers, who fear that the usual careful procedures were rushed. But if approved, a vaccine would be highly touted by health officials and celebrities.
  • What’s not known about the rollout of the vaccine is whether private companies and schools will make inoculation mandatory for workers and children.
  • Among the news items that may have been overlooked during Thanksgiving celebrations, Canada announced it would bar the exports of drugs to the U.S. if it would cause shortages there. Trump and some states, including Florida, have been pushing for importation programs to help lower drug costs in the U.S.
  • Also last week, the 5th Circuit Court of Appeals agreed that Texas could remove Planned Parenthood from its list of Medicaid providers and said that patients in the federal-state health program do not have a right to challenge state decisions on which providers are accepted into the program. The decision is likely headed to the Supreme Court.

Also this week, Rovner interviews KHN’s Julie Appleby, who wrote the latest KHN-NPR “Bill of the Month” feature — about a boy, a bicycle accident and a really big bill. If you have an outrageous medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: ProPublica’s “States With Few Coronavirus Restrictions Are Spreading the Virus Beyond Their Borders,” by David Armstrong

Margot Sanger-Katz: Science Magazine’s “Public Needs to Prep for Vaccine Side Effects,” by Meredith Wadman

Paige Winfield Cunningham: Politico’s “Biden’s Chief of Staff Has Battled Pandemics Before. Here’s How He Plans to Beat This One,” by Alice Miranda Ollstein

Alice Miranda Ollstein: The New York Times’ “Prisons Are Covid-19 Hotbeds. When Should Inmates Get the Vaccine?” by Roni Caryn Rabin

To hear all our podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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During ACA Open Enrollment, Picking a Plan Invites New COVID Complications

People buying their own health insurance have even more to think about this year, particularly those post-COVID-19 patients with lingering health concerns, the “long haulers,” who join the club of Americans with preexisting conditions.

What type of plan is best for someone with an unpredictable, ongoing medical concern? That question is popping up on online chat sites dedicated to long haulers and among people reaching out for assistance in selecting insurance coverage.

“We are hearing from a lot of people who have had COVID and want to be able to deal with the long-term effects they are still suffering,” said Mark Van Arnam, director of the North Carolina Navigator Consortium, a group of organizations that offer free help to state residents enrolling in insurance.

The good news for those shopping for their own coverage is that the Affordable Care Act bars insurers from discriminating against people with medical conditions or charging them more than healthier policyholders. Former COVID patients could face a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression. Although some of these issues will dissipate with time, others may turn out to be long-standing problems.

So sign up, said Van Arnam and others to whom KHN reached out for tips on what people with post-COVID-19 should consider when selecting coverage. There’s no one-size-fits-all answer, but they all emphasized the need to consider a wide range of factors.

But don’t delay. Open enrollment in ACA plans is ongoing until Dec. 15 in most states — longer in some of the 14 states and the District of Columbia that run their own marketplaces.

Here are tips if you are shopping for health insurance, especially if you are a COVID long hauler or have other health issues:

Make sure to select an ACA-qualified plan.

It may be tempting to consider other, often far less expensive types of coverage offered by insurers, brokers, organizations and private websites. But those non-ACA plans offer less comprehensive coverage — and are not eligible for federal subsidies to help people who qualify cover the cost of the premiums. These are key factors for patients experiencing medical problems after battling the coronavirus.

Short-term, limited-duration plans, for example, are cheaper, but the insurers offering them don’t have to accept people with preexisting conditions — or, if they do enroll those people, the plans don’t cover the members’ medical conditions. Many short-term plans don’t cover benefits such as prescription drugs or mental health care.

Another type of plan that doesn’t meet ACA requirements are “sharing ministries,” in which members agree to pay one another’s medical bills. But such payments aren’t guaranteed — and many don’t cover anything considered preexisting.

Shop around to consider all the ACA plans available in your region.

This will help you meet your post-COVID medical needs while also getting the best buy.

Comparison-shopping also lets consumers adjust their income information, which may have changed from last year, especially after being sick, and could affect subsidy levels for those eligible for assistance in purchasing a plan.

Under the ACA, subsidies to offset premium costs are available on a sliding scale for people who earn between 100% and 400% of the federal poverty level. That range next year is $12,760 to $51,040 for an individual and $26,200 to $104,800 for a family of four.

Networks matter. Look for your doctor or hospital in the plan.

One of the first things to do once you’ve narrowed down your choices of plans is to dig deeper to see if the doctors, specialists and hospitals you use are included in those plans’ networks. Also, check plan formularies to see if the prescription medications you take are covered.

Many insurance plans don’t have out-of-network benefits, except for emergency care. That means if a doctor or hospital doesn’t participate in the network, consumers must switch medical providers or risk huge bills by receiving out-of-network care. This should be a concern for long haulers.

This subset of COVID patients who report lingering health concerns may need to see a range of specialists, including pulmonologists, cardiologists, neurologists, rheumatologists and mental health professionals.

“So, you are already talking about five or six,” said Erika Sward, assistant vice president for national advocacy at the American Lung Association.

To check the network status of medical providers, go to the healthcare.gov website, which will direct you to your state site if you are in one of the 14 states or the District of Columbia, which run their own. Enter a ZIP code and some other information to start looking for available plans.

Narrow the search using the “add your medical providers” button on healthcare.gov, or access each plan’s “provider directory” under plan documents to see which specific doctors and hospitals are included. To be safe, Sward said, call each office to make sure they are participating with that insurer next year.

Don’t just look at premium costs: Deductibles also matter.

Consumers must pay deductible amounts before the bulk of financial assistance kicks in. That can be a big hit, especially for those who need complex care all at once or very expensive prescription drugs. Long haulers, as well as others with chronic health conditions, often fall into this category.

Median deductibles — the mark at which half cost more and half cost less — vary across the different “tiers” of ACA plans, hitting $6,992 for bronze plans; $4,879 for silver plans and $1,533 for gold plans, according to an analysis by the Centers for Medicare & Medicaid Services.

Generally, plans with higher deductibles have lower monthly premiums. But getting past the deductible is a challenge for many.

What’s best for those with ongoing health conditions depends on individual circumstances.

“Balancing the deductibles and premiums is a really important consideration for consumers,” said Laurie Whitsel, vice president of policy research and translation at the American Heart Association.

Those with ongoing health conditions need to carefully weigh the expected annual out-of-pocket costs for various health plans, given that they may well be moderate to high users of health services. Healthcare.gov has a financial estimator tool that can help with the decision. Consumers can select whether they think they will have low, medium or high medical use next year to see the estimated total annual costs of each plan.

Frequent users of health services may discover that plans that initially seem least expensive, based solely on the premium or the deductible, may be costlier once all out-of-pocket factors are considered.

Finally, insurers in some markets are touting zero-deductible plans.

Instead of an annual deductible, such policies have higher copayment or coinsurance amounts each time a patient sees a doctor, gets a test or has surgery. Those can range from $50 to more than $1,000, depending on the visit, test or service provided. Still, for some costly services, those payments may amount to less than paying a deductible.

Broker John Dodd in Columbus, Ohio, said such plans appeal to some people who don’t want to have to shell out thousands of dollars in deductible payments before their insurance picks up the bulk of medical costs.

Still, he cautioned that many of the zero-deductible plans do have what can be a sizable deductible — hundreds or even thousands of dollars — for brand-name prescription drugs.

Long haulers should weigh those factors carefully, as such zero-deductible plans may be more suited to those who don’t expect to use a lot of medical care.

Read the fine print, because there are other costs.

While plans may tout similar premiums, their dissimilar structures could affect how much a consumer will shell out in flat-dollar copayments or percentage coinsurance to see a doctor, pick up a prescription, get a blood test or spend the night in the hospital. This is, again, something long haulers should focus on.

These details are spelled out in the plan’s “summary of benefits,” a required document under the ACA, which can be found on healthcare.gov or insurers’ websites.

Still, ACA plans limit how much a consumer must pay out-of-pocket for the year. Next year, the maximum is $8,550 for an individual or $17,100 for a family plan.

Ask for help.

While services such as Van Arman’s navigator program have seen stiff budget cuts during the past few years, consumers there and in many states still have access to online or phone help. Healthcare.gov has a “find local help” button that can refer people by ZIP code to navigators, assisters and brokers.

Finally, those affected by COVID who miss the open enrollment deadline can request an extension under rules that allow special enrollment for emergencies or disasters.

“It’s not a guarantee and you have to telephone the call center and ask for it,” said Karen Pollitz, a senior fellow at KFF.

Still, she said, it’s best to sign up before Dec. 15.

“Just get it done,” Pollitz said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: How to Avoid a Big Bill for Your COVID Test

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Tests for the coronavirus are supposed to be free. And, usually, they are. But sometimes … things happen. Here’s how to keep those things from happening to you.

New York Times reporter Sarah Kliff has been asking readers to send in their COVID-testing bills. She’s now seen hundreds of them, and she ran down for us the most common ways things can go sideways, and how to avoid them.

First off, she said: “I don’t want people to think, ‘Holy crap,  I should just not get tested for coronavirus because it’s going to cost me a ton of money.’ You absolutely should. And the odds are that you will not get a surprise bill, and it will cost zero dollars.” Still, if only 2% of people end up with a surprise bill and a million people a day are getting coronavirus tests, that’s a lot of surprise bills, she noted.

Kliff’s top tip is to avoid getting a test in an emergency room, where you might get charged a “facility fee” that your insurance doesn’t cover.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.


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Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Were You Notified About Missing Tax Forms for Your ACA Subsidy? Blame COVID.

The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.

As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.

When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.

“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”

Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.

Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.

State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.

People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.

Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.

“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”

Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.

Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.

According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.

Straw recommends a more hands-on approach.

“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.

Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”

Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)

Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.

That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)

Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.

Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.

After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.

He hopes that’s the end of it.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Surprise Federal Drug Rule Directs Insurers to Reveal What They Pay for Prescription Drugs

Health insurance companies will have to give their customers estimated out-of-pocket costs for prescription drugs and disclose to the public the negotiated prices they pay for drugs, under an unexpected new Trump administration rule.

The administration said those requirements, part of a broader rule issued Oct. 29 forcing health plans to disclose costs and payments for most health care services, will promote competition and empower consumers to make better medical decisions.

The new rule does not, however, apply to Medicare or Medicaid.

The drug price provisions, which would not begin until 2022, were a surprise because they were not included in the original proposed rule issued in 2019.

It’s the departing Trump administration’s most ambitious effort to illuminate the complex, secret and lucrative system of prescription drug pricing, in which health plans, drug manufacturers and pharmacy benefit management firms agree on prices. The administration and Congress have tried and failed to reform part of that system — the rebates paid by drugmakers to the pharmacy benefit managers to get their products onto insurance plan formularies. Those payments, which some call kickbacks, are widely blamed for driving up costs to patients.

Patient advocates and policy experts, while generally supportive of the administration’s transparency concept, are divided on the cost-saving value of the new rule. Many say Congress needs to take broader action to curb drug prices and cap patient costs. Groups representing drugmakers, pharmacy benefit managers and commercial health plans have denounced the initiative, saying it will damage market competition and raise drug prices.

Advocates say the new rule will help patients in private health plans, including employer-based plans, and their physicians choose less expensive medications. It may even enable health plans to buy drugs more cheaply for their members. Three in 10 Americans say they have opted not to use a prescribed drug as directed because of the high cost, according to a KFF survey last year. (KHN is an editorially independent program of KFF.)

Under the new federal rule, starting in 2024 an insurance plan member can request and receive estimates of out-of-pocket costs for prescription drugs, both online and on paper, taking into account the member’s deductible, coinsurance and copays. Insurers say most plans already offer such cost-estimator tools.

Helping patients find drugs that cost them less could boost their compliance in taking needed medicines, thus improving their health.

“You can call your insurer now and ask what your copay is,” said Wendy Netter Epstein, a health law and policy professor at DePaul University in Chicago. “Patients often don’t do that. Whether or not this has an impact depends on whether patients take the initiative to obtain this information.”

Starting in 2022 under the new rule, private plans also will have to publish the prices they negotiated with drug companies and benefit management companies online in a digital, machine-readable format. That may be particularly helpful to employers that provide health insurance to workers, enabling them to seek the lowest price the drug manufacturer is offering to other purchasers.

The rule will not require plans to disclose rebates and other discounts they negotiate with drugmakers and pharmacy benefit managers.

That’s a disappointment to employers that provide health insurance for their workers. “We’d like a much clearer idea of how much we’re paying for every drug every time it’s dispensed,” said James Gelfand, senior vice president for health policy at the ERISA Industry Committee, which represents large self-insured employers. “We want to know where every cent in rebates and discounts is going. We’ll at least begin peeling back the onion. You have to start somewhere.”

But other experts argue the rule will do little to make medications more affordable. Indeed, they warn that publishing what health plans pay drug manufacturers could crimp some plans’ ability to get price concessions, raising the premiums and drug prices that plan members pay. That’s because manufacturers won’t want to give those discounts knowing other health plans and pharmacy benefit managers will see the published rates and ask for the same deals.

“Insurers and pharmacy benefit managers currently use rebates that are hidden from view to drive prices lower,” said Dr. Aaron Kesselheim, a professor of medicine at Harvard University who studies prescription drug policy. “If you make that transparent, you kind of reduce the main strategy payers have to lower drug prices.”

Patient advocates also questioned how useful the published rates will be for patients, because plans don’t have to post list prices, on which patient cost-sharing amounts are based. There also are practical limits to patients’ ability to price-shop for drugs, considering there may be only one effective drug for a given medical condition, such as many types of cancers.

Still, if the public knows more about how much health plans pay for drugs — and can estimate the size of the rebates and discounts that aren’t being passed on to patients — that could heighten pressure on federal and state elected officials to tackle the thorny issues of high prices and gaps in insurers’ drug coverage, which powerful industry groups oppose.

“If the information is presented to consumers so they realize they are paying a higher price without the benefit of the rebates, you’ll get a lot of angry consumers,” said Niall Brennan, CEO of the Health Care Cost Institute, a nonprofit group that publishes cost data.

The Biden administration is expected to keep the new price disclosure rule for health plans. In July, the Biden campaign issued a joint policy statement with Sen. Bernie Sanders (I-Vt.) favoring increased price transparency in health care.

But Kesselheim and other experts say Congress needs to consider stronger measures than price transparency to address drug affordability. These include letting the federal government negotiate prices with drugmakers, limiting the initial price of new drugs, capping price increases and establishing an impartial review process for evaluating the clinical value of drugs relative to their cost. Those are policies Biden has said he supports.

“There’s a limit to what transparency can do,” said Shawn Gremminger, health policy director at the Pacific Business Group on Health, which represents large self-insured employers. “That’s why we’re increasingly comfortable with policies that get at the underlying prices of drugs.” As an example, he cited the Trump administration’s proposal to tie what Medicare pays for drugs to lower prices in other countries.

Commercial insurers, drug manufacturers and pharmacy benefit managers are strongly opposed to the drug transparency rule. “This rule will disrupt the marketplace dynamics and undermine the highly competitive negotiations that kept net prices for brand medicines at a growth rate of just 1.7% in 2019,” said Katie Koziara, a spokesperson for the Pharmaceutical Research and Manufacturers of America. She wouldn’t say whether her group would sue to block the rule.

The survival of the rule, which draws its legal authority from the Affordable Care Act, also depends on the U.S. Supreme Court upholding the constitutionality of that law in a case argued on Nov. 10.

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: For Your Next Health Insurance Fight, an Exercise in Financial Self-Defense

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A listener asked: ‘How do I remain cool when calling insurance companies?” So we called veteran self-defense teacher Lauren Taylor for advice. She leads Defend Yourself, an organization that works to empower people against violence and abuse. 

As Taylor teaches it, self-defense involves a lot more than hitting and kicking. It’s about standing up for yourself in all kinds of difficult situations. Striking that posture includes using your words, and we asked Taylor to talk us through her top strategies. This year, she used them in her own health insurance fight.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

KHN Editor-in-Chief Elisabeth Rosenthal discussed how to manage unexpected health care costs with CBSN on Wednesday.

KHN chief Washington correspondent Julie Rovner discussed the Affordable Care Act case before the Supreme Court with WBEZ’s “Reset” and WDET’s “Detroit Today” on Tuesday and with WHYY’s “Radio Times” on Wednesday.

KHN partnerships editor and senior correspondent Mary Agnes Carey discussed the ACA Supreme Court case on Newsy’s “Morning Rush” on Tuesday and on Connecticut Public Radio’s “Where We Live” on Nov. 6.

On Thursday, KHN correspondent Rachana Pradhan discussed with Newsy the challenges President-elect Joe Biden faces in trying to seat Food and Drug Administration leadership quickly to deal with the pandemic.

KHN senior correspondent Sarah Jane Tribble discussed KHN’s “Where It Hurts” podcast with Kansas Public Radio’s “KPR Presents” on Nov. 1.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Fiscal general de California: los jueces deben ver que ACA es “indispensable”

Sacramento.- Cuando la Corte Suprema de los Estados Unidos esté escuchando el martes 10 un caso que podría decidir el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), California liderará la defensa de la ley federal que impacta en casi todos los aspectos del sistema de salud del país.

Por lo general, es tarea del gobierno federal defender una ley federal, pero la Administración Trump quiere que ACA, también conocida como Obamacare, se revoque.

Por eso, el fiscal general de California, Xavier Becerra, respaldado por más de 20 estados, defiende la ley contra el desafío presentado hace dos años por una coalición de funcionarios estatales republicanos.

Becerra ha sido uno de los adversarios más formidables de Trump: ha llevado a la administración a los tribunales decenas de veces por sus políticas, que van desde la inmigración y el control de la natalidad hasta el cambio climático. Se le considera uno de los principales contendientes para llenar la vacante del Senado que se abrirá ahora que la senadora por California Kamala Harris ha sido elegida vicepresidenta.

“Tan enérgicamente como un presidente y su administración están luchando para destruir la Ley de Cuidado de Salud a Bajo Precio, nosotros estamos luchando para salvarla para todos los estadounidenses”, dijo Becerra a los periodistas en una conferencia de prensa el lunes 9.

Si el tribunal anula toda la ley, el impacto se sentiría ampliamente. La ley proporciona seguro médico a más de 23 millones de estadounidenses. Permite a las personas que califican comprar seguros a través de los mercados estatales y el federal, y recibir subsidios.

También ha recomendado  a los estados expandir sus programas de Medicaid a más personas; previene que las compañías de seguros nieguen cobertura a personas con afecciones médicas preexistentes; prohíbe los límites de por vida en la cobertura; agrega beneficios a Medicare; y permite que los hijos permanezcan en los planes de sus padres hasta los 26 años.

El tema central en California vs. Texas es la multa fiscal federal por no tener seguro médico, como exige la ley. En 2017, el Congreso liderado por los republicanos redujo esta multa a cero, pero mantuvo intacta al resto de la ley, una medida que, según Becerra y otros expertos en leyes, muestra la intención del Congreso de apoyarla.

Sin embargo, funcionarios estatales republicanos dicen que la pérdida de la penalidad invalida el mandato de tener un seguro, así como toda la ley.

Becerra dijo que es posible que el tribunal determine que los impugnadores no tienen legitimidad para demandar al gobierno porque nadie ha sido perjudicado por una multa que cuesta cero.

Aunque la corte ha ratificado dos veces esta ley, la composición de la corte ha cambiado desde su último fallo sobre ACA en 2015. Desde entonces, Trump ha nombrado a tres jueces conservadores. Dos reemplazaron a otros conservadores, pero Amy Coney Barrett, quien fue confirmada a fines de octubre, ocupa el asiento de un ícono liberal, la jueza Ruth Bader Ginsburg.

Abbe Gluck, directora del Centro Salomón de Derecho y Políticas de Salud de la Escuela de Derecho de Yale, dijo que si el tribunal cree que el requisito del seguro médico es inconstitucional sin la penalidad, debería simplemente declarar inválida esa sección de la ley, pero no anularla por completo.

Pero “he aprendido que nunca se puede predecir lo que sucede en la corte cuando se trata de la Ley de Cuidado de Salud a Bajo Precio”, dijo Gluck. “Por eso hay más preocupación, porque el estatuto se ha vuelto tan fundamentalmente importante para una quinta parte de nuestra economía y para la atención médica de prácticamente todos los estadounidenses”.

Becerra habló con Samantha Young de California Healthline sobre su defensa del Obamacare y el enorme alcance de la influencia de la ley. La entrevista ha sido editada por extension, y para mayor claridad.

¿Cuáles son las posibilidades de que la Corte Suprema derogue la Ley de Cuidado de Salud a Bajo Precio?

Confiamos en que no solo verán la lógica legal detrás de esto, sino también la sabiduría y el éxito práctico de la Ley de Cuidado de Salud a Bajo Precio, lo cual pesa mucho a favor de que los jueces reconozcan no solo que es legal, sino indispensable. Cuando los jueces examinen los fundamentos de la Ley de Cuidado de Salud a Bajo Precio, encontrarán que es constitucional.

La composición de la Corte Suprema de los Estados Unidos ha cambiado desde la última vez que se pronunció sobre ACA. ¿Por qué cree que estos jueces decidirán de la misma manera?

Eso no debería cambiar el hecho de que los fundamentos de la ley siguen siendo los mismos. Los fundamentos de ACA son sólidos y funcionan. Espero que nueve jueces que revisan la misma ley observen ese precedente.

¿A qué debe prestar atención el público durante los argumentos orales?

Algo interesante de observar es cómo la corte interpreta las acciones tomadas por el Congreso en 2017, cuando aprobaron el proyecto de ley de exención de impuestos y redujeron a cero la tarifa o multa por el mandato individual. Ahora, estamos ante un presidente y al menos una cámara en el Congreso que está preparada para defender la Ley de Cuidado de Salud a Bajo Precio. ¿Cómo podría considerar el tribunal el hecho de que otro Congreso podría restablecer parte de ese mandato?

¿Cómo se relaciona esto con el argumento legal de que haber reducido a cero el mandato de alguna manera provocó la inconstitucionalidad de toda la ley? Creo que es una cuestión que el tribunal tendrá que examinar.

¿Qué pasará si la Corte Suprema de los Estados Unidos declara inconstitucional la Ley de Cuidado de Salud a Bajo Precio?

Volverán las preocupaciones. La atención preventiva de Medicare desaparecería. Los días en que los estadounidenses no tenían que preocuparse por la bancarrota por haber pisado un hospital prácticamente se esfumarían.

Tengo tres hijas. Hubo un tiempo que, como adultas, las tres estaban en nuestra cobertura de atención médica. Eso desaparecería porque la disposición que permite que los hijos adultos menores de 26 años permanezcan en la cobertura de los padres desaparecería. Y podría seguir y seguir.

¿Podrían los estados, incluido California, darse el lujo de intervenir por su cuenta?

No sé si hay algún estado que tenga la capacidad de reemplazar lo que hace la Ley de Cuidado de Salud a Bajo Precio. Es casi imposible. Parte de eso se debe a que no podemos replicar algunas de las cosas que puede hacer el gobierno federal. No tenemos esa jurisdicción federal, no tenemos esa amplitud y profundidad de alcance.

Si el tribunal anula ACA, ¿el Congreso no puede aprobar protecciones parciales que cuenten con el apoyo de los republicanos, como la cobertura de afecciones preexistentes?

Hemos escuchado a los republicanos decir “revocar y reemplazar” durante más de 10 años, y ha sido una retórica vacía desde el principio. Para los padres que tienen hijos con afecciones médicas preexistentes, no es reconfortante que alguien les prometa que reemplazarán un derecho que saben que ahora tienen para que sus hijo vayan al hospital. Y, ¿por qué desecharías eso por una promesa vacía que ya lleva 10 años?

La mayoría de los estadounidenses dirían: sigue construyendo sobre la base de la Ley de Cuidado de Salud a Bajo Precio. Mejorémosla, pero no descartemos lo que ha funcionado.

¿Cómo sabe que la Ley de Cuidado de Salud a Bajo Precio está funcionando?

Mi antiguo distrito congresional en Los Ángeles se encontraba entre los distritos congresionales con más cantidad de personas sin seguro de salud de la nación. En cuestión de años, una vez que entró en vigor la Ley de Cuidado de Salud a Bajo Precio, la tasa de personas sin seguro en ese distrito se redujo en un 50%. Fue simplemente astronómico.

La Ley de Cuidado de Salud a Bajo Precio hizo posible que las familias trabajadoras pudieran obtener cobertura y eso es enorme. Ese es el tipo de carga que se quita del alma.

¿Cree que tener a Joe Biden como presidente y a Kamala Harris como vicepresidenta en la Casa Blanca llevará a una mejora en la Ley de Cuidado de Salud a Bajo Precio?

Como candidato a presidente, Joe Biden dijo que se basaría en el éxito de la presidencia de Obama-Biden y se aseguraría que sigamos aumentando el número de estadounidenses con acceso a una atención médica asequible. Lo bueno es que finalmente tienes a alguien en la parte superior del tótem que dice que lo vamos a mejorar. Por eso esta elección fue tan importante.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Justices Bound to See ACA as ‘Indispensable,’ Says Californian Leading Defense

SACRAMENTO — When the U.S. Supreme Court hears a case Tuesday that could decide the fate of the Affordable Care Act, California will be leading the defense to uphold the federal law that touches nearly every aspect of the country’s health care system.

It’s usually the federal government’s job to defend a federal law, but President Donald Trump’s administration wants this law, also known as Obamacare, to be overturned.

So California Attorney General Xavier Becerra, backed by more than 20 other states, is defending the law against the challenge brought by a coalition of Republican state officials two years ago.

Becerra has been one of Trump’s most formidable adversaries, taking the administration to court scores of times over its policies, ranging from immigration and birth control to climate change. He is considered one of the leading contenders to fill the Senate vacancy that will open now that Sen. Kamala Harris of California has been elected vice president.

“Just as vigorously as a president and his administration are fighting to destroy the Affordable Care Act, we are fighting to save it for every American,” Becerra told reporters in a press conference Monday.

Should the court overturn the entire law, the impact would be felt widely. The law provides health insurance to more than 23 million Americans. It allows qualified people to buy subsidized insurance through federal or state insurance exchanges; permits states to expand their Medicaid programs to more people; prevents insurance companies from denying coverage to people with preexisting medical conditions; bans lifetime limits on coverage; adds benefits to Medicare; and allows children to stay on their parents’ plans up to age 26.

At issue in California v. Texas is the federal tax penalty for not having health insurance, as the law requires. The Republican-led Congress in 2017 zeroed out the penalty but kept the rest of the health law intact, a move Becerra and some other legal experts say shows congressional intent to support the law. The Republican state officials, however, say the loss of the tax invalidates the mandate to have insurance — as well as the entire law.

Becerra said it’s possible the court may determine that the challengers don’t have standing to sue the government because no one has been harmed by a zero-tax penalty.

Although the court has twice upheld the federal health care law, the composition of the court has changed since its last ACA ruling in 2015. Trump has appointed three conservative judges since then. Two replaced other conservatives, but Amy Coney Barrett, who was confirmed in late October, took the seat of a liberal icon, Justice Ruth Bader Ginsburg.

Abbe Gluck, faculty director of the Solomon Center for Health Law and Policy at Yale Law School, said that if the court believes the health insurance requirement is unconstitutional without the penalty, it should just hold that section of the law invalid but not overturn the entire law.

But “I have learned that you can never predict what happens in court when it comes to the Affordable Care Act,” Gluck said. “And that is why there is this heightened sense of concern, because the statute has become so fundamentally important to one-fifth of our economy and the health care of virtually all Americans.”

Becerra talked to California Healthline’s Samantha Young about his defense of Obamacare and the far-reaching influence of the law. The interview has been edited for length and clarity.

Q: What are the chances the Supreme Court could overturn the Affordable Care Act?

We’re confident they will see not just the legal logic behind it, but the wisdom and the practical success of the Affordable Care Act — all of which weigh heavily in favor of the justices recognizing that it’s not only legal but indispensable. When the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional.

Q: The makeup of the U.S. Supreme Court has changed since it last ruled on the ACA. Why do you think these justices will rule the same way?

That shouldn’t change the fact that the fundamentals of the law have remained the same. The fundamentals of the ACA are grounded, they’re solid, and they work. I would hope that nine justices reviewing the same law would look at that precedent.

Q: What should the public pay attention to during the oral arguments?

One thing interesting to watch is how the court interprets the actions taken by Congress in 2017 when they passed the tax break bill and zeroed out the individual mandate fee or penalty. Now, we’re looking at a president and at least one house in Congress that’s prepared to defend the Affordable Care Act. How might the court look at the fact that another Congress could reinstitute part of that mandate?

What does that do to the legal argument that having zeroed out the mandate somehow triggered the unconstitutionality of the entire law? I think that’s a question the court will have to examine.

Q: What happens if the U.S. Supreme Court declares the Affordable Care Act unconstitutional?

The worries return. Preventative care under Medicare would be gone. The days when Americans don’t have to worry about going personally bankrupt for having visited a hospital would pretty much be gone.

I’ve got three daughters. There was a time when all three of them as adults were on our health care coverage. That would be gone because the provision that allows adult children under the age of 26 to remain on a parent’s coverage would disappear. I could go on and on.

Q: Could states, including California, afford to step in on their own?

I don’t know if there’s any state who has the capacity to replace what the Affordable Care Act does. It’d be almost insurmountable. Part of that is because we can’t replicate some of the things that the federal government can do. We don’t have that federal jurisdiction, we don’t have that breadth and depth of reach.

Q: If the court overturns the ACA, can’t Congress pass piecemeal protections that have Republican support, such as coverage for preexisting conditions?

We have heard Republicans say “repeal and replace” for more than 10 years, and it’s been empty rhetoric from the beginning. I’ve gotta tell you that for parents who have children with preexisting medical conditions, it is no comfort to have someone promise you that they will replace a right that you know you now have for your child to visit a hospital. And, why would you throw that away for an empty promise that’s 10 years old?

Most Americans would say, Keep building on the Affordable Care Act. Let’s make it better, but don’t scrap what’s worked.

Q: How do you know the Affordable Care Act is working?

My former congressional district in Los Angeles ranked among the most uninsured congressional districts in the nation. In a matter of years, once the Affordable Care Act took place, the uninsured rate in that congressional district had gone down by 50%. It was just astronomical.

The Affordable Care Act made it possible for working families to secure coverage and that’s huge. That’s the kind of burden that’s lifted off your soul.

Q: Do you think having a President Joe Biden and a Vice President Kamala Harris in the White House will lead to an improved Affordable Care Act?

As a candidate for president, Joe Biden said that he would build on the success of the Obama-Biden presidency and make sure that we continue to increase the number of Americans who have access to affordable health care. The good thing is you finally have someone at the top of the totem pole who says we’re going to make it better. And that’s why this election was so important.



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: David vs. Goliath: How to Beat a Big Hospital in Small Claims Court

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When Jeffrey Fox and his wife got an outrageous medical bill for a simple test, he said to his wife, “No way am I paying this.” In a classic — and hilarious — David vs. Goliath story, Fox takes on a huge hospital, and wins.

He’s a bit of an expert in using small claims court to get satisfaction and shared detailed instructions with the rest of us.

Fox doesn’t only take on big opponents. He said even his small wins are a way to get better at standing up for himself.

It’s pretty good practice for us all.

Want more? Here are some extras:

Our episode Can They Freaking DO That?!? describes how some folks have used just the threat of small claims court to get outrageous bills lowered.

Law professor Christopher Robertson describes some of the legal theory behind this method in this post from a Harvard Law School blog.

Fox posted documents from his case and a brief narrative.

Finally, here’s this episode transcript.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A $200 Debit Card Won’t Do Much for Seniors’ Drug Costs

If they’ve been listening to President Donald Trump, seniors may be expecting a $200 debit card in the mail any day now to help them pay for prescription drugs.

He promised as much this month, saying his administration soon will mail the drug cards to more than 35 million Medicare beneficiaries.

But the cards — if they are ever sent — would be of little help. Policy experts say that what Medicare beneficiaries really need, as well as younger Americans, are sweeping federal changes to close the gap between what their health insurance pays and what drugs cost them.

The nation’s 46.5 million enrollees in Medicare’s Part D prescription drug program — except for those who qualify for low-income subsidies — face unlimited out-of-pocket exposure to drug costs even though the Affordable Care Act finally closed the infamous “doughnut hole.” After Part D enrollees have spent $6,550 and reached the catastrophic threshold in a given year, they still must pay 5% coinsurance on the list price of their drugs.

Congress was considering legislation to lower drug prices and cap out-of-pocket costs until early this year, when the COVID-19 pandemic took center stage. But partisan disagreement, federal budget concerns and opposition from drug manufacturers and other health care industry groups hampered the efforts.

Many observers question the value, timing and legality of Trump’s drug card plan, with the promise coming just ahead of an election in which the president wants to shore up the support of older voters.

“A $200 card is better than a sharp stick in the eye, but it won’t be that meaningful,” said Tom Scully, the Medicare chief under President George W. Bush who in 2004 implemented a two-year, $1,200 drug card program passed by Congress as part of the law creating the Part D prescription drug benefit.

Two hundred dollars won’t go very far. One million Part D plan enrollees have out-of-pocket drug spending way above the program’s catastrophic coverage threshold, with average annual costs exceeding $3,200, according to KFF. (KHN is an editorially independent program of KFF.) Last year, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to a 2019 JAMA study.

“A lot of people don’t have $2,000 or $3,000 to pay out-of-pocket when they go to the pharmacy,” said Stacie Dusetzina, a drug policy expert at Vanderbilt University.

Steven Hadfield, 68, of Charlotte, North Carolina, has a rare blood cancer requiring treatment with Imbruvica, with a list price of $132,000 a year. He also needs two different medications for Type 2 diabetes, including insulin at $300 a bottle, a blood pressure drug and a muscle relaxer to relieve leg cramps.

He continues to work at Walmart and holds three part-time jobs. He pays more than $4,000 a year for his drugs, out of his $12-an-hour wages and monthly $1,100 Social Security check. The only way he can afford Imbruvica is through the manufacturer’s copay cards.

If he left his Walmart health plan and signed up for Medicare Part D drug coverage, he would have to pay thousands of dollars more because, under Medicare rules, he would no longer be able to use copay cards. “My whole Social Security check would go to drugs, and I’d have nothing left for my car or anything,” he said

Asked about Trump’s $200 drug card, Hadfield said, “I’d be happy to get anything, but they need to do more. Our representatives need to create some kind of program to lower prices.”

The Republican-controlled Senate refused to consider a sweeping drug cost bill passed by House Democrats a year ago that would have capped Part D out-of-pocket costs at $2,000 a year, penalized drugmakers for raising prices above inflation rates and let Medicare negotiate drug prices. Trump threatened to veto it.

In addition, Senate Republican leaders wouldn’t take up a bipartisan bill backed by the White House capping Part D out-of-pocket costs at $3,100 and also imposing penalties for price hikes above inflation.

The lack of action hasn’t stopped Trump from claiming, mostly inaccurately, that he has implemented policies that have reduced drug prices and saved seniors lots of money.

“Day after day I’m fighting to defend seniors from Big Pharma,” Trump said Oct. 16 in a Florida speech promising drug price cuts of 50% to 80%. “We have this terrible system that’s taken years and years to rig.”

The president’s centerpiece proposal is to index the drug prices paid by Medicare to lower prices paid by foreign countries. But his administration has not yet issued a rule to carry that out, and any such rule would face a strong legal challenge from drugmakers.

Joe Biden’s drug cost platform includes allowing Medicare to negotiate prices with drug manufacturers, limiting launch prices for new drugs, capping price increases at the inflation rate and letting consumers buy cheaper medicines from other countries. His plan would also likely spark opposition from drug companies.

Trump’s $200 drug card appears to be in trouble within his own administration. White House chief of staff Mark Meadows said last week that details will be finalized shortly and that the cards will be mailed to seniors in November or December.

But the general counsel of the Department of Health and Human Services warned in an internal memo the plan could violate election law. Congressional Democrats have called for an investigation, saying Trump is “attempting to buy votes.”

In a draft document obtained by Politico, the White House set the cost of the drug card plan at nearly $8 billion. To avoid having to seek congressional approval for the expenditure, Trump’s advisers want to call it a demonstration project, testing whether lowering Medicare patients’ out-of-pocket drug costs boosts their compliance in taking medications.

It’s also unclear whether the Office of Management and Budget will approve the plan because Medicare demonstrations must be designed so they do not increase the federal budget deficit. Yet the money would have to come from the government’s general revenues or Medicare payroll taxes or premiums, likely causing a negative budget impact.

“It will be difficult to learn anything from this demonstration project that we do not already know from other studies,” Dusetzina said.

“It’s a whole lot of money that would be more effectively focused on people with cancer and serious chronic illnesses who are struggling with high out-of-pockets,” said Daniel Klein, CEO of the Patient Access Network Foundation, which provides grants to help patients with drug costs.

Maureen Allen, 80, a retired marketing specialist who lives in Talking Rock, Georgia, said she could apply the $200 card to her annual cost of more than $2,000 for the anti-blood clot drug Eliquis and other medicines.

“It would help me with one month of Eliquis,” she said. “We’ll take the card because we need the money. But don’t think for a moment it will have the slightest impact on my vote.”

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Haiku Winner Unmasked! Read If You Dare

A big thanks to our readers who participated in our second annual KHN Halloween Haiku Contest. Your entries — like our health care system — ranged from eerie and haunting to downright spooky. And, based on a review by our expert panel of judges, here’s the winner and a sampling of finalists. Also, keep an eye on KHN’s social media accounts (Twitter, Instagram and Facebook) for more of our favorites. Enjoy!

•••
WINNER

Boo! It’s virus

Glad you are trick or treating

What luck, I am too

— JK

Inspiration: How Families Are Keeping Halloween From Turning Into a COVID Nightmare

•••
FINALISTS

Ghost of the mandate

lives on, haunting the high court,

sending chills down spines.

— Barbara Armstrong

Inspiration: Potential Impact of California v. Texas Decision on Key Provisions of the Affordable Care Act

Trump’s “beautiful”

health care plan. Real? Or just an

invisible ghost?

— Shefali Luthra

Inspiration: Back to the Future: Trump’s History of Promising a Health Plan That Never Comes

If sickness scares you

Wait for the debt collectors

Liens and lawsuits lurk

— Arielle Levin Becker

Inspiration: UVA Health Still Squeezing Money From Patients — By Seizing Their Home Equity

Shivers down your spine

An indifferent voice sighs

“You’re out-of-network.”

— Annaliese Johnson

 

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A $10,000 Obamacare Penalty? Doubtful.

“Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

In a Facebook post, Oct. 20, 2020

A viral Facebook post claims that former President Barack Obama’s health insurance law penalized a family a large amount of money for not buying health insurance and that President Donald Trump was responsible for stopping the practice.


This story was produced in partnership with PolitiFact. It can be republished for free.

The post features writing on the back of a car windshield that says, “Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about  PolitiFact’s partnership with Facebook.) We found a similar post on Instagram.

The post appears to refer to the individual mandate penalty, a tax under the Affordable Care Act placed on those who chose not to get health insurance. At the end of 2017, Republican-backed tax legislation, also supported by Trump, zeroed out the fine. Beginning in 2019, people could no longer be penalized for not having health insurance. Thus, the mandate hasn’t been in effect for about two years.

But $10,000 — the hefty amount this family was supposedly penalized for not having health insurance — raised questions for us. And was that money really used to pay for other people’s health insurance? We decided to look into it.

The History of the Individual Mandate

The ACA was implemented in 2010 during the Obama administration. The aim of the health care law — often referred to as Obamacare — was to ensure everyone had health insurance.

To that end, the law used what health policy experts call a “carrot-and-stick” approach. For low-income and middle-income individuals who had difficulty affording health insurance, the government would provide tax subsidies to reduce the cost of insurance — that was the carrot. And to make sure everyone enrolled in a health insurance plan, those who didn’t sign up were fined, under what was known as the individual mandate provision. That was the stick.

The individual mandate, which didn’t kick in until 2014, was unpopular with the American public, according to polling at the time. A 2017 KFF poll showed that 55% of Americans supported the idea of eliminating the requirement that everyone must have health insurance or pay a fine. (KHN is an editorially independent program of KFF.)

Although one of Trump’s key campaign promises was to repeal and replace the ACA, efforts to do so failed in 2017 when the Republican-held Senate failed to get the votes it needed.

Instead, in their 2017 tax bill, Republicans set the penalty for the individual mandate to $0. Starting in 2019, Americans no longer had to pay a fine for not having health insurance. Trump signed the 2017 tax bill into law. So, it is true that Trump and congressional Republicans were responsible for neutralizing the penalty.

However, experts pointed out that the individual mandate is still in place, it’s just that the penalty is set to $0. In fact, the end of the penalty is behind the justification for a court case attempting to overturn the ACA, brought by Republican attorneys general and supported by the Trump administration. The plaintiffs argue that the health care law is no longer constitutional because the penalty no longer “produces at least some revenue” for the federal government. The Supreme Court will hear oral arguments on the case Nov. 10.

The Math

The viral social media posts claim that the family “couldn’t afford health insurance” and was penalized $10,000.

Health policy experts told us that while the social media post doesn’t give all the specifics needed to know if this was absolutely true, it seems unlikely a penalty would be this high.

One issue is the post doesn’t specify whether the $10,000 penalty was incurred in one year or over multiple years. It also doesn’t say how many individuals were part of the family.

Assuming the $10,000 penalty was incurred in one year, multiple experts told us that the family would have had an annual income above $400,000 and at least one person would have had to be uninsured for the entire year. That math is based on the penalty structure in place in 2018, the last year the mandate was enforced.

In 2018, the penalty was calculated one of two ways. The fine was the greater of the two results:

  • $695 for an adult and $347.50 for a child, up to a max of $2,085 per family annually, or
  • 2.5% of family income above a certain tax filing threshold (KFF estimated the tax filing threshold was $10,650 for a single individual or $21,300 for joint filers in 2018).

The first way to calculate the penalty obviously doesn’t apply since the max was $2,085 per year. So, the second would be the only way to get a $10,000-a-year penalty. To arrive at such a number, you would have to take 2.5% of the family’s income. In this case, 2.5% of a $400,000 income gets you close to $10,000.

And experts said it is highly unlikely that a family with a $400,000 income would have had difficulty affording health insurance.

“So I would highly doubt the veracity of what is written on that car windshield,”Karen Pollitz, a senior fellow in health reform and private insurance at KFF wrote in an email. “People with that much income almost always have job-based health benefits and, if not, generally are inclined to insure themselves very well in order to protect assets — otherwise, if hospitalized and uninsured, they could owe many multiples of the penalty amount in medical bills.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, also pointed out that a $10,000 penalty would have been rare.

“Very few American families would have paid anything close to that amount in penalty for not having insurance — the average penalty per person in 2017 was around $700,” Oberlander wrote in an email. “Moreover, only a small percentage of Americans ever paid the penalty for not having health insurance — in 2017, 4.6 million persons,” or about 1% of the population. (In 2017, 325 million people lived in the U.S., according to the Census Bureau.)

It’s also unclear whether it would have just been cheaper for the family to pay for health insurance rather than incur a $10,000 penalty, said Matthew Fiedler, a health policy scholar at the Brookings Institution.

“It depends on the ages of the members of the family, where they live, what year (or years) we are talking about, and the family’s income,” Fiedler wrote in an email. “There are conceivable scenarios where the family could have found a bronze plan for $10k or less. But there are also plenty of plausible scenarios where they could not have. Without knowing more about the family’s circumstances, it’s just hard to say with any confidence.”

Where Did the Penalty Money Go?

Experts also told us that the post’s assertion that the penalties paid for not having health insurance were directly applied to fund other people’s health insurance was off the mark.

The individual mandate penalties were assessed during each annual tax filing, and then payments were made the year after there was a lapse in insurance coverage.

Those penalties were collected just like any other tax payment.

“As a strict accounting, keep in mind, everything gets dumped into the Treasury regardless of the source, and then it is appropriated out of the Treasury by Congress,” said Edmund Haislmaier, a senior research fellow in health care policy at the Heritage Foundation. “It’s not like money goes into one account and then another.”

So, while it’s certainly possible that the penalty money could have been used to help pay for some of the ACA subsidies for other people, the money also could have gone to any other number of things the government pays for, like the military, disaster relief or education.

“You don’t know exactly where your taxes or penalties go,” said Evan Saltzman, an assistant professor in economics at Emory University. “Maybe a small share went to Obamacare, but that’s a stretch. You can’t track where every dollar you spent on your taxes is going.”

It’s also misleading to say that other individuals received “free Obamacare” from the penalty payment. The experts said that while Medicaid expansion, which was a part of the ACA, does provide health care coverage for low-income people who are eligible, those who bought insurance on the marketplace would still likely have paid for some part of their coverage after subsidies were applied.

Our Ruling

A viral social media post claims that a family was penalized $10,000 for not being able to afford health insurance. It also claimed the penalty money was taken to pay for others’ “free ObamaCare” and Trump stopped that practice.

It is true that Trump and Congress did zero out the individual mandate requirement, so people could no longer be penalized for not having health insurance. But after that, skepticism abounds.

For instance, it’s very unlikely that a family would face a $10,000 penalty in one year. Moreover, if such a family did face this penalty for not having health insurance, they would likely be in a high-income bracket for which health insurance tends to come from an employer or be affordable. And the charge that the penalty was used to provide “free coverage” for others doesn’t fit with federal accounting processes.

Experts said, though, that the lack of specifics about this family’s situation makes it difficult to be completely definitive.

We rate this claim Mostly False.

SOURCES

Census Bureau, QuickFacts United States,  accessed Oct. 27, 2020

The Commonwealth Fund, “The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors,” July 11, 2018

Email interview with Christine Eibner, the Paul O’Neill Alcoa chair in policy analysis at Rand Corp., Oct. 23, 2020

Email interview with Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill, Oct. 25, 2020

Email interview with Karen Pollitz, senior fellow in health reform and private insurance at KFF, Oct. 26-27, 2020

Email interview with Matthew Fiedler, fellow with the USC Brookings-Schaeffer Initiative for Health Policy at the Brookings Institution, Oct. 26, 2020

5th Circuit Court of Appeals’ technical revisions of opinion, accessed Oct. 27, 2020

H.R.1 — 115th Congress (2017-18), accessed Oct. 27, 2020

IRS.gov, “Individual Shared Responsibility Provision — Reporting and Calculating the Payment,” accessed Oct. 27, 2020

KFF, “Explaining California v. Texas: A Guide to the Case Challenging the ACA,” Sept. 1, 2020

KFF, Individual Mandate Penalty Calculator, Nov. 17, 2017

KFF, “Kaiser Health Tracking Poll — November 2017: The Role of Health Care in the Republican Tax Plan,” Nov. 15, 2017

LeadStories.com, “Fact Check: Trump, Congress DID End Tax Penalty for Non-Insured, but $10,000 Penalty NOT Likely,” Oct. 22, 2020

Phone interview with Edmund Haislmaier, Preston A. Wells Jr. senior research fellow at the Heritage Foundation, Oct. 23, 2020

Phone interview with Evan Saltzman, assistant professor in economics at Emory University, Oct. 23, 2020

PolitiFact, Repeal Obamacare Trump-O-Meter, July 15, 2020

Rand Corp., “How Does the ACA Individual Mandate Affect Enrollment and Premiums in the Individual Insurance Market?” published in 2015

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospital Bills for Uninsured COVID Patients Are Covered, but No One Tells Them

When Darius Settles died from COVID-19 on the Fourth of July, his family and the city of Nashville, Tennessee, were shocked. Even the mayor noted the passing of a 30-year-old without any underlying conditions — one of the city’s youngest fatalities at that point.

Settles was also uninsured and had just been sent home from an emergency room for the second time, and he was worried about medical bills. An investigation into his death found that, like many uninsured COVID-19 patients, he had never been told that cost shouldn’t be a concern.

Back at the end of June, Settles and his wife, Angela, were both feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.

“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the 911 recordings obtained by WPLN News.

Darius Settles was stabilized and tested for the coronavirus at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.

Three days later, they did. And now he also knew he had COVID-19; his test results were in.

But Settles was between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance.

His wife, who works for Tennessee State University, said he was worried about costs as he went back to the hospital a second time; she tried to reassure him

“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she said.

When he returned to TriStar Southern Hills Medical Center, owned by the for-profit hospital chain HCA, physicians tested his blood oxygen levels, which are usually a first sign that a COVID-19 patient is in trouble. They had dropped to 88%. An X-ray of his lungs “appears worse,” the physician wrote in the record.

But the doctor also noted that after a few hours in the emergency room his oxygen saturations had improved and he was breathing on room air. The records show they discussed why he might not want to be admitted to the hospital since he was otherwise young and healthy and didn’t note any risk factors for complications.

And when Angela Settles called to check in, he seemed to be OK with leaving despite his persistent struggle to breathe.

He was a COVID-19 patient so, “I could not go up there to see him,” she said. “He was saying that I might as well go home.”

Angela Settles was surprised since her husband was the one who wanted to go to the hospital in the first place.

At first, she thought the hospital just didn’t want to admit a man without insurance who would have trouble paying a big bill. But TriStar Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson.

And in this case, the federal government would have paid the bill. But no one said that when it might have made a difference to Darius Settles.

The Message Never Makes It to Patients

TriStar, like most major health systems, participates in a program through the Centers for Medicare & Medicaid Services in which uninsured patients with COVID-19 have their bills covered. It was set up through the pandemic relief legislation known as the CARES Act.

But TriStar doesn’t tell its patients that upfront. Neither do other hospitals or national health systems contacted by WPLN News. There’s no requirement to, which is one of the program’s shortcomings, said Jennifer Tolbert of KFF, who studies uninsured patients. (KHN is an editorially independent program of KFF.)

“This is obviously a great concern to most uninsured patients,” Tolbert said. Her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they asked enough questions.

Tolbert said the problem with the COVID-19 uninsured program is that even doctors don’t always know how it works or that the program exists.

“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she said. “And it’s not always clear that that is happening.”

Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay, under a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.

Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.

“I don’t want to absolutely promise anything,” said Dr. Ryan Stanton, an ER physician in Lexington, Kentucky, and a board member of the American College of Emergency Physicians.

“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the health care system,” he said.

‘Could I Have Done More?’

Darius Settles knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles, and asked his father to come pray for him.

When the elder Settles replied that he was always praying for his son, Darius said, “No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,” David Settles recalls, and so he went, despite concerns about getting COVID-19 himself.

He sat by his son’s side. Darius’ wife made some peppermint tea, and when they put it to his lips, Darius didn’t sip. They thought he had fallen asleep. But he was unconscious.

At that point, they called 911 again and the operator instructed them to get Darius to the floor and perform chest compressions until paramedics arrived.

For 11 minutes, Angela Settles pumped her husband’s chest, occasionally asking the dispatcher “what’s taking so long,” the 911 recordings show. Even after help showed up, Darius never revived.

Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “The Lord gives, and the Lord takes away.”

Darius Settles left behind his own son, who was 6. And his widow’s head is still spinning. She said she can’t shake a sense of personal guilt.

“Could I have done more?” Angela Settles asked. “That’s hard, and I know that he would not want me to feel like that.”

She wondered, too, if the hospital could have done more for him. And even after failing to disclose its policy for uninsured COVID-19 patients, it did send her a bill for part of her husband’s care. Asked why, a TriStar spokesperson said it was sent in error and does not have to be paid.

This story is from a reporting partnership that includes WPLNNPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Readers and Tweeters Shed Light on Vaccine Trials and Bias in Health Care

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

On the ‘Subject’ of Vaccine Trial Participants

In the piece about the AstraZeneca vaccine trial subject who suffered severe spinal cord inflammation, that person was repeatedly referred to as a “patient” (“NIH ‘Very Concerned’ About Serious Side Effect in Coronavirus Vaccine Trial,” Sept. 14). Once someone is enrolled in a trial, everything that happens to them is because they are a “subject,” not a patient. A patient is someone getting health care; a subject is willingly participating to be exposed to something that has nothing to do with their health or wellness. Please use the right term so that the reader can be reminded that the person was participating in this trial. Nice piece.

— Robin Chalmers, Atlanta

Don’t worry about Trump rushing a #vaccine. Worry about pharma companies hiding data from the FDA and NIH.https://t.co/BoxSZILoyx

— Mike’s Hard Left Turn🏴 🏴‍☠️ (@ozofperception) September 17, 2020

— Michael Berger, Canton, Ohio

Just read the story by Arthur Allen and Liz Szabo on risk/benefit of vaccine trials where a serious illness occurs. It hit home. I took Proscar for seven years in a prostate cancer prevention trial. I was in the third cohort. At some point short of the planned 10 cohorts, the test was aborted: Benefits were so great that the placebo would be unethical. I was lucky. My little blue pill was the real thing. That earned me a spot in the selenium/vitamin E trial to see if that combo prevented prostate cancer. That trial was aborted when serious health effects were diagnosed and there was a causal link. Good. I didn’t get both but I don’t know whether I got selenium or vitamin E. No problems. I know I did not get the placebo.

Now I’m doing the Pfizer COVID-19 vaccine trial at Cincinnati Children’s Hospital/Gamble Institute. So far, two shots, no immediate problems. Ask me in two years.

It’s important to say: A trial can stop because benefits wildly outweigh risks or because harms become obvious. I’ve had every vaccine relevant to my life and work for 82 years. I’ve seen smallpox and measles in southern Africa and polio in my hometown, Minneapolis. I got a typhus jab before going out to Africa from London almost 60 years ago. I’m a believer. Thanks for your clear-headed and well-written and -edited reporting. We need it more than ever.

Ben Kaufman, Cincinnati

Regardless of widespread distrust caused by @realDonaldTrump ‘too many cooks’ syndrome on vaccine vetting has scientists saying such plans by individual states could backfire, confusing public & eroding confidence in any eventual #coronavirus vaccine. https://t.co/gCufRJ2FjJ

— Lindsay Resnick (@ResnickLR) October 7, 2020

— Lindsay Resnick, Chicago

Racial sensitivity training is essential. The healthcare system is not made to support people of color. Providers should not be another obstacle to receiving equitable healthcare #MedTwitter

Unconscious Bias Crops Up In Health Care, Even During A Pandemic https://t.co/tDwkCOO6qH

— Taylor Ross (@taycraye) October 21, 2020

— Taylor Ross, Columbia, Missouri

A Universal Problem

I want to let Karla Monterroso from the April Dembosky piece on unconscious bias in health care (“‘All You Want Is to Be Believed’: The Impacts of Unconscious Bias in Health Care,” Oct. 21) know that I have no doubt her experience was horrific, and I do not want to, in any way, disagree or diminish that it is related to unconscious bias. However, I am a skinny, white woman (and a nurse and nurse practitioner, by the way, and therefore better able to advocate for myself), and my interface with emergency, primary care and a few specialty practices in the “health care” system during the time of COVID-19 has also been most unfortunately and horrifically similar.

I, too, am utilizing my resources to speak up and speak out, knowing that for everyone who speaks up there are hundreds if not thousands who don’t. So please convey my gratitude to her, and to KHN for publishing her story. I hope that it and Kaiser Permanente’s research shed some light, not only on unconscious bias, but also the realities of today’s medical-industrial complex.

— Christine Fasching Maphis, Harrisonburg, Virginia

The Need for Trust Between Physician and Patient

Throughout history, there has been an extreme level of mistrust between health care providers and African American communities. So in 2020, when being asked to enter a trial for a coronavirus vaccine, the answer is easily no, without hesitation (“COVID Vaccine Trials Move at Warp Speed, But Recruiting Black Volunteers Takes Time,” Sept. 16).

Misconduct and mistreatment of patients presently and in the past, such as Henrietta Lacks and the many lives lost during the Tuskegee Syphilis Study, have forever been etched in the minds of many individuals, and trust is not easily given. When strengthening the relationship between patient and provider, trust must first be built before Black communities would even consider being test subjects.

What Dr. Vladimir Berthaud has been able to provide Robert Smith and the rest of his patients with is comfort, which is developed when the care is patient-centered. Effectively communicating with patients to ensure they understand what’s going on and what’s at stake, listening to their concerns, and respecting their preferences when it comes to receiving care can affect the decision patients decide to make in this very difficult time.

With over 8 million cases of COVID-19 in the United States, Black people make up 17.6% of reported cases from states who provided data on race/ethnicity, according to the CDC. With little to no volunteers willing to enter the trial, the likelihood of finding a vaccine to build the immune systems of all citizens is becoming further from achievable and even more difficult. Representation for people of color is needed, and providers need to take the extra step to encourage the Black community to participate in the trial that affects them, just as much as any other race.

— Tre’Jenae Mack, Baltimore

(Today is day 1 for me. An hour until vaccine or placebo) As COVID-19 Vaccine Trials Move At Warp Speed, Recruiting Black Volunteers Takes Time https://t.co/T4zkkUJ7qZ

— Ty Russell (@TRussellCBS4) September 29, 2020

— Ty Russell, Miami

Ghosting Your Friends This Year

Regarding your story about Halloween safety (“How Families Are Keeping Halloween From Turning Into a COVID Nightmare,” Sept. 23), a mother is quoted as saying she will host a small sleepover with relatives instead of trick-or-treating. Isn’t having non-household members over to spend the night considered a high-risk thing to do? I’m confused.

— Sarah Kishler, San Jose, California

Editor’s note: Indeed. With COVID cases on the rise in at least 36 states, especially in the Midwest, CDC Director Robert Redfield said recently: “What we’re seeing as the increasing threat right now is actually acquisition of infection through small household gatherings.”

Such a good way to put it: We pay farmers not to plant. Shouldn’t we pay bars to stay closed? via @NYTOpinion https://t.co/vQWww4B6r0

— leslie ehrlich (@leslieehrlich) October 22, 2020

— Leslie Ehrlich, New York City

A Eureka Moment on Bar Closings

I am a professor at the School of Social Work at the University of Michigan-Ann Arbor. I teach courses in policy management, leadership and community organization. I am in the “wholesale” branch of social work, not the “retail” (clinical) side.

I want to congratulate you on your recent piece on closing the bars (“Analysis: Winter Is Coming for Bars. Here’s How to Save Them. And Us,” Oct. 22). More specifically, your linking the farm program of paying farmers not to grow to paying bars not to open. Reading that I had a eureka moment — stupendous! An idea with broad applications. I have taught about “policy borrowing,” but that idea never crossed my mind — brilliant — one of those once-in-a-lifetime inspirations. The potential application of farm subsidies to other policy arenas opens a door (as in “The Secret Garden”).

I just had to find a way to tell you how intellectually exciting that is.

— John Tropman, Ann Arbor, Michigan

@RosenthalHealth⁩ It’s not just bars that are a central problem in creating “heterogenous” explosive outbreaks. It is bar owners, banded together fiercely opposing reasonable temporary controls. Witness the tavern league in Wisconsin. https://t.co/QQd8qoWVHM

— Steve Morrison (@MorrisonCSIS) October 22, 2020

— Steve Morrison, Washington, D.C.

Plagued by Misinformation

Should you wear a mask? Should you stay home? Is it worse than the flu? Don’t ask the United States government because you won’t get a consistent answer (“Signs of an ‘October Vaccine Surprise’ Alarm Career Scientists,” Sept. 21). Since COVID-19 began to afflict the U.S. in early March, the Trump administration has consistently disseminated unreliable messages leading to surges in cases, mass personal protective equipment shortages and over 220,000 deaths. Inconsistent statements that contradict evidence-based recommendations from well-regarded government agencies have plagued the government’s response to the novel coronavirus.

The administration is, again, pushing controversial treatments and contradicting experts in the premature release of the COVID-19 vaccination, making it one of its most dangerous maneuvers yet. A politically charged release of a vaccine that has not been fully tested will result in low trust levels. While this cutting-corners approach may appear to increase the chance of reelection, it puts the scientific community’s reputation in jeopardy, possibly destroying confidence in vaccination, a topic scientists have been battling for decades. The U.S. is currently leading the world in cases and deaths, proving that an unclear and decentralized approach to the crisis is ineffective. It’s imperative that elected officials begin to work together and take America’s health seriously.

— Amelia Flocchini, Madison, Wisconsin

This is a terrifying scenario. If it comes to this, I promise to actually (gulp) speak up against vaccines. I hope and pray we don’t go down this road.

(In the meantime: existing, approved #VaccinesWork… Go get your flu shot!) https://t.co/ypIl3LojjP

— Megan Ranney MD MPH 🗽 (@meganranney) September 21, 2020

— Dr. Megan Ranney, Providence, Rhode Island

Buckling Down on Analogies

In Elisabeth Rosenthal’s “Analysis: We Follow Laws on Seat Belts and Smoking. Why Not on Masks? (Oct. 1), the seat belt analogy doesn’t quite fit. Seat belts primarily help the user. You should instead use speed limits or laws against driving drunk. Those help others primarily, like masks.

— Thomas Kahn, St. Louis

@gavin4annapolis Useful article given the large number of non-mask wearing scofflaws I routinely see down at the harbor. There is police “presence” but no obvious enforcement efforts. https://t.co/bneoV3WHzN

— Phelim Kine “老 康“ (@PhelimKine) September 30, 2020

— Phelim Kine, Annapolis, Maryland

The Crisis of 911 Mental Health Calls

Reading your story about Daniel Prude, I assume this interests KHN because of the failures in mental health care (“You’re Going to Release Him When He Was Hurting Himself?” Sept. 29). The narrative seems to be that this sort of thing happens only to people of color and not that the proportion of officer-involved use-of-force incidents are far greater among those in mental health crisis than solely because of race. Take this story, for example, in which a Minnesota crisis unit was called twice, refusing first to assist, then a second time not arriving before the child was gassed out of a home where he was alone and shot 11 times on a sunny Friday morning in his own front yard. Then the district attorney used protected health information (PHI) to make a case to justify the killing.

— Don Amorosi, Wayzata, Minnesota

As we focus more on the intersection of the justice system & racial equity, how we approach mental healthcare is – & should be – part of the discussion. The tragic circumstances of Daniel Prude’s death in Rochester shines a spotlight on this. https://t.co/CIt9AGCgxB

— Kody H. Kinsley 😷 (@KodyKinsley) October 2, 2020

— Kody H. Kinsley, Raleigh, North Carolina

This story brought light to the serious problem of lack of access to inpatient psychiatric care. State laws are too restrictive, and hospitals are legally aware and wary. Strong Memorial Hospital clearly did not take into account the patient’s behavior that caused his family and police to act to have him hospitalized. Nevertheless, while I highly appreciate the facts this article brings to light, I am somewhat dismayed that the highlighted topic is race rather than the risk of all mentally ill patients of being denied access to inpatient care. There appears to be a trend of viewing events and news primarily through these identity lenses. My father was Hispanic and also had problems getting access to care before he committed suicide. Thank you for covering this story.

— Christina Nuñez Daw, Greenbelt, Maryland

Heartbreaking Bills, Lawsuit and Bankruptcy — Even With Insurance https://t.co/Ws6dNPfMsJ via @khnews In any other developed country in the world, he would have been taken care of. #Medicare4All now

— Kathy Staub (@mrsstaub) September 25, 2020

— Kathy Staub, Manchester, New Hampshire

When Illness Leaves a Patient Little Choice

I write to expand on Laura Ungar’s Sept. 25 article, “Bill of the Month: Heartbreaking Bills, Lawsuit and Bankruptcy — Even With Insurance.” The article follows the story of a man diagnosed with a rare condition — flu-induced heart disease — who received surprise medical bills, which led to a lawsuit and his filing for bankruptcy. Ungar notes that “a hospital representative suggested [the patient] apply for financial assistance. She followed up by sending him a form, but it went to the wrong address because [the patient] was in the process of moving.”

Though nonprofit hospitals are required to provide some sort of financial aid for indigent patients — according to 26 C.F.R. §1.501(r) of the Internal Revenue Code — the statute does not define exactly how a hospital must provide that aid. For example, a hospital can offer financial assistance but require patients complete extensive documentation to discourage patients from using it. Though it is unclear in Ungar’s article whether the hospital attempted to resend the form or to contact the patient after the form went to the wrong address, it is unlikely. If the hospital was willing to pursue legal action — leading to the patient’s bankruptcy — it is possible the hospital did not attempt to contact the patient again as a tactic to avoid providing financial assistance, a tactic allowed under the IRC.

Ungar failed to mention how patients with chronic conditions would fare in similar circumstances. As someone with a chronic condition, I know firsthand that those with chronic conditions do not pick and choose when they have expensive surgeries or procedures; often, the condition makes that choice. A patient with ulcerative colitis or Crohn’s disease does not choose when he has a flare that might require an emergency colonoscopy or surgery to remove part of their intestines. A flare, by definition, occurs randomly and violently. Often, procedures and surgeries to quell such flares require expensive treatment options. Scheduling such procedures is desirable but unrealistic. Even the patient in the article — who suffered a rare acute condition — did not choose when he needed care; his health made the choice. The article should address chronic conditions but as another example to emphasize her point about how debilitating medical bills can be.

— Daniel Klapper, Pittsburgh

1. Why the “Breaking Bad” plot line (cooking meth to cover cancer treatment costs) is an “only in America” story; 2. Why patient investment in high-connection wellness/care solutions has an ROI given US healthcare system costs. https://t.co/TxWjpYUGqe

— Jim Eischen (@JimEischenEsq) September 25, 2020

— Jim Eischen, San Diego

Oh, Canada Health Care!

Regardless of the platitudinous praises our health care system typically receives, Canada is the only country with a universal plan (theoretically, anyway) that doesn’t also fully cover medications (“New Laws Keep Pandemic-Weary California at Forefront of Health Policy Innovation,” Oct. 1). The bitter pill is: Many low-income outpatients cannot afford to fill their prescriptions and resultantly end up back in the hospital system, thus burdening the system far more than if those patients’ generic-brand medication was also covered. This lesson was learned and implemented by enlightened European nations with genuinely universal all-inclusive health care systems that also cover necessary medication.

Within our system are important treatments that seem to be either universally nonexistent or, more to the point, universally inaccessible, except to those with relatively high incomes and/or generous employer health insurance coverage. The only two health professions’ appointments for which I’m fully covered by the public health plan are the readily pharmaceutical-prescribing psychiatry and general practitioner health professions. Such non-pharmaceutical-prescribing mental health specialists as psychotherapists and counselors (etcetera) are not at all covered.

Logic says we cannot afford to maintain such an absurdity that costs Canada billions extra annually. It’s not coincidental that the absence of universal medication coverage also keeps the pharmaceutical industry’s profits soaring.

— Frank Sterle Jr., White Rock, British Columbia

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Savvy Patient Fought for the Price She Was Quoted − And Didn’t Give Up

When Tiffany Qiu heard how much her surgery was going to cost her, she was sure the hospital’s financial department had made a mistake. Qiu, who already knew from a breast cancer scare earlier that year that her plan required a 30% coinsurance payment on operations, pressed the person on the phone several times to make sure she had heard correctly: Her coinsurance payment would be only 20% if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.

“I was kind of in doubt, so I called them a second time,” said Qiu. “They gave me the exact same amount.”

Qiu had been diagnosed with uterine polyps, a benign condition that was making her periods heavier and more unpredictable. Her OB-GYN proposed removing them but said it was safe to wait. Qiu said that she asked about the possibility of doing it in the doctor’s office under local anesthesia to make the procedure cheaper, but that her doctor rebuffed her suggestion because of her preference for general anesthesia.

Because Qiu thought she was getting a deal on her usual 30% share of the bill, she decided to go ahead with the polyp removal on Nov. 5, 2019. As she sat in the waiting room filling out forms, staffers let her know she needed to pay in full before the surgery.

Unease set in. The hospital asked for the 20% coinsurance — $1,656.10 — that she had been quoted over the phone, but Qiu hadn’t been told she needed to pay on the day of the procedure. As she handed over her credit card, she confirmed one more time that this would be her total patient responsibility, barring complications.

The surgery was over in less than 30 minutes, and she walked out of the hospital with her husband, feeling perfectly fine.

Then the bill came.

Patient: Tiffany Qiu is a 49-year-old real estate agent and mother of two who lives in Temecula, California. Her family of four is covered by a Blue Shield of California policy that she and her husband purchased on the marketplace. Last year, they paid a $1,455 monthly premium, with an individual annual $1,850 deductible and an individual out-of-pocket maximum of $7,550.

Total Bill: Palomar Health billed Blue Shield $22,219.64 for the polyp removal, which the insurer negotiated down to $8,576.79. Blue Shield paid $5,769.72 and stated in an explanation of benefits document that Qiu was responsible for a $334.32 deductible and $2,472.75 coinsurance.

Because Qiu had already paid $1,873.20 on the day of surgery, the hospital billed her an additional $933.87, which meant Qiu was on the hook for the remainder of her 30% coinsurance.

These figures don’t include the fees Qiu paid for anesthesia or her doctor’s services.

Service Provider: Palomar Medical Center in Poway is one of three hospitals in the Palomar Health system. Palomar Health is a San Diego County public health care district, which means the health care facilities are nonprofit and receive property taxes as a portion of their revenue stream. The system is governed by a board of directors elected from within the district’s boundaries.

What Gives: Hospitals and surgery centers sometimes offer discounts if patients are uninsured and able to pay with cash or a credit card. Physicians may even offer discounts on a patient’s share of the costs if they know the patient is unemployed or has fallen on hard times. But regularly offering discounts to attract patients is not common, and could even be fraudulent if the patients are insured through Medicare, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy.

In Qiu’s case, the hospital seemed to be offering a discount on the insurer’s normally required coinsurance.

“The hospital would be in breach of their contract with the insurance if they did not bill her for that amount,” said Martine Brousse, a California-based patient advocate and medical billing consultant for AdvimedPRO. “She owes what the insurance has calculated, and the facility has every right to demand payment.”

Copayments and coinsurance exist, in theory, so patients have “skin in the game.” They have to pay a clearly defined portion of the cost of their care, according to their policy, so they will shop around and use medical care judiciously (though many health experts say coinsurance amounts have gotten so high that many cannot afford them).

Resolution: If she hadn’t been quoted 20%, Qiu said, she would have shopped for a better deal. She flies to China often to visit her mother and was open to getting the surgery done there.

Qiu called the hospital to ask why she was being billed a second time, despite the lack of complications during the surgery. She remembers the back-and-forth over the remaining bill was exhausting, especially because it happened over the holidays.

“I got tired and said, ‘I don’t want to play this game anymore,’” Qiu recalled. “‘If you want to send it to collections, you can do it, but I’m not going to pay for it.’”

The bill landed at a collection agency called IC System. In a May 23 phone call, Qiu said, a representative offered to slash the remaining bill by 25% if she would just pay that day.

But Qiu refused, though she could easily afford to pay. She’s undaunted by the risk the unpaid bill poses to her credit score, preferring instead to fight the hospital on behalf of other patients who may not have the time or luxury to persist.

The experience left her feeling as if the hospital offered her a fake discount to reel in her business.

“I double-checked and tripled-checked with them,” Qiu said. “They have financial departments that should be verifying this with my insurance company.”

Another thing to note is how much the hospital billed Qiu for a simple outpatient procedure: $22,219.64. That amount is “totally laughable,” said Dr. Merrit Quarum, founder of WellRithms, a company that works with self-funded employers and other clients to make sense of complex medical claims.

Not only is the charge far out of line with what that procedure typically costs in that region (around $5,500), but Qiu is now stuck paying a larger amount as her share under the terms of her insurance. This is how those “sticker prices” that few people pay still drive up costs for individuals.

After a reporter’s call, Palomar Health looked back at phone records, confirmed Qiu’s version of events and said a hospital staffer had made a mistake by quoting her a 20% cost-sharing obligation. That percentage then got automatically put into her patient notes and was on the bill of estimated costs she signed and paid on the day of surgery, even though it was incorrect.

They apologized for giving the mistaken impression that Qiu was getting a discount. Staff members are not authorized to offer discounts when providing estimates, said Derryl Acosta, a spokesman for Palomar Health.

Acosta also pointed out other communication breakdowns, like dropping the complaint Qiu phoned in after she received the second bill in late November. Her issue did not get put into the standard customer complaint process, which would have elevated the problem and triggered an investigation into the phone records. That’s why Qiu’s bill was sent to the collection agency.

“We definitely admit that the call should have been handled differently,” Acosta said. “We now have a new call center that we believe will handle this type of call better.”

Because Palomar Health was able to see in their phone records that a staffer had confirmed the erroneous 20% coinsurance amount to Qiu, the health system will change her bill to reflect what she was promised. Qiu will get a statement in the mail saying she has a zero balance, Acosta said.

The Takeaway: Multiple medical billing advocates who reviewed Qiu’s case praised her for her tenacity in calling the hospital financial department twice before the procedure. But as she herself acknowledged, most people don’t have the time or spine to fight.

To avoid such situations, experts advised, patients should check in with their insurer about the discounts offered, as hospital staffers may be poorly trained or ill informed.

If a patient hears conflicting information about charges before a procedure, they need to approach their insurer to confirm the details of their own policy, said Brousse, the patient advocate.

The simple fact that a hospital staffer misinformed a patient isn’t a legal reason to force a hospital to lower a bill, Brousse said.

Also, get promises in writing — before the day of surgery. Make sure the offer is explicit about which services are included and what might count as a complication. Ask whether you’ll have to pay upfront.

Initial estimated bills can be full of asterisks and “weasel words,” said Akshay Gupta, co-founder of CoPatient, a medical bill review and patient advocacy company.

“Even though she tried to be diligent, obviously she still didn’t know that she would need to get something that was legally enforceable,” said Gupta.

Dan Weissmann, host of the podcast “An Arm and a Leg,” reported the radio interview of this story. Joe Neel of NPR produced the interview with KHN Editor-in-Chief Elisabeth Rosenthal on “Morning Edition.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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If Trump Wins, Don’t Hold Your Breath Waiting for That ACA Replacement Plan

If President Donald Trump wins reelection next week, it seems unlikely he will unveil the health plan he’s been promising since before his election in 2016. Still, other aspects of health care could be featured in his second-term agenda.

Not having a replacement plan for the Affordable Care Act may be just fine with many of his supporters and conservatives. Most Republicans don’t want the federal government to remake the nation’s health system, said Grace-Marie Turner, of the conservative Galen Institute. “It’s a different philosophy from Democrats, who think it needs to be a big program,” she said. “Conservatives, we think of it in a more targeted way.”

Trump, of course, repeatedly promises something big. “We will have Healthcare which is FAR BETTER than ObamaCare, at a FAR LOWER COST – BIG PREMIUM REDUCTION,” he tweeted Oct. 12 — hardly the first time he’s made a similar promise. “PEOPLE WITH PRE EXISTING CONDITIONS WILL BE PROTECTED AT AN EVEN HIGHER LEVEL THAN NOW. HIGHLY UNPOPULAR AND UNFAIR INDIVIDUAL MANDATE ALREADY TERMINATED. YOU’RE WELCOME!”

But Trump needs a contingency plan if the Supreme Court accepts his argument that the ACA should be overturned. The justices are scheduled to hear the case the week after Election Day. Administration health officials have pledged to have an alternative if the high court does as they ask. But they have refused to publicly share any details.

In September, Trump unveiled a package of health care proposals at a speech in North Carolina. The “America First Healthcare Plan” is less than an actual plan, though. It’s a vague set of claims about things that have not happened yet — like bringing down prescription drug prices — along with a laundry list of some of his administration’s lesser accomplishments on health issues, such as the initiative to help Americans with severe kidney disease and efforts to improve the availability of health care in rural areas.

As part of that overall health plan, Trump issued an executive order declaring “it has been and will continue to be the policy of the United States … to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.” But there is nothing in the order — or in the broader outline — to ensure that would be the case if the ACA were struck down. It would take congressional action to guarantee that.

The current court controversy over the ACA arose because Congress in its 2017 tax bill eliminated the financial penalty for not having health insurance. But Congress didn’t have the votes to get rid of the mandate itself under the rules for the tax bill. Republican state officials then sued, arguing that since the Supreme Court had once upheld the ACA’s mandate, calling it a tax, once the penalty was gone, the law should also be invalidated.

Trump frequently heralds his actions, erroneously saying he killed the mandate and arguing that he got rid of the most detested part of the law.

“He likes to use words, but I don’t think there’s been a substantive policy yet,” said Len Nichols, a health policy professor at George Mason University. “I have no clue what he would do” in a second term “other than trying to repeal the ACA.”

One thing Trump accomplished in his first term is a set of potentially far-reaching regulatory actions, many of which have been challenged in federal courts. Those include allowing states to implement work requirements for people who receive Medicaid health benefits and requiring hospitals and other health providers to make their negotiated prices available to the public.

Legal analysts have doubted the administration’s authority to implement many changes Trump has proposed. But considering Trump has appointed hundreds of federal judges, including Supreme Court justices, the legal landscape may be changing and more of those proposals could be allowed to proceed.

Still, Trump faces uphill battles on some of his preferred health initiatives, even if Republicans control Congress.

For example, said Dan Mendelson of the consulting group Avalere Health, “I would expect that if he’s reelected there would be a drug pricing agenda he continues to push.” Among his proposals is having Medicare pay for drugs based on what the medicines sell for in countries that negotiate prices. That would be complicated, Mendelson said, by the fact that “the broader Republican Party doesn’t want to move to a regulatory model in this country.”

But the Galen Institute’s Turner said not to discount the changes Trump has made, such as allowing broader sales of short-term health plans that are less expensive but offer fewer benefits than ACA plans. She said to expect actions in a similar vein in a second term. “He really has done a lot, using his executive authority, based on trying to make markets work better and give people more choice,” she said. “They are strategic, targeted approaches to specific problems.”

He’ll certainly have a specific problem if the ACA is struck down. Americans losing their insurance won’t want to wait to find out if he has a plan.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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North Carolina Treasurer Took On the Hospitals. Now He’s Paying Political Price.

Cartel is a term frequently associated with illegal narcotics syndicates. In North Carolina, it has become the favored word of State Treasurer Dale Folwell to describe the state’s hospital industry, the antagonist in his quest to lower health care prices for state employees.

The treasurer manages the state employees’ health plan, which insures about 727,000 teachers, police officers, current and retired state workers and dependents. Folwell, a Republican, has tried to persuade hospitals to accept lower payments, but he has struggled to discover the existing rates the plan pays each hospital.

“These organizations’ business model is secrecy,” Folwell said, “from the billing all the way up to the way these hospitals’ organizations receive their tax-exempt status.”

Now, as Folwell, 62, seeks a second four-year term, the state’s hospitals are coming after him.

The North Carolina Healthcare Association, the hospital trade group, has endorsed Folwell’s Democratic challenger. It is a rare instance of a health care lobby seeking to topple an incumbent. Over 26 years, North Carolina’s hospital association donated $2.1 million to sitting officeholders but bestowed just $29,700 to challengers, according to a tally from the National Institute on Money in Politics, a Montana-based nonprofit. All donations made this year will not be fully disclosed until after the election.

In many states, hospital associations are political powerhouses, with stables of lobbyists and the influence that comes with often being the largest employer in many legislative districts. In the previous election cycle of 2018, the hospital industry across the country donated $71 million to local and state candidates, political parties and ballot initiatives, according to the Money in Politics data. That amounted to a fifth of all spending by the health care industry and nearly three times that spent by pharmaceuticals and health products companies.

“The hospitals have very strong political clout in North Carolina, and increasingly so as they get bigger,” said Aaron McKethan, a resident scholar at the Margolis Center for Health Policy at Duke University’s Fuqua School of Business. “They are huge sources of employment. If anything, COVID has reinforced and strengthened them — the job of wagging your finger at hospitals over their prices has gotten harder.”

Nationally, hospitals account for a third of health care spending. The prices hospitals charge private insurers including the state health plan are driving much of the increase in health care premiums. In North Carolina, hospital inpatient prices for private insurers rose by 10% from 2014 to 2018, according to the Health Care Cost Institute.

Folwell’s critics complain that, despite his verbal provocations about hospital power, his efforts to transform health care pricing have mostly fizzled. They also lament that he has made no effort to try to persuade the legislature to expand Medicaid, which would help shore up hospital finances.

“The treasurer has, for some reason, insisted on taking a ‘my way or the highway’ approach, rather than engage in honest conversations and negotiations,” Cynthia Charles, the hospital association’s spokesperson, said in an email. “As we have repeatedly said, we are willing to work together to redesign the plan in a manner to advance goals for cost reductions, price transparency and provider inclusion.”

Folwell’s Democratic challenger, Ronnie Chatterji, and the hospital industry insist a better way to bring health costs under control would be to tie payments to the quality of care, an approach Blue Cross and Blue Shield of North Carolina has begun experimenting with. With blunt cuts, “you’re just going to put people’s health care access in jeopardy,” said Chatterji, an economist at the Fuqua School who served on former President Barack Obama’s Council of Economic Advisers.

The bad blood between Folwell and North Carolina hospitals primarily traces back to 2018, when the treasurer told hospitals, doctors and other medical providers that to avoid having to ask the legislature for more money or raise employee contributions, he wanted to reduce by $300 million the amount the $3.3 billion health plan paid medical providers each year.

Folwell proposed to base prices on Medicare rates, an approach known as reference pricing. His plan offered to pay most hospitals 175% of what Medicare reimbursed them for inpatient services and 225% for outpatient services, on average. Rural hospitals, which tend to be in worse financial shape, would have received more, but their rates would also have been pegged to Medicare.

The plan would have amounted to a pay cut for most hospitals. A recent Rand Corp. study of hospital prices found that North Carolina hospitals in 2018 were paid on average 221% of Medicare rates for inpatient services and 334% of Medicare rates for outpatient services — well above what the treasurer was proposing.

The state’s two big nonprofit systems, Atrium Health and Novant Health, earned substantially more, according to the Rand data. For example, Atrium Health Mercy hospital in Charlotte collected 423% of Medicare outpatient prices. Forsyth Medical Center in Winston-Salem, owned by Novant, collected 377% of what Medicare paid for outpatient services.

In its newsletter, the hospital association told its members that it tried to negotiate with the treasurer but that “Folwell has responded with disinterest and hostility towards these overtures and is instead engaging in a public campaign to malign hospitals.”

The hospitals warned customers that if no agreement could be reached with the state plan, the hospitals would be classified as out-of-network providers and state employees would end up having to pay far more for their services.

Those arguments about financial penury obscured the fact that North Carolina’s major hospital systems run huge surpluses in most years. Financial disclosure documents show that Atrium, which owns 36 hospitals in the state, ended 2019 with a $370 million surplus, a 6% margin. Novant, which owns 12 hospitals in North Carolina, that year earned $155 million, a 3% margin.

UNC Health, which amassed $271 million — a 6.4% margin — in its 2019 fiscal year, said in a statement that the treasurer’s plan would have cost it $47 million in its 2020 fiscal year and “jeopardized the financial viability of some of our rural hospitals.”

“We’re overpaying for no reason but to build multimillion reserves for these hospital corporations,” said Ardis Watkins, executive director of the State Employees Association of North Carolina.

Ultimately, the hospitals maintained a solid wall of opposition. Only three of North Carolina’s 108 hospitals signed on to the treasurer’s plan.

Duke’s McKethan said it was “predictable” that the hospitals would refuse to give up the negotiating advantages they held. “On the diagnosis of the problem — we’ve got these opaque prices that vary — he’s on solid ground,” he said about Folwell. “But when a good idea runs into the disadvantageous structure of the health care market, it doesn’t go anywhere.”

Apart from hospitals, the treasurer had some success in persuading about 25,000 of the state’s 60,000 doctors, therapists and other medical providers to accept the new payment system, which he named the Clear Pricing Project. Dr. Dale Owen, CEO of Tryon Medical Partners, a large independent physicians’ group based in Charlotte, said his group’s reimbursements will come out about the same under the plan.

“Quite honestly, even if it had been a tiny loss, no big deal because it was the right thing to do for everybody,” said Owen, who formed his group with fellow physicians who seceded from Atrium. “What he’s doing is, he’s opening a sore and a problem that people have not been willing to deal with and pushed under the rug.”

The Clear Pricing Project has yet to demonstrate the ability to save the state money. In fact, the effort may be costing the state more because many of the providers that signed on — such as primary care doctors and behavioral health specialists — are getting higher reimbursements than they had been while those that would have lost money, like hospitals, have stayed away.

Asked why he thought the hospitals would volunteer to forgo higher payments, Folwell said he had hoped they would realize that their long-term survival is endangered by the unsustainable increase in health care costs.

“I thought they would want to be partnering with a solution instead of the same old way,” he said in an interview. “I don’t think they accept the notion that they’re going to be on the wrong side of history.”

The hospital industry has been taking steps to try to make Folwell and his proposal history. During his attempt to get hospitals to agree to the pricing plan, the industry’s allies in the legislature introduced a bill that would have blocked the state health plan from instituting any reference pricing plan through 2021. That effort ultimately died.

Folwell has continued to rankle the hospitals with his opposition to further concentration of hospital ownership. He has opposed the pending sale of a county-owned hospital based in Wilmington, which Novant is purchasing. That followed his 2018 attempt to challenge an ultimately unsuccessful merger of Atrium and UNC Health by requesting a $1 billion performance bond if the deal ultimately raised prices for the state health plan.

Last month, the hospital association gave Chatterji its endorsement with a clear swipe at Folwell. The association’s president, Steve Lawler, said in the statement that “it is apparent that Mr. Chatterji genuinely wants to collaborate.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Florida Fails to Attract Bidders for Canada Drug Importation Program

Florida’s plan to import cheaper prescription drugs from Canada — designed by Gov. Ron DeSantis and endorsed by President Donald Trump — has tasted its first bitter pill.

No private firms bid on Florida’s $30 million contract to set up and operate a drug importation program. Bids were due at the end of September.

The setback is likely to delay by at least several months Florida’s effort to become the first state to import drugs.

A spokesperson for the Florida Agency for Health Care Administration said the state is exploring its options. “The agency remains confident it will find a qualified vendor soon,” the spokesperson said. The state had planned to award a contract to a private vendor in December.

The disclosure of no bidders comes less than a month after the Trump administration cleared the way for states to apply for federal permission to set up an importation program — reversing nearly two decades of U.S. policy.

A 2003 law allows drug importation from Canada, but only if the head of the federal Department of Health and Human Services deems it safe and cost-effective. HHS Secretary Alex Azar made that declaration Sept. 24 and approved final rules for such initiatives.

Jane Horvath, a health consultant in College Park, Maryland, said potential bidders on the Florida contract were likely put off because the final federal rules were not set until late September. And private firms didn’t want to bid on a contract that would have to change if the Florida rules conflicted with those from Washington, she said.

Several inconsistencies are apparent between the Florida plan and what is allowed under the HHS final rules, she said. For example, Florida aims to give bonus-scoring points to contractors that repackage and relabel drugs in Florida, which is not allowed under the federal rules.

Another problem is that the private contractor has to determine which prescription drugs will produce the most savings for Florida’s Medicaid program, which is difficult since Medicaid rebates and other discount pricing are confidential.

“It could be that the $30 million contract is not enough either,” Horvath said.

Drug prices are lower in Canada because the country limits how much drugmakers can charge for medicines. The United States lets drugmakers and their distributors dictate prices.

Trump, who made lowering prescription drug prices a key campaign issue in 2016, has promoted importation, especially in messages geared to seniors during his reelection bid.

Critics say importing drugs from Canada would threaten the drug supply with counterfeit products. Because high-cost biologic drugs, including insulin, and intravenously injected medicines are not allowed to be imported under current law, the strategy could have limited impact.

Even with HHS backing, drug importation faces several challenges. Most notably, Canada has vowed to stop any effort that would exacerbate drug shortages there, which could make it challenging to identify a Canadian exporter. And the pharmaceutical industry opposes the program and is likely to sue to stop it.

Florida plans to set up an importation program to help lower drug prices for people covered by state programs such as Medicaid and the Corrections Department. The state has projected savings of up to $150 million a year.

The federal rules take effect Nov. 30, which is when states can formally apply to HHS to set up their program.

A chief architect of Florida’s importation plan, Mary Mayhew, who was secretary of the Florida Agency for Health Care Administration, resigned in September to become CEO of the Florida Hospital Association.

Mayhew refused to comment for this story.

Vermont, Colorado, Maine, New Hampshire and New Mexico are also devising programs to import drugs from Canada.

Colorado officials plan to seek out private contractors for that state’s program in 2021, and they hope to get final federal approval by summer 2022, officials said during a recent call with stakeholder groups.

Colorado plans to allow consumers to get drugs from Canada at their U.S. pharmacy or through mail order. It estimates residents could save an average of 61% off the price of medicines in Colorado today.

It’s unclear what impact the outcome of the presidential election will have on drug importation. Democratic nominee Joe Biden said he supports importing drugs from Canada. But, if elected, he is also likely to review many of the Trump administration’s actions.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Progressive Group Highlights Trump, Tillis Weakness on Insulin Price Tags

 

 

During the first presidential debate of 2020, President Donald Trump touted his efforts to curb skyrocketing drug prices and declared that insulin is now “so cheap, it’s like water.” The response on social media was swift, and divided, with some people sharing pharmacy bills showing thousands of dollars they’d spent on insulin, while others boasted of newfound savings.

The next day, a self-described progressive political action committee called Change Now jumped into the fray by releasing an ad that circulated on Facebook attacking Trump and Sen. Thom Tillis (R-N.C.) on this issue.

In the 30-second ad, a North Carolina woman in her 30s explains she was diagnosed with Type 1 diabetes at age 4.

“Donald Trump and Thom Tillis opposed legislation that would lower the price of insulin and other prescription drugs,” she says. “People with diabetes can’t afford to wait for Trump and Tillis to fight for us. … We need affordable insulin now.”

(Posts sharing the quote were flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed. Read more about PolitiFact’s partnership with Facebook.)

In recent years, politicians on both sides of the aisle have committed to addressing the cost of insulin. This election cycle — coinciding with a looming threat to the Affordable Care Act and millions of people losing jobs and employer-sponsored health insurance during the pandemic — the high price of prescription drugs has gained new significance.

Tillis is in one of the most heated Senate races in the country and has been repeatedly criticized by his opponent for receiving more than $400,000 in campaign contributions from the pharmaceutical and health product industries. Across the country, many voters say lowering prescription drug costs should be the top health priority for elected officials.

So, did Trump and Tillis really oppose policies that would accomplish that goal? We decided to take a closer look.

It turns out they’ve both opposed certain pieces of legislation that could have lowered the price of insulin and other prescription drugs, but they’ve also offered alternatives. The question is how aggressive those alternatives are and how many Americans would benefit from them.

Opposing the Strongest Reforms

Change Now pointed to two congressional bills to support the ad’s claim: one opposed by Trump, and the other by Tillis.

The first bill, known as H.R. 3, passed the House in December 2019, largely due to Democratic votes. It contains three main elements: decreasing out-of-pocket costs for people on Medicare, penalizing pharmaceutical companies that raise the price of drugs faster than the rate of inflation and — the most aggressive and controversial feature — allowing the federal government, which administers Medicare, to negotiate the price of certain drugs, including insulin. It also requires manufacturers to offer those agreed-on prices to private insurers, extending the benefits to a wider swath of Americans.

Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine, called it “the broadest-reaching policy that has been put forward” on drug pricing.

“While a lot of reform has focused on Medicare beneficiaries, that misses many insulin users,” Dusetzina said. “H.R. 3 does the most to affect prices for young consumers, like the woman in the ad.”

At the time, Trump vowed to veto that bill, saying the price controls it imposed “would likely undermine access to lifesaving medications” by decreasing the incentive for companies to innovate. When we checked in with the Trump campaign about the ad, a spokesperson reiterated this position, adding that the president continues to seek better legislative options.

The House bill in question, though, never made it to the president’s desk because the Senate didn’t take it up. Instead, the Senate Finance Committee proposed its own bill, which brings us to the second piece of legislation cited by Change Now.

Known as the Prescription Drug Pricing Reduction Act of 2019, the Senate bill echoes two aims of the House proposal: decreasing out-of-pocket costs for people on Medicare and putting an inflation-based cap on some drug prices.

That bill, too, stalled, with several Republican senators wary of the inflation cap. Among them was Tillis, who expressed concern that the measure could hamper innovation.

So, it’s true that Trump and Tillis have both opposed legislation that could lower the cost of insulin and other prescription drugs. But that’s not the full picture of what either politician has done on this issue.

Alternative Solutions for a Smaller Group of Americans

The Trump campaign provided a long list of actions taken by his administration to curb the high costs of medication, including a flurry of executive orders related to insulin and prescription drugs. Tillis’ campaign highlighted an alternative bill the senator co-sponsored to target drug costs. Let’s break them down one at a time.

One of Trump’s orders aims to have Federally Qualified Health Centers provide insulin and EpiPens at a discounted rate to the low-income individuals they serve. These centers, however, are already required to offer sliding-scale payments, and a full discount to patients who earn below the federal poverty line, said Rachel Sachs, an associate professor of law at Washington University in St. Louis, who tracks drug-pricing laws.

Another order deals with the importation of drugs from Canada, where they are often cheaper. Although the order specifically excludes biologic drugs, including insulin, the administration has requested proposals from private companies on how insulin could be safely brought in from other countries.

The president also issued a particularly ambitious order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The Trump administration, however, hasn’t released final regulations to implement that policy, which could take years. If implemented, the policy is expected to be challenged in court by the drug industry.

Perhaps the most notable measure on insulin at the moment, experts said, is a federal demonstration project that Medicare plans can voluntarily opt into, to cap the monthly copay for insulin at $35 for some seniors. The project is slated to begin in January 2021, but its long-term future is uncertain, Sachs said, because it relies on parts of the Affordable Care Act, which could be struck down by a Supreme Court ruling later this year.

In Congress, Tillis and five other Republican senators introduced an alternative drug-pricing bill last December, called the Lower Costs, More Cures Act.

Tillis believes this is “the better option,” campaign spokesperson Andrew Romeo said, because “in addition to helping control drug prices, the legislation also seeks to preserve America’s capacity to research and develop lifesaving medications.” It includes a monthly cap on insulin copays for Medicare beneficiaries and requires manufacturers to disclose prices in consumer ads.

But experts said Tillis’ proposal is weaker than other options before the House and Senate. It doesn’t include an inflation cap, Sachs said, and the bill’s benefit would likely be limited to some seniors on Medicare, leaving out the more than 150 million Americans covered by private insurance.

Jason Roberts, an associate professor of political science at the University of North Carolina-Chapel Hill, said the bill is largely symbolic.

“Tillis is getting hit for not supporting a bill that could move,” Roberts said. “Instead, he introduces something that has no chance of going anywhere, and he knows that. But it’s a way of trying to deflect that criticism without getting a lot accomplished.”

Our Ruling

An ad sponsored by a progressive political action committee claims that Trump and Tillis have opposed legislation that would decrease the cost of insulin and other prescription drugs.

Based on the two pieces of drug-pricing legislation Change Now points to, that’s accurate. Trump and Tillis have voiced opposition to prominent bills that experts say could decrease the cost of insulin for a broad group of Americans.

However, both politicians have also proposed alternative policies to lower the price of insulin and other prescription drugs. Most of their proposals have not taken effect yet and are largely targeted at seniors.

We rate the ad’s claim Mostly True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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UVA Health Still Squeezing Money From Patients — By Seizing Their Home Equity

Doris Hutchinson wanted to use money from the sale of her late mother’s house to help her grandchildren go to college.

Then she learned the University of Virginia Health System was taking $38,000 of the proceeds because a 13-year-old medical bill owed by her deceased brother had somehow turned into a lien on the property.

“It was a mess,” she said. “There are bills I could pay with that money. I could pay off my car, for one thing.”

Property liens are the hidden icebergs of patient medical debt, legal experts say, lying unseen, often for decades, before they surface to claim hard-won family savings or inheritance proceeds.

An ongoing examination by KHN into hospital billing and collections in Virginia shows just how widespread and destructive they can be. KHN reported a year ago that UVA Health had sued patients 36,000 times over six years for more than $100 million, often for amounts far higher than what an insurer would have paid for their care. In response to the articles, the system temporarily suspended patient lawsuits and wage garnishments, increased discounts for the uninsured and broadened financial assistance, including for cases dating to 2017.

Those changes were “a first step” in reforming billing and collection practices, university officials said at the time.

However, UVA Health continues to rely on thousands of property liens to collect old bills, in contrast to VCU Health, another huge, state-owned medical system examined by KHN. VCU Health pledged in March to stop seizing patients’ wages over unpaid bills and to remove all property liens, which are created after a creditor wins a court judgment.

Working courthouse-by-courthouse, VCU Health now says it has discovered and released 45,000 property liens filed against patients just in Richmond, its home city, some dating to the 1990s. There are an estimated 35,000 more in other parts of the state. Fifteen thousand of those have been canceled and they are working on the rest, officials said. These figures have not been previously reported. The system is part of Virginia Commonwealth University.

VCU Health’s total caseload is “a huge number” but perhaps not astonishing given the energy with which many hospital systems sue their patients, said Carolyn Carter, deputy director of the National Consumer Law Center.

Despite having suspended patient lawsuits, UVA Health has continued to create property liens based on older court cases, court records show. The number of new liens is “small,” said UVA Health spokesperson Eric Swensen.

An advisory council of UVA Health officials and community leaders is expected to deliver new recommendations by the end of October, Swensen said. The council, whose schedule has been slowed by the coronavirus crisis, has discussed property liens, Don Gathers, an activist and council member, said in an interview this summer.

Nobody knows how many old or new UVA Health liens are scattered through scores of Virginia courthouses. The health system, which has sued patients in almost every county and city in the state, has failed to respond to repeated requests over two years to disclose the number and value of its property liens.

But in Albemarle County alone, which surrounds the university’s Charlottesville home, “there are thousands” of UVA Health judgments filed in the land records, which creates a lien, said Circuit Court Clerk Jon Zug.

Not just Virginia homes are at risk. UVA Health lawyers search the nation for property or other assets owned by patients with outstanding bills and have filed liens in Maryland, West Virginia, Ohio and Florida, court records show.

The system put a lien on a Nevada vacation condo owned by Veronica Musie’s family a decade ago over a $30,600 hospital bill, said Musie, who lives in northern Virginia. The family has since paid the debt.

Virginia property liens expire after 20 years. But UVA Health often renews them. Since 2017, just in Albemarle County, it has renewed more than three dozen liens. That means the medical system could seize families’ home equity until 2039 for bills dating to the last century.

UVA Health and other medical systems rarely force the sale of a home to claim money. Instead, they wait for families to refinance or sell, taking their cut at the settlement table. But with 6% simple interest accumulating year after year after the court judgment, as allowed by Virginia law, the final amount owed can be much more than the original charges.

UVA Health treated Hutchinson’s brother for heart disease in the early 2000s. The unpaid bill was $24,868. The system laid claim to their mother’s home because he was one of her heirs. The claim is up to $38,000 now, she said, because of interest charges. Hutchinson has been disputing it for more than a year.

VCU Health and its MCV Physicians affiliate estimate that eliminating two decades of property liens in courthouses across the state, which they began to do last year after KHN published its reports, won’t be finished until spring.

Richmond was especially problematic. Because releasing 40,000 Richmond liens by hand would have been impractical, VCU Health got a judge’s permission to do it with computer code.

Creditors such as UVA and VCU don’t need addresses to create liens. All they have to do is file a judgment in county or city land records. If debtors own any property there, title companies won’t approve a sale until the debt is paid, often with home equity.

Often owners don’t know debts exist until paralegals unearth them when homes are sold, property pros say. Old debts can create liens on newly acquired real estate.

“It could be your grandmother’s house, and as soon as you’ve inherited it, and you’ve got judgments, those [liens] are now attached,” said Richmond Court Clerk Edward Jewett.

Frequently debtors own no property, so judgments in the land records expire without hospitals or other creditors getting anything.

VCU and MCV had no idea how many liens they had placed across the state until they began investigating last year after KHN’s inquiries, officials said.

“It’s an incredibly manual process” to cancel the claims, partly because computer systems at many courthouses prohibit an easy tech solution, said Melinda Hancock, VCU Health’s chief administrative and financial officer. But it’s worth it to remove a burden on patients, she said, adding, “This is an outdated collections practice whose time has come and gone.”

But many medical systems still do it, consumer debt experts say, noting that obtaining a complete picture of hospital property liens is impossible.

Land and judgment records are held by thousands of local court clerks, often using separate computer systems. Records are difficult or impossible to obtain in bulk.

“There is not a good nationwide study that I know of that looks at how widespread this is, how many consumers are affected, what’s the average size of a lien,” said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing.

Mike Miller and Kitt Klein are among those hoping UVA Health follows VCU Health in canceling thousands of property liens. They fear a $129,000 judgment won by UVA in 2017 against Miller will cost them the equity in their home in Quicksburg, Virginia.

They make about $25,000 a year. Miller, a house painter, was insured but received out-of-network radiation at UVA that doctors said was necessary to treat his lung cancer.

After KHN wrote about his case a year ago, benefits firm WellRithms analyzed his UVA bill and found that a commercial insurer would have paid a little more than $13,000, not $129,000, for the treatment.

“We know all [health care] providers bill a lot, but usually ‘a lot’ is three to six times what reasonable prices would be,” said Jordan Weintraub, vice president of claims for WellRithms. Trying to collect 10 times as much, she said, “is really out there.”

UVA Health does not comment on individual patient cases, Swensen said.

KHN found last year that UVA frequently sued patients for far more than what the system could have collected from insurance.

Early this year Miller and Klein emailed UVA President James Ryan, asking for help in reducing or eliminating the judgment. His office phoned in February, saying it would review the case.

“I became very emotional, filled with gratitude,” Klein said. “I couldn’t talk.”

Months went by with no contact. Recently a lawyer from the office of Virginia Attorney General Mark Herring offered to settle the case for $120,000, Klein said, reducing the bill by only $9,000. They don’t have the money. Miller’s cancer has returned. Interest is mounting at 6%.

University officials do not comment on legal matters or individual cases, a Ryan spokesperson said. Herring’s office did not respond to requests for comment.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Vetting TikTok Mom’s Advice for Dealing With Debt Collectors

Can’t see the audio player? Click here to listen.

TikTok mom Shaunna Burns used to be a debt collector, so she knows a few things about what’s legal and what’s not when a company contacts you to settle a debt. We fact-checked her advice with a legal expert: Jenifer Bosco, an attorney with the National Consumer Law Center.

Bosco said most of Burns’ advice totally checks out.

A recent report from ProPublica shows that debt collectors have thrived during the pandemic; they’re out in force to get people to pay up. But we have rights. Scroll down for some consumer protection resources.

You don’t need to have heard our earlier episode about Burns and her story; you can start right here. (Both conversations contain lots of strong language, so maybe listen when the kids aren’t around.)

Meanwhile, here are links to resources:

Burns’ Dealing-With-Debt-Collectors TikTok Videos

Be sure to note Jen Bosco’s legal caveats, but Burns will get you in the fighting spirit.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Al sopesar los temas de salud, la mayoría de los votantes se inclinan hacia Biden

Al menos la mitad de los votantes prefiere el enfoque de la atención médica del ex vicepresidente Joe Biden al del presidente Donald Trump, lo que sugiere que la preocupación por reducir los costos y manejar la pandemia podría influir en el resultado de esta elección, según revela una nueva encuesta.

Los hallazgos, de la encuesta mensual de KFF, indican que los votantes no confían en las garantías del presidente de que protegerá a las personas con condiciones preexistentes de las compañías de seguros si la Corte Suprema anulara la Ley de Cuidado de Salud a Bajo Precio (ACA).

Un mes antes de que el tribunal escuche los argumentos de los fiscales generales republicanos y la administración Trump a favor de revocar la ley, la encuesta muestra que el 79% del público no quiere que el Supremo cancele las protecciones de cobertura para los estadounidenses con afecciones preexistentes. La mayoría de los republicanos, el 66%, dijo que no quiere que se anulen esas garantías.

Además de dejar a unos 21 millones de estadounidenses sin seguro, revocar ACA podría permitir a las compañías de seguros cobrar más o negar cobertura a las personas porque tienen condiciones preexistentes, una práctica común antes que se estableciera la ley, y que un análisis del gobierno reveló en 2017 que podría afectar hasta a 133 millones de estadounidenses.

Casi 6 de cada 10 personas dijeron que tenían un familiar con una condición preexistente o crónica, como diabetes, hipertensión, o cáncer, y aproximadamente la mitad dijo que les preocupa que un ser querido no pueda pagar la cobertura, o la pierda por completo, si se anulara la ley.

La encuesta revela una preferencia sorprendente por Biden sobre Trump cuando se trata de proteger a las personas con condiciones preexistentes, un tema que el 94% de los votantes dijo que ayudaría a decidir por quién votar. Biden tiene una ventaja de 20 puntos: un 56% prefiere su enfoque, contra un 36% para Trump.

De hecho, el sondeo muestra una preferencia por Biden en todos los problemas de atención médica que se plantean, incluso entre los mayores de 65 años y en temas que Trump ha dicho que eran sus prioridades mientras estuviera en el cargo, lo que indica que los votantes no están satisfechos con el trabajo del presidente para reducir los costos de la atención médica, en particular. El apoyo a los esfuerzos de Trump para reducir el precio de los medicamentos recetados ha disminuido, y los votantes ahora prefieren el enfoque de Biden, del 50% al 43%.

La mayoría de los votantes dijeron que prefieren el plan de Biden para lidiar con el brote de COVID-19, 55% a 39%, y para desarrollar y distribuir una vacuna para COVID, 51% a 42%. Trump ha delegado en gran medida la gestión de la pandemia a los funcionarios estatales y locales, al tiempo que prometió que los científicos desafiarían las expectativas y producirían una vacuna antes del día de las elecciones.

Cuando se les preguntó qué tema era más importante para decidir por quién votar, la mayoría de los encuestados señaló a la atención médica. El 18% eligió el brote de COVID-19 y el 12% mencionó el cuidado de salud en general. Casi una proporción igual, el 29%, optó por la economía.

La encuesta se realizó del 7 al 12 de octubre, después del primer debate presidencial y el anuncio de Trump de que había dado positivo para COVID-19. El margen de error es más o menos 3 puntos porcentuales para la muestra completa y 4 puntos porcentuales para los votantes.

(KHN es un programa editorialmente independiente de KFF).

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Majority of Voters Tilt Toward Biden as Health Issues Weigh Heavily

At least half of voters prefer former Vice President Joe Biden’s approach to health care over President Donald Trump’s, suggesting voter concern about lowering costs and managing the pandemic could sway the outcome of this election, a new poll shows.

The findings, from KFF’s monthly tracking poll, signal that voters do not trust assurances from the president that he will protect people with preexisting conditions from being penalized by insurance companies if the Supreme Court overturns the Affordable Care Act. (KHN is an editorially independent program of KFF.)

Coming a month before the court will hear arguments from Republican attorneys general and the Trump administration that the health law should be overturned, the poll shows 79% of the public does not want the court to cancel coverage protections for Americans with preexisting conditions. A majority of Republicans, 66%, said they do not want those safeguards overturned.

In addition to leaving about 21 million Americans uninsured, overturning the ACA could allow insurance companies to charge more or deny coverage to individuals because they have preexisting conditions — a common practice before the law was established, and one that a government analysis said in 2017 could affect as many as 133 million Americans.

Nearly 6 in 10 people said they have a family member with a preexisting or chronic condition, such as diabetes or cancer, and about half said they worry about a relative being unable to afford coverage, or lose it outright, if the law is overturned.

The poll reveals a striking preference for Biden over Trump when it comes to protecting preexisting conditions, an issue that 94% of voters said would help decide who they vote for. Biden has a 20-point advantage, with voters preferring his approach 56% to 36% for Trump.

In fact, it shows a preference for Biden on every health care issue posed, including among those age 65 and older and on issues that Trump has said were his priorities while in office — signaling voters are not satisfied with the president’s work to lower health care costs, in particular. Support for Trump’s efforts to lower prescription drug costs has been slipping, with voters now preferring Biden’s approach, 50% to 43%.

A majority of voters said they prefer Biden’s plan for dealing with the COVID-19 outbreak, 55% to 39%, and for developing and distributing a vaccine for COVID-19, 51% to 42%. Trump has largely left it up to state and local officials to manage the outbreak, while promising that scientists would defy expectations and produce a vaccine before Election Day.

Asked which issue is most important to deciding whom to vote for, most pointed to health care issues, with 18% choosing the COVID-19 outbreak and 12% saying health care overall. Nearly an equal share, 29%, selected the economy.

The survey was conducted Oct. 7-12, after the first presidential debate and Trump’s announcement that he had tested positive for COVID-19. The margin of error is plus or minus 3 percentage points for the full sample and 4 percentage points for voters.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Job-Based Health Insurance Costs Are Up 4% This Year, 55% in Past Decade

Health insurance costs for Americans who get their coverage through work continued a relentless march upward with average family premiums rising 4% to $21,342 this year, according to a study published Thursday.

The annual survey by KFF found workers on average are paying nearly $5,600 this year toward family coverage, up from about $4,000 in 2010 and $1,600 in 2000. (KHN is an editorially independent program of KFF.)

While health insurance costs rose a modest amount in 2020, as has been the trend in recent years, they soared 55% in the past decade — more than twice the pace of inflation and wages.

About 157 million Americans rely on employer-sponsored coverage — far more than any other type of coverage, including Medicare, Medicaid and individually purchased insurance on the Affordable Care Act exchanges. More than half of employers provide insurance to at least some workers.

“Conducted partly before the pandemic, our survey shows the burden of health costs on workers remains high, though not getting dramatically worse,” Drew Altman, KFF’s CEO, said in a statement. “Things may look different moving forward as employers grapple with the economic and health upheaval sparked by the pandemic.”

The survey was conducted from January to July as the coronavirus pandemic took hold and upended the nation’s economy. Many of the details of the employers’ plans that the researchers examined were set before the virus hit.

Since 2012, the cost of family coverage has increased 3% to 5% annually. It’s been more than 15 years since these costs were rising at double-digit rates.

Employers help shield workers from much of the cost of their health insurance premiums, though employees often feel the impact via higher deductibles, copayments and lower wages.

On average, workers pay 17% of the premium for single coverage and 27% for family coverage, the survey found. Workers at smaller companies pay 35% of the premium for family coverage, compared with 24% for larger companies, the survey found.

The average annual deductible for single coverage is now $1,644, up 25% in the past five years and 79% in the past decade.

Workers with coverage are exposed to higher costs when using the hospital since 65% have coinsurance, which means they are responsible for a fixed share of the charge, and 13% contribute a copayment, or fixed fee per visit or service. The average coinsurance for hospital admission is 20% and average copayment is $311 per hospital admission.

Workers are protected for catastrophic costs through limits set on their out-of-pocket spending in provider networks, although those amounts vary by employer: 11% face a maximum of less than $2,000, while 18% are in a plan with a maximum of $6,000 or more.

The study also noted that large employers have made it easier for workers to access care by adopting coverage for telemedicine in recent years. Nearly 9 in 10 companies that have 200 or more workers and offer insurance covered these medical appointments done via telephone or computer this year, up from fewer than 3 in 10 in 2015, according to the research. During the pandemic, telemedicine usage has increased markedly as people sought care from the safety of their home.

The KFF study is based on a telephone survey of 1,765 randomly selected nonfederal public and private employers with three or more workers from January to July.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Moved by Plight of Young Heart Patient, Stranger Pays His Hospital Bill

Even with insurance, Matthew Fentress faced a medical bill of more than $10,000 after a heart operation. A cook at a senior living community in Kentucky, he figured he could never pay what he owed — until a stranger who lives 2,000 miles away stepped in to help.

“The system still failed me,” said Fentress, 31. “It was humanity that stepped up.”

Karen Fritz, a retired college professor in Las Vegas, saw part of his story on “CBS This Morning,” which partners with KHN and NPR on the crowdsourced Bill of the Month investigation. Fritz found the story online, and then she called the hospital to donate $5,000 toward Fentress’ bill.

“I’ve been a young person in college with medical bills. I just really felt convicted to help him out, to help him get beyond his financial struggles. I had no hesitation; I felt led by the Holy Spirit to do that,” said Fritz, 64, who taught business and marketing at various schools. “When you help other people, it gives you joy.”

Fentress was just 25 when doctors diagnosed him with viral cardiomyopathy, a heart disease that developed after a bout of the flu. In his six years of grappling with that chronic condition, which could lead to heart failure, he had already been sued by his hospital after missing a payment and declared bankruptcy.

Financial fears reignited this year when his cardiologist suggested he undergo an ablation procedure to restore a normal heart rhythm. He said hospital officials at Baptist Health Louisville assured him he wouldn’t be on the hook for more than $7,000, a huge stretch on his $30,000 annual salary.

Though the procedure went well, the bill filled him with dread. His portion totaled more than $10,000 for the ablation and related visits in 2019 and 2020. After an adjustment, a spokesperson for his insurer, United Healthcare, said he owed nearly $7,900. That was the same as the annual out-of-pocket maximum for in-network care under his plan, which also included a $1,500 annual deductible. Like millions of other Americans, Fentress is considered underinsured.

Fentress said he learned about Fritz’s donation when he got a call from a hospital representative. He submitted a recent pay stub to the hospital, and its financial aid program covered the rest.

Hospital officials said Fentress at one point had been under the incorrect impression that he’d have to pay big monthly payments and couldn’t apply for financial assistance because he’d gotten it before.

“Baptist Health consistently has encouraged Mr. Fentress to apply for financial assistance to provide the information we need to determine a qualifying amount,” Charles Colvin, Baptist Health’s vice president for revenue strategy, said in a statement. “We are pleased to have received the additional information needed to provide that financial assistance.”

Fentress said he’s incredibly grateful to Fritz. He plans to stay in touch with her, and he’s sending her a T-shirt he designed with a picture of a heart and the words “Be nice.”

“This is the first time ever since I was 25 that I haven’t had medical debt. It’s a wonderful feeling. It gives me a lot of peace of mind,” Fentress said. “But I feel guilty that a lot of other people are still suffering.”

Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Refuge in the Storm? ACA’s Role as Safety Net Is Tested by COVID Recession

The Affordable Care Act, facing its first test during a deep recession, is providing a refuge for some — but by no means all — people who have lost health coverage as the economy has been battered by the coronavirus pandemic.

New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.

That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.

And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.

From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.

The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.

What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.

“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”

Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.

Coverage Was Already on the Decline

Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.

But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.

In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.

The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.

In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around 10 million workers and their dependents would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.

A more recent Urban Institute report, released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.

Another recent study, using different methods, reported higher numbers for the same period. The analysis released by the Economic Policy Institute last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.

Other findings support the notion that the health insurance loss trend shifted by mid summer. KFF, for example, published an analysis Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of KFF.)

“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a KFF vice president and director for the Program on the ACA.

Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program grew by 4 million between February and June, a nearly 6% increase since the beginning of the coronavirus crisis.

The Impact of the Marketplaces

Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.

A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.

About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.

Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.

Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.

“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”

Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.

In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”

In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.

“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Fighting for Patient Protections While Attacking ACA — Hard to Have It Both Ways

Throughout the 2020 election cycle, candidates’ positions on health care have been particularly important for voters with underlying and often expensive medical needs — in short, those with preexisting conditions.

It’s no surprise, then, that protections for people who have chronic health problems like diabetes and cancer have become a focal point for candidates nationwide — among them, Matt Rosendale, the Republican contender for Montana’s only U.S. House seat.

On Sept. 22, Rosendale’s campaign hit airwaves and online streaming services with an ad featuring a Whitefish resident named Sandee, whose son was diagnosed with a life-threatening disease. Sandee told the story of how Rosendale came to her family’s aid, concluding that “Matt fights for everyone with a preexisting condition.”

As is often the case with health care policy, however, the truth is far from simple. Rosendale and many other Republican congressional candidates face the challenge of convincing voters they support these safeguards even as they oppose the Affordable Care Act, which codifies those safeguards.

Polls show broad public support for keeping the ACA’s preexisting condition protections.

We decided to investigate.

Rosendale is up against Democrat Kathleen Williams for the congressional seat now occupied by Republican Rep. Greg Gianforte, who has entered the state’s gubernatorial race. The open seat has been controlled by the GOP for the past 12 terms, but this year’s race is expected to be close. Williams, who also ran for the seat in 2018, has made health care her top campaign issue.

We contacted the Rosendale campaign to find out the basis for his ad’s claim. Campaign spokesperson Shelby DeMars listed a range of health policies backed by the candidate that would help people with preexisting conditions directly or indirectly by holding down health care costs. She specifically pointed to Rosendale’s work on the state’s reinsurance program as Montana’s state auditor and insurance commissioner, a post he was elected to in 2016.

“Matt Rosendale is a champion for those with pre-existing conditions and he has the record to prove it,” DeMars said via email. “It is because of the Reinsurance program he implemented that Montanans with pre-existing conditions can access the affordable healthcare coverage they need.”

Examining Reinsurance

In a nutshell, Montana’s reinsurance program is designed to help insurers cover costly medical claims with a mix of federal pass-through dollars and funding generated by a premium tax on all major medical policies in the state. Gov. Steve Bullock announced the formation of a bipartisan group tasked with developing reinsurance program legislation in fall 2018, and the state’s legislature approved the plan in 2019, allowing Rosendale to apply for and receive the necessary waiver under the Affordable Care Act.

Subsequent news accounts indicated the idea worked. In-state insurers credited the program with lowering premiums by 8% to 14% for 2020. As Montana Health Co-op CEO Richard Miltenberger told MTN News shortly after the 2019 legislative session, “It allows the insurance companies to have rate stabilization for those really big claims, the ones that are the earthquakes in health insurance.” He went on to say that this stability “brings the cost down for the consumer.” More to the point, the American Medical Association has also stated that reinsurance not only serves to subsidize high-cost patients but “protects patients with pre-existing conditions.”

But there’s a rub.

The reinsurance program that Rosendale touts wouldn’t exist without a state innovation waiver created by the ACA, which Rosendale says he’ll work to repeal. That effort will doubtless continue to fuel pitched battles in Congress, and how the U.S. Supreme Court may rule on a pending ACA challenge remains a point of speculation. One thing is clear, though: If the entire ACA is thrown out, the reinsurance program goes with it, along with Montana’s Medicaid expansion and the ban on insurers from excluding people with health problems from affordable coverage.

When asked about the resulting elimination of the reinsurance program, DeMars reiterated that Rosendale’s work as auditor has created a system that will ensure protections for preexisting conditions “regardless of what happens to the ACA.” She did not elaborate or explain what protections would remain if the ACA were repealed.

The Short-Term Plan Component

In defending his stance on preexisting conditions, Rosendale continues to be haunted by another health care policy specter from his political past. During his unsuccessful challenge against Democratic U.S. Sen. Jon Tester in 2018, Rosendale faced criticism for promoting short-term, limited-duration health insurance plans. Unlike plans offered on the individual marketplace, these short-term plans are exempt from the ACA’s ban on excluding people with preexisting conditions. And, under a 2018 regulatory change pushed by the Trump administration, the length of these short-term plans has been extended from three months to 12, with the potential to renew for up to three years.

As state auditor, Rosendale included those plans in his March 2020 roundup of year-round options for immediate coverage. They often exclude coverage for a variety of higher-cost benefits. In Montana, for example, a review by KFF found that of four short-term plans available in Billings in 2018, none offered coverage for maternity care, mental health, substance abuse or prescription drug services. (KHN is an editorially independent program of KFF.)

Historically, short-term plans were designed to help individuals fill gaps in health coverage. According to Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms, the role short-term plans play on today’s health insurance landscape is to attract younger, healthier individuals seeking low-cost options to cover catastrophic events. That splits insurers into two pools — those who are less likely to incur medical expenses, and those who are more likely to incur them. Costs on the individual market go up as a result, leaving people with preexisting conditions no other option than to pay higher premiums. Short-term plans are, Palanker said, “actively hurting people with preexisting conditions.”

“Promoting short-term plans and stumping on supporting protections for preexisting conditions are mutually exclusive,” she continued.

Asked whether the cost-lowering effect of a reinsurance program would be enough to offset the effects of short-term plans, Palanker said the only way such an offset would be enough is if the program encompassed short-term plans. She hasn’t seen that happen anywhere.

Our Ruling

A campaign ad says Rosendale “fights for everyone with a preexisting condition.” While it is true that health insurance premiums have dropped during Rosendale’s tenure as state auditor, the choice to establish Montana’s reinsurance program ultimately fell to decision-makers in the state’s legislature and the governor’s office. Since his ad’s claim simply states that he “fights” for people with preexisting conditions, his testimony in support of that program and role in securing the state waiver do seem to fit the bill.

In the long-term, however, Rosendale’s positions begin to run counter to the claim. His support for short-term, limited-duration plans poses a considerable threat to keeping health insurance affordable for all, and absent a solid plan from Congress to ensure that state reinsurance programs survive, his stated goal of repealing the ACA would actually serve to unravel the very protection he’s built his case on.

We rate this statement as Mostly False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: TikTok Mom Takes On Medical Bills

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Shaunna Burns went viral on TikTok, partly because of a series of videos dishing out real-talk advice on fighting outrageous medical bills. She said the way to deal with medical debt is to be vigilant about what debt you incur in the first place.

“What you can say is I don’t want you to run any tests or do any procedures or anything without running it by me,” she said.

Burns has three children of her own, and she has become the virtual mom that thousands of Gen Z followers love. She’s funny, smart and relatable — and she has stories that’ll make your hair stand on end. Oh, and she can swear like a sailor. So maybe listen to this episode when the kids aren’t around. Also, some of her stories are kind of intense.

(You can first check the transcript to see if this episode is one you want to share with your kids.)

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Not Pandemic-Proof: Insulin Copay Caps Fall Short, Fueling Underground Exchanges

DENVER — D.j. Mattern had her Type 1 diabetes under control until COVID’s economic upheaval cost her husband his hotel maintenance job and their health coverage. The 42-year-old Denver woman suddenly faced insulin’s exorbitant list price — anywhere from $125 to $450 per vial — just as their household income shrank.

She scrounged extra insulin from friends, and her doctor gave her a couple of samples. But as she rationed her supplies, her blood sugar rose so high her glucose monitor couldn’t even register a number. In June, she was hospitalized.

“My blood was too acidic. My system was shutting down. My digestive tract was paralyzed,” Mattern said, after three weeks in the hospital. “I was almost near death.”

So she turned to a growing underground network of people with diabetes who share extra insulin when they have it, free of charge. It wasn’t supposed to be this way, many thought, after Colorado last year was the first of 12 states to implement a cap on the copayments that some insurers can charge consumers for insulin. But as the COVID pandemic has caused people to lose jobs and health insurance, demand for insulin sharing has skyrocketed. Many patients who once had good insurance are now realizing the $100 cap is only a partial solution, applying just to state-regulated health plans.

Colorado’s cap does nothing for the majority of people with employer-sponsored plans or those without insurance coverage. According to the state chapter of Type 1 International, an insulin access advocacy group, only 3% of patients with Type 1 diabetes under 65 could benefit from the cap.

Such laws, often backed by pharmaceutical companies, give the impression that things are improving, said Colorado chapter leader Martha Bierut. “But the reality is, we have a much longer road ahead of us.”

The struggle to afford insulin has forced many people into that underground network. Through social media and word-of-mouth, those in need of insulin connect with counterparts who have a supply to spare. Insurers typically allow patients a set amount of insulin per month, but patients use varying amounts to control their blood sugar levels depending on factors such as their diet and activity that day.

Though it’s illegal to share a prescription medication, those involved say they simply don’t care: They’re out to save lives. They bristle at the suggestion that the exchanges resemble back-alley drug deals. The supplies are given freely, and no money changes hands.

For those who can’t afford their insulin, they have little choice. It’s a your-money-or-your-life scenario for which the American free-market health care system seems to have no answer.

“I can choose not to buy the iPhone or a new car or to have avocado toast for breakfast,” said Jill Weinstein, who lives in Denver and has Type 1 diabetes. “I can’t choose not to buy the insulin, because I will die.”

Exacerbated by the Pandemic

Surveys conducted before the pandemic showed that 1 in 4 people with either Type 1 or Type 2 diabetes had rationed insulin because of the cost. For many Blacks, Hispanics and Native Americans, the pinch was especially bad. These populations are more likely to have diabetes and also more likely to face economic disparities that make insulin unaffordable.

Then COVID-19 arrived, with economic stress and the virus itself hitting people in those groups the hardest.

This year, the American Diabetes Association reported a surge in calls to its crisis hotline regarding insulin access problems. In June, the group found, 18% of people with diabetes were unemployed, compared with 12% of the general public. Many are wrestling with the tough choices of whether to pay for food, rent, utilities or insulin.

Rep. Dylan Roberts, a Democrat who sponsored Colorado’s copay cap bill, said legislators knew the measure was only the first step in addressing high insulin costs. The law also tasked the state’s attorney general to produce a report, due Nov. 1, on insulin affordability and solutions.

“We went as far as we could,” Roberts said. “While I feel Colorado has been a leader on this, we need to do a whole lot more both at the state and national level.”

According to the American Diabetes Association, 36 other states have introduced insulin copay cap legislation, but the pandemic stalled progress on most of those bills.

Insulin prices are high in the U.S. because few limits exist for what pharmaceutical manufacturers can charge. Three large drugmakers dominate the insulin market and have raised prices in near lockstep. A vial that 20 years ago cost $25 to $30 now can run 10 to 15 times that much. And people with diabetes can need as many as four or five vials per month.

“It all boils down to cost,” said Gail deVore, who lives in Denver and has Type 1 diabetes. “We’re the only developed nation that charges what we charge.”

Before the COVID crisis triggered border closures, patients often crossed into Mexico or Canada to buy insulin at a fraction of the U.S. price. President Donald Trump has taken steps to lower drug prices, including allowing for the importation of insulin in some cases from Canada, but that plan will take months to implement.

The Kindness of Strangers

DeVore posts on social media three or four times a year asking if anybody needs supplies. While she’s always encountered demand, her last tweet in August garnered 12 responses within 24 hours.

“I can feel the anxiety,” deVore said. “It’s unbelievable.”

She recalled helping one young man who had moved to Colorado for a new job but whose health insurance didn’t kick in for 90 days. She used a map to choose a random intersection halfway between them. When deVore arrived on the dusty rural road after dark, his car was already there. She handed him a vial of insulin and testing supplies. He thanked her profusely, almost in tears, she said, and they parted ways.

“The desperation was obvious on his face,” she said.

It’s unclear just how widespread such sharing of insulin has become. In 2019, Michelle Litchman, a researcher at the University of Utah’s College of Nursing, surveyed 159 patients with diabetes, finding that 56% had donated insulin.

“People with diabetes are sometimes labeled as noncompliant, but many people don’t have access to what they need,” she said. “Here are people who are genuinely trying to find a way to take care of themselves.”

If insulin affordability doesn’t improve, Litchman suggested in a journal article, health care providers may have to train patients on how to safely engage in underground exchanges.

The hashtag #Insulin4all has become a common way of amplifying calls for help. People sometimes post pictures of the supplies they have to share, while others insert numbers or asterisks within words to avoid social media companies removing their posts.

Although drug manufacturers offer limited assistance programs, they often have lengthy application processes. So they typically don’t help the person who accidentally drops her last glass vial on a tile floor and finds herself out of insulin for the rest of the month. Emergency rooms will treat patients in crisis and have been known to give them an extra vial or two to take home. But each crisis takes a toll on their long-term health.

That’s why members of the diabetes community continue to look out for one another. Laura Marston, a lawyer with Type 1 diabetes who helped to expose insulin pricing practices by Big Pharma, said two of the people she first helped secure insulin, both women in their 40s, are in failing health, the result of a lifetime of challenges controlling their disease.

“The last I heard, one is in end-stage renal failure and the other has already had a partial limb amputation,” Marston said. “The effects of this, what we see, you can’t turn your back on it.”

The underground sharing is how Mattern secured her insulin before recently qualifying for Medicaid. When someone on a neighborhood Facebook group asked if anybody needed anything in the midst of the pandemic, she replied with one word: insulin. Soon, an Uber driver arrived with a couple of insulin pens and replacement sensors for her glucose monitor.

“I knew it wasn’t altogether legal,” Mattern said. “But I knew that if I didn’t get it, I wouldn’t be alive.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Watch: Young Man Faces Medical Bankruptcy — Even With Insurance

“CBS This Morning” tells the story of Matthew Fentress, a young man who developed serious heart disease after a bout of flu when he was just 25. Now 31, he owes more than $10,000 in hospital bills. KHN Editor-in-Chief Elisabeth Rosenthal explains that the same cardiomyopathy Fentress got can also be a complication of COVID-19.

Fentress’ story is the latest in the ongoing crowdsourced Bill of the Month investigation, a collaboration with KHN, NPR and “CBS This Morning.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump’s COVID Program for Uninsured People: It Exists, but Falls Short

In a wide-ranging executive order, President Donald Trump this month outlined some of the efforts he has made to affect health care since taking office.

One involved uninsured people and the current pandemic. The administration, Trump said, set up a program to provide them “access to necessary COVID-19-related testing and treatment.”

Did it?

We asked the White House for more specifics about the program Trump mentioned but did not get a reply.

Nonetheless, experts said he is likely referring to reimbursement assistance to help pay the COVID testing and treatment costs of uninsured patients, which is available through the Provider Relief Fund.

This fund was established by Congress in the Coronavirus Aid, Relief and Economic Security Act to bolster eligible health care providers for lost revenue or expenses related to the pandemic.

The Trump administration said this spring it would tap into the fund to reimburse providers who test and treat uninsured COVID patients; hence, the executive order’s reference to “coverage access.” Here’s how it works: The assistance doesn’t go directly to patients. Instead, health care providers can apply for reimbursement of costs associated with testing or treating uninsured people for COVID-19. Patients must be uninsured and their primary diagnosis must be COVID-19. The program does not check immigration status in determining eligibility.

Our experts acknowledged that the fund overall has helped providers by making money available, especially important since many physicians, hospitals and other health care facilities are struggling with reduced income as elective surgeries and visits have nose-dived during the pandemic. The relief fund pays providers at standard Medicare rates for testing or treating uninsured COVID patients.

Still, many patients, and some providers, don’t know about the funding to reimburse for uninsured costs. And even providers who are aware of it don’t necessarily know how to use it. Hospitals and other providers are not required to publicize it. Additionally, eligibility restrictions can make it hard for some patients to qualify to have their bills paid.

“It’s absolutely not broad protection or a guarantee of coverage,” said Karen Pollitz, a senior fellow with KFF. “People are uninsured. They remain uninsured. If they don’t know how to ask for this or the provider can’t figure out how to use it, [their bills] are uncollectable.” (KHN is an editorially independent program of KFF.)

What Exactly Is ‘Coverage Access’?

Even before the pandemic, uninsured patients had a hard time finding medical care, often delaying needed medical services until a crisis sent them to the hospital. Federal law ensures that no one needing emergency care is turned away and must be treated until stabilized.

The relief fund program came amid calls from health insurers, Democrats and others for the Trump administration to reopen enrollment in the Affordable Care Act through the federal marketplace, which operates in 38 states.

Usually, the insurance sign-up period occurs each November. When the virus began causing concern in the U.S. in the spring, some of the 12 states (and the District of Columbia) that run their own marketplaces moved to reopen because of the pandemic, so uninsured residents could sign up.

But the Trump administration decided not to reopen the federal marketplace. Uninsured people who want to enroll either have to wait to sign up starting in November for coverage next year or see if they qualify for special enrollment because they have experienced one of several “qualifying life events.” One such event is job loss that ends health coverage.

That potentially left hospitals and other medical providers holding the bag for the uninsured who fall sick with COVID.

Enter the relief fund.

The Health Resources and Services Administration said the fund so far has handed out a little more than $1 billion for uninsured patient reimbursement, a substantial amount but well short of publicized estimates of what it will ultimately cost hospitals and medical providers to test and treat uninsured COVID patients.

“We are appreciative” that Congress and the administration “did provide some coverage for the uninsured,” said Molly Smith, vice president for coverage and state issues at the American Hospital Association. “But we don’t think it’s the best approach for covering the uninsured.” Hospitals would have preferred something that “would have expanded comprehensive coverage.”

Parts of the program work well, she said, but “there are some pretty substantial flaws.”

Why ‘Access’ Becomes a Slippery Term

When it comes to program eligibility, two main criteria present hurdles for patients: fitting the definition of “uninsured” and receiving a primary diagnosis of COVID-19.

Failing either test could make a patient ineligible. In that case, the hospital or medical provider can either seek payment from the patient — or eat the cost.

To qualify for coverage, the patient cannot have any kind of health insurance coverage, according to guidelines published online by HRSA.

Even having very limited coverage — such as a program in Medicaid that covers only family planning services such as birth control — would disqualify a patient, said Smith. Another disqualification would be the purchase of one of the limited coverage plans touted by the administration that don’t cover all the same services an ACA plan would include.

The second hurdle: COVID-19 must be the primary diagnosis.

“If someone with a heart attack comes in and it turns out COVID is also involved — or could have even been the trigger,” the provider might not be eligible for reimbursement, said Jack Hoadley, a research professor emeritus at Georgetown University.

Another common example, Smith said, is a patient with COVID-19 who develops sepsis, a life-threatening blood infection. Under long-standing coding and billing rules, sepsis would be the primary diagnosis, making any coronavirus-related patient care ineligible under the provider relief program.

Our Ruling

The Trump administration did implement a program to reimburse medical providers for testing and treatment of some uninsured patients, tapping into funding allocated by Congress.

Whether — and to what extent — the measure improved “coverage access” to care is hard to determine. The fund has paid out more than $1 billion so far.

The administration chose this route, which experts said was an incomplete fix, over following some states’ lead in allowing a special enrollment period on the federal marketplace, which would have enabled people without health insurance to buy more comprehensive coverage. Meanwhile, the program has not been publicized and has confusing eligibility rules — both of which have led to speculation that it is not being used as widely as possible.

The administration’s program appears to provide narrow financial assistance for COVID-related health care costs. But patients who fall through the cracks may find themselves facing substantial bills.

We rate this statement as Mostly True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Opposition to Obamacare Becomes Political Liability for GOP Incumbents

In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.

Six years later, those senators are up for reelection. Not only is the law still around, but it’s gaining in popularity. What was once a winning strategy has become a political liability.

Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.

With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.

“The fall election will significantly revolve around people’s belief about what [candidates] will do for their health coverage,” said Dr. Daniel Derksen, a professor of public health at the University of Arizona.

The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.

Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama’s assertion that “if you like your health care plan, you’ll be able to keep your health care plan.”

But now, Hanel said, the ACA’s policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.

“This time it’s the opposite,” Hanel said. “The people bringing up the Affordable Care Act are the Democrats.”

Despite Gardner’s multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.

Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.

His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he’s campaigning on that record, with promises to expand health care access even further.

Polling Data

Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

“Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views” of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. “This really solidified in 2017 after the failed repeal in the Senate.”

The foundation’s polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.

Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents’ health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.

“We’re 10 years along and the sky hasn’t caved in,” said Sabrina Corlette, a health policy professor at Georgetown University.

Political Messaging

Following the passage of the ACA, Democrats didn’t reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.

“They ran on any other issue they could find,” Fowler said.

Republicans, she said, kept promising to “repeal and replace” but weren’t able to do so.

Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.

“In the decade I have been tracking political advertising, there wasn’t a single-issue topic that was as prominent as health care was in 2018,” she said.

As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven’t explicitly focused on the ACA. Many highlight Republicans’ support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.

“Cory Gardner has been running a lot on his environmental bills and conservation funding,” Fowler said. “It’s not difficult to figure out why he’s doing that. It’s easier for him to tout that in a state like Colorado than it is to talk about health care.”

Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.

“I did vote to repeal and replace Obamacare,” McSally said on conservative pundit Sean Hannity’s radio show during the 2018 campaign. “I’m getting my ass kicked for it right now.”

She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.

“Kelly doesn’t have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won’t be taken away,” said Derksen, the University of Arizona professor.

The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh’s nomination to the Supreme Court and for not doing more to oppose President Donald Trump.

In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state’s Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montanans were covered through the expansion.

As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines’ votes to repeal cost-saving provisions of the ACA.

“People are losing jobs, and their jobs bring health care with them,” Parker said. “I don’t think it’s a good space for Daines to be right now.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump Again Claims He’s Bringing Down Drug Prices, But Details of How Are Skimpy

President Donald Trump has long considered lowering the high cost of prescription drugs to be one of his signature issues, and it is likely to be a talking point he relies on throughout the upcoming campaign.

During his afternoon speech Monday ― delivered on the first day of the Repubublican National Convention after delegates had unanimously renominated him to seek reelection ― he returned to this theme.

“Now, I’m really doing it,” he said, referring to a series of four executive orders he issued in July. These orders touched on a range of issues, including insulin prices and drug importation. He focused on two specifically.

“But the fact is that we signed a favored nations clause and a rebate clause, and your numbers are going to come down 60, 70%,” he said.

However, those executive orders are far from being implemented, and multiple experts told us it’s unlikely the measures would pass along drug-pricing discounts to a majority of Americans. And the text of one, the favored nation executive order, has not yet been made public ― making it hard to know how exactly the initiative would work.

“Details are a bit murky,” Matthew Fiedler, a health care fellow with the Brookings Institution, wrote in an email.

We checked in with the White House to find out more details about the favored nation order and when the text might be released. However, we did not get a response. Still, we decided to dig in.

What We Know

The favored nation executive order was supposed to match U.S. prices for a certain class of drugs with the lower amount paid in certain European countries, which negotiate drug prices. It reportedly would have applied only to drugs covered by Medicare Part B ― those that patients receive at their doctors’ offices, such as infused cancer drugs ― but not those purchased at the pharmacy counter. Drug companies criticized the executive order, and the Trump administration offered to consider an alternative plan if the firms offered it by Aug. 24. So far, the industry has not made a counter offer.

A spokesperson for PhRMA, the lobbying group that represents major drugmakers, said in a statement that “the most favored nation executive order is an irresponsible and unworkable policy that will give foreign politicians a say in how America provides access to treatments and cures for seniors and people struggling with devastating diseases.” The group did not confirm on the record whether an alternative drug-pricing plan had been discussed with the White House.

The Trump administration floated a similar idea in 2018, which met with swift criticism from some of its usual supporters, such as Americans for Tax Reform, a right-leaning advocacy group that opposes tax increases. The criticism was marked by TV ads warning that this approach to drug costs was a step toward socialism. We found that claim to be Mostly False. The Centers for Medicare & Medicaid Services estimated at that time the resulting savings from such a plan would be 30%, but it was never enacted.

Multiple experts questioned Trump’s claims about how much costs would come down as a result of the more recent proposal.

That’s in part because the full text of the executive order has not been published, and so classifying the president’s statement as true “requires a leap of faith,” said Benedic Ippolito, a resident scholar who studies health care costs at the American Enterprise Institute.

Ippolito allowed that because some drug prices in other countries are far below those in the U.S., a reduction of 60% or 70% could be plausible for an individual product. But, in order for that to happen, the policy would have to be implemented.

Seeing this 60% to 70% decrease “relies on the idea that this policy ever happens. And I think there is reason to be very skeptical there,” Ippolito wrote in an email.

Rachel Sachs, an associate professor of law at Washington University in St. Louis, who has analyzed the drug-pricing executive orders, agreed there’s no solid foundation to support those percentages.

“I don’t know about the 60 or 70%,” she said. “I don’t know what he’s talking about.”

Another executive order attempted to address the rebates paid to pharmacy benefit managers within Medicare by directing that these payments instead be used as discounts for beneficiaries within the Part D program, the plans that pay for prescription medications.

However, experts pointed out that those discounts usually go toward lowering insurance premiums for seniors. Without applying the discount there, premiums would likely go up. And, in order to keep premiums down, the federal government would need to spend more on subsidies.

Analyses from the Congressional Budget Office and other groups predicted that Trump’s rebate proposal would lower drug prices for some seniors, but would also increase federal spending and increase seniors’ premiums.

There is also a stipulation in the text of the order, which says the order cannot be implemented if it leads to increased government spending or higher premiums for beneficiaries. Thus, it’s unclear how such a proposal would be implemented.

“The executive order on the rebate is internally contradictory, which makes you wonder how they can do this,” said Sachs.

Why It Matters

Trump is likely to continue saying he has reduced drug prices, not only during the Republican National Convention but for the remainder of the 2020 campaign.

Trump likes to present proposals in the works as having been implemented, and we’ve fact-checked him twice before on similar drug-pricing statements.

In May 2019, he claimed he brought down drug prices for the first time in 51 years, which we found to be Mostly False. And in early August of that year, we fact-checked a claim about another of his drug-pricing executive orders that inflated his efforts to reduce insulin prices, which we also found to be Mostly False.

This time, Trump referenced two different drug-pricing executive orders. While it is true that he signed both of them (though the text of only one is publicly available), experts have expressed skepticism about whether these proposals will be implemented, as well as whether they would lower drug prices significantly for Americans.

And this isn’t the first time Trump has made this promise to the American people.

“He promised to lower drug prices as part of his campaign in 2016 and has done absolutely nothing of substance about drug prices at all while he’s been in office,” Aaron Kesselheim, a professor of medicine at Harvard, wrote in an email.

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Republican Convention, Day 1: A Campaign-Style Trump Speech and More

Before the prime-time GOP showcase began, President Donald Trump took to the podium Monday afternoon and delivered an approximately one-hour campaign-style speech to delegates after he was officially renominated by the Republican Party as its candidate for president.

His comments were wide-ranging, and our partners at PolitiFact found many to be either wrong, misleading, premature or in need of clarification. Here is the complete rundown from that speech and a wrap-up story detailing the rest of the evening. (PolitiFact also fact-checked former Vice President Joe Biden’s acceptance speech during the Democratic National Convention.)

Monday’s evening broadcast was full of platitudes. Amy Ford, a West Virginia nurse, applauded Trump’s steps during the pandemic to expand telemedicine, saying these policies are “essential” and will “continue to aid many that are unable to find transportation or a way to the doctor for regular checkups. This is especially true in rural America.” Dr. G.E. Ghali, a Louisiana oral surgeon and chancellor of a medical research center, spoke as both a clinician and a patient about how the administration’s efforts to provide emergency-use authorization for emerging treatments saved lives.

Video vignettes heralded Trump’s leadership during the coronavirus, focusing on things like Operation Warp Speed, the administration’s initiative to speed vaccine development, rather than the statistics: nearly 6 million Americans who have contracted COVID-19 or the more than 177,000 who have died. Trump also spoke with a group of first responders — including nurses, postal workers and a police officer from Colorado who said she had contracted COVID-19 in late March and has since recovered. “That means we don’t have to be afraid of you at all, right?” Trump said to her. “Once you’re recovered, we have the whole thing with plasma happening. That means your blood is very valuable, you know that, right?”

What follows are some of Trump’s statements from his afternoon speech geared to health policy issues:

Trump has repeatedly claimed that President Barack Obama left him with an empty national stockpile of emergency supplies. But this is an exaggeration.

The stockpile had a shortage of N95 masks, which were depleted as a result of the H1N1 outbreak in 2009 and not substantially replenished during the Obama or Trump administrations.

ProPublica found that the budget battles during Obama’s tenure after the Republicans won the 2010 election also hurt the stockpile’s budget.

Budget figures going back to 2009 show overall funding for the stockpile dropped to its lowest level in 2013, to about $477 million. Allocations have grown steadily since then to a 2020 budget of $705 million.

“We eliminated Obamacare’s horrible and very unfair individual mandate, which basically knocked out Obamacare. We knocked out Obamacare.”

Saying Republicans “knocked out Obamacare” is a stretch. Trump did sign legislation to eliminate the requirement that Americans have health insurance or pay a tax penalty, but eliminating this requirement did not get rid of Obamacare, or the Affordable Care Act, as it is officially known.

The administration supports a lawsuit by a group of Republican state attorneys general that argues that the ACA should be ruled unconstitutional. The lawsuit’s argument focuses on the Supreme Court’s previous ruling that the ACA was constitutional because it was based on a tax, which Congress has the authority to levy. With the tax penalty now eliminated, the lawsuit argues, the law should be scrapped entirely. The Supreme Court has agreed to hear the case.

In the meantime, much of the health law’s key provisions remain in force. In 2020, at least 11.4 million Americans have purchased insurance through the online marketplaces created under the act. More than 10 million others have signed up for Medicaid under the expanded eligibility requirements passed as part of the law. And people who have private insurance have benefited from new rules enacted by the law, from the ability to keep young adults on a parent’s policy to an end to out-of-pocket payments for certain preventive measures.

“So we protected your preexisting conditions, very strongly protected.”

We rated a similar claim as Pants on Fire. Protections for preexisting conditions under Obamacare remain on the books, but it’s not for lack of trying by the Trump administration.

For starters, the administration backs the lawsuit that would eliminate protections for preexisting conditions by getting rid of Obamacare.

In addition, the administration has not put forth any plan that might keep those guarantees in place. Every replacement health bill the administration has endorsed has offered protections less generous than those offered by the ACA.

Finally, the administration has issued a rule loosening restrictions on the length of so-called short-term health plans. While such plans could be more affordable for individuals in the market for insurance, they are not required to provide preexisting condition protections.

PolitiFact’s Louis Jacobson, Amy Sherman, Samantha Putterman and Miriam Valverde contributed to this story.

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Rather Than Give Away Its COVID Vaccine, Oxford Makes a Deal With Drugmaker

In a business driven by profit, vaccines have a problem. They’re not very profitable — at least not without government subsidies. Pharma companies favor expensive medicines that must be taken repeatedly and generate revenue for years or decades. Vaccines are often given only once or twice. In many parts of the world, established vaccines cost a few dollars per dose or less.

Last year only four companies were making vaccines for the U.S. market, down from more than 20 in the 1970s. As recently as Feb. 11, Dr. Anthony Fauci, the government’s top infectious disease expert, complained that no major drug company had committed to “step up” to make a coronavirus vaccine, calling the situation “very difficult and frustrating.”

Oxford University surprised and pleased advocates of overhauling the vaccine business in April by promising to donate the rights to its promising coronavirus vaccine to any drugmaker.

The idea was to provide medicines preventing or treating COVID-19 at a low cost or free of charge, the British university said. That made sense to people seeking change. The coronavirus was raging. Many agreed that traditional vaccine development, characterized by long lead times, manufacturing monopolies and weak investment, was broken.

“We actually thought they were going to do that,” James Love, director of Knowledge Ecology International, a nonprofit that works to expand access to medical technology, said of Oxford’s pledge. “Why wouldn’t people agree to let everyone have access to the best vaccines possible?”

A few weeks later, Oxford—urged on by the Bill & Melinda Gates Foundation—reversed course. It signed an exclusive vaccine deal with AstraZeneca that gave the pharmaceutical giant sole rights and no guarantee of low prices—with the less-publicized potential for Oxford to eventually make millions from the deal and win plenty of prestige.

Other companies working on coronavirus vaccines have followed the same line, collecting billions in government grants, hoarding patents, revealing as little as possible about their deals—and planning to charge up to $37 a dose for potentially hundreds of millions of shots.

Even as governments shower money on an industry that has not made vaccines a priority in the past, critics say, failure to alter the basic model means drug industry executives and their shareholders will get rich with no assurance that future vaccines will be inexpensively available to all.

“If there were ever an opportunity” to change the economics of vaccine development, “this would have been it,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who studies drug-pricing regulation. Instead, “it is business as usual, where the manufacturers are getting exclusive rights and we are hoping on the basis of public sentiment that they will price their products responsibly.”

In the United States and other developed nations, the solution to drug-company reluctance was to shower them with billions of dollars in public funds to persuade them to help. The Trump administration has announced deals worth more than $10 billion with seven companies to try to turn basic research—often funded by the government—into effective, widely distributed vaccines—but with no guarantee they would be widely affordable or available.

That approach has driven up stock prices in the past four months and enriched drug executives betting with somebody else’s money.

AstraZeneca stock and options owned by CEO Pascal Soriot have increased by nearly $15 million in value since early April, according to calculations by KHN based on company disclosures. The stock hit an all-time high in July. The stock market value of Novavax, a biotech that never recorded a profit in more than two decades, soared tenfold to $10 billion after a nonprofit and the Trump administration agreed to give it $1.6 billion to make a vaccine.

Companies “say we have to charge high prices because we are taking a risk,” said Mohga Kamal-Yanni, an independent consultant on global health based in the United Kingdom. “Actually, the public is taking the risk. The public is paying for the cost of research and development and probably the cost of manufacturing as well.”

Moderna, another company working on a vaccine candidate, received nearly $1 billion from the U.S. government to pay essentially all costs to research the product and get it approved by regulators. It’s using a vaccine designed in large part by the National Institutes of Health and academic scientists using federal grants.

If the vaccine works, the company gets an additional $1.5 billion to cover 100 million doses, a deal that U.S. Rep. Lloyd Doggett, a Texas Democrat, likened to giving taxpayers “the privilege of purchasing that same vaccine that we already paid for.”

That deal comes to $15 a dose. Moderna told Wall Street analysts it might charge as much as $37 a dose for smaller-volume contracts.

“This is greedy, and the taxpayers who have funded all of this should have expected better negotiation on the part of the U.S. government,” said Margaret Liu, a globally respected vaccine scientist who once worked for Merck and is now chairperson of the International Society for Vaccines.

The U.S. Health and Human Services Department “conducted extensive market research and price analysis” to ensure prices are fair, said a senior HHS official who asked for anonymity. “We are prohibited from disclosing price discussions and details.”

Even if Moderna distributed a successful vaccine at a loss to make it widely available, it would reap enormous benefits because government support would have helped validate its technology for future products, Liu said. Moderna did not respond to requests for comment.

Nonprofits such as Oxfam and Doctors Without Borders have been pressuring drug companies to change for years. Exclusive patents and high prices that sometimes make lifesaving medicines unaffordable in rich countries often render them completely unavailable in the poor world, they argue.

One workaround has been enormous private and government subsidies, including from the U.K., the United States and the Gates Foundation, to promote developing-nation vaccines through the Geneva nonprofit Gavi, formerly known as the Global Alliance for Vaccines and Immunization.

The Gates Foundation helped launch another non-governmental organization, the Coalition for Epidemic Preparedness Innovations, in 2017. CEPI was created to fight something exactly like the coronavirus: potential infectious threats ignored or slighted by pharmaceutical companies.

CEPI’s early principles of “equitable access” drew praise from reformers. The group asked for public data disclosure from drug-company grantees, “transparent” accounting to show true vaccine cost and the right to step in and take over a vaccine project if the developer failed to deliver.

The pharma industry immediately objected. Even though they were bankrolled by public money, drug companies were “concerned about the precedent that could be set if they allowed an outside entity, in this case CEPI, to set [the] price of a product unilaterally,” CEPI reported in February. The nonprofit backed down, removing most references to prices in a new policy that Doctors Without Borders called “an alarming step backwards.”

The original policy was intended to be “interim,” and CEPI’s “commitment to equitable access as a principle is the same,” said spokesperson Rachel Grant.

Some thought the worst infectious disease crisis in a century, along with the enormous public investments, would change industry behavior.

Governments could have demanded transparency and low prices. They could have offered developers cash prizes for vaccines that would have incentivized science but let the public retain the marketing rights, said Love, of Knowledge Ecology International.

Agreement by researchers to publish the virus genome in January set the stage for global scientific cooperation, many believed.

“The full sequence was shared with the world without any strings attached,” said Manuel Martin, a U.K.-based adviser to Doctors Without Borders on access to medical innovations.

The World Health Organization set up a “COVID-19 Technology Access Pool” to promote the sharing of patents and other knowledge. Oxford stepped forward and said it would offer nonexclusive, royalty-free licenses for its vaccine, meaning multiple parties could sell it at a low cost.

“I personally don’t believe that in a time of pandemic there should be exclusive licenses,” Adrian Hill, director of Oxford’s Jenner Institute, which is developing the vaccine, told The New York Times in April.

Instead, little has changed. No vaccine maker has offered open licenses, although NIH is sharing key technology it developed with multiple vaccine companies. Governments are signing lucrative deals with manufacturers to ensure vaccines for their own populations. WHO has made no announcements about contributions to its COVID-19 shared technology pool since it launched in May, patent experts said. WHO officials did not respond to a reporter’s queries.

After Oxford announced the exclusive AstraZeneca deal, the company said it would sell vaccines at no profit—but only during the pandemic. Johnson & Johnson’s pledge to earn no vaccine profit is similarly limited.

With financial information kept confidential, no one will be able to confirm whether the vaccines are truly being sold at cost. And if vaccine immunity is only temporary and endemic coronavirus strains require regular shots for years, the companies will make plenty of money down the road, critics say.

Under its deal with AstraZeneca, Oxford will receive no royalties during the pandemic but could make millions after it ends through a web of patents including those held by Vaccitech, a for-profit spinoff. Vaccitech’s ownership includes a 50% stake held directly or indirectly by Oxford and 5.25% each owned by Hill and Jenner’s other top vaccine scientist, Sarah Gilbert, U.K. regulatory filings show.

The potential for vaccine profits at Vaccitech was first reported by The Wall Street Journal.

Pharma company officials say that only decades of industry research could have made it even possible to produce a coronavirus vaccine at the present speed.

“The federal government cannot research, develop and manufacture vaccines and other new treatments on its own,” said Andrew Powaleny, a spokesperson for the Pharmaceutical Research and Manufacturers of America, a lobbying group. Large and early government investment “is a well-accepted approach to addressing public health crises,” he said.

Many argue that a health crisis is not the time to worry about overpaying for vaccines or backing some candidates that won’t deliver. Getting a good vaccine as quickly as possible requires spreading bets, they say.

“Spending some extra billions on vaccines is the right choice when human life is at stake and trillions in economic loss is at risk,” said Edward Scolnick, a top scientist at the Broad Institute and former head of research for Merck. He owns no stock in Merck or other pharma companies, he said.

Oxford backed off from its open-license pledge after the Gates Foundation urged it to find a big-company partner to get its vaccine to market.

“We went to Oxford and said, Hey, you’re doing brilliant work,” Bill Gates told reporters on June 3, a transcript shows. “But … you really need to team up.” The comments were first reported by Bloomberg.

AstraZeneca, one of the U.K.’s two major pharma companies, may have demanded an exclusive license in return for doing a deal, said Ken Shadlen, a professor at the London School of Economics and an authority on pharma patents—a theory supported by comments from CEO Soriot.

“I think IP [intellectual property, or exclusive patents] is a fundamental part of our industry and if you don’t protect IP, then essentially there is no incentive for anybody to innovate,” Soriot told the newspaper The Telegraph in May.

Some see the Gates Foundation, a heavy funder of Gavi, CEPI and many other vaccine projects, as supporting traditional patent rights for pharma companies.

“[Bill] Gates has staked out this outsized role in the vaccine world,” Love said. “He has an ideological belief that the intellectual property system is a wonderful mechanism that is necessary for innovation and prosperity.”

The Gates Foundation requires all its grantees to commit to making products “widely available at an affordable price,” a spokesperson said.

Oxford officials, including Hill and Gilbert, did not respond to requests for comment. AstraZeneca, for its part, would set a “reasonable” post-pandemic price and is “committed to ensure equitable access, globally” in the meantime, a spokesperson said. The company has signed deals with CEPI, Gavi and the Serum Institute of India to bring more than a billion doses to low- and middle-income countries, he said.

If nothing else, governments and vaccine makers should be open about their relationships, including making contracts public, said Duncan Matthews, a patent law professor at the Queen Mary University of London.

“We simply don’t know what’s in these deals,” he said. “The biopharma industry is applying old rules of commercial confidentiality in a situation that is unprecedented.”

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Veteran’s Appendectomy Launches Excruciating Months-Long Battle Over Bill

In late August 2019, Shannon Harness awoke to serious pain in the lower right side of his abdomen — a telltale sign of appendicitis.

He booked it to the emergency room of the only hospital in the county: Heart of the Rockies Regional Medical Center in Salida, Colorado. After a CT scan, doctors told Harness he had acute appendicitis and required immediate surgery.

A surgeon performed an appendectomy that night and released Harness the next day.

But a couple of days later, Harness felt sharp pains where his appendix had been. The pain grew until he was on the floor screaming.

“It was disturbing,” said Eliza Novick-Smith, his partner. “He has a pretty high pain tolerance,” given previous injuries from military service and mountain biking.

Harness went back to the hospital, where another CT scan revealed a blood clot the size of a brick floating in his pelvic area, a rare complication that most likely came from clipping and stapling the appendix tissue in the first surgery, said his surgeon. He would need another operation to check for the source of bleeding and to remove the clot.

After four more days in the hospital, he went home. It took him a couple of months to fully recover.

Then the bill came.

Patient: Shannon Harness, 39, an operations manager for a company that builds mountain bike trails across the country and a Marine Corps veteran. At the time of this incident, Harness had no insurance.

Total Owed: The original hospital bill was $80,232 for both surgeries — the first surgery cost $35,906 and the clot surgery cost $44,326. These amounts do not include payments to the surgeon, anesthesiologist, pathologist or radiologist.

Service Provider: Heart of the Rockies Regional Medical Center, a nonprofit critical access hospital in Colorado, where the surgeries were performed. Anesthesia, radiology and pathology were performed by other providers.

Medical Services: Laparoscopic appendectomy, followed by a second surgery a few days later, to resolve complications.

What Gives: Uninsured patients are extremely vulnerable to exorbitant hospital bills. It’s difficult to negotiate with a hospital without the leverage and bargaining power of an insurance company. Worse, uninsured patients are often billed three or four times what an insurer or government program would pay for the same service, said Anthony Wright, executive director of Health Access California, an organization advocating for affordable health care in California.

“As somebody who’s uninsured, you are getting an unnegotiated rate,” Wright said, derived from the hospital’s master price list. Insurers typically pay a rate that is a tiny fraction of that cost.

Harness was uninsured for seven years before this incident. His employer didn’t offer insurance, and the Affordable Care Act plan he qualified for cost $350 a month — an amount he didn’t have.

One option for uninsured patients is a hospital’s financial assistance program, a requirement in some states. In Colorado, every hospital is supposed to have a comprehensive charity care program for uninsured patients who earn less than 250% of the federal poverty level.

Heart of the Rockies hospital determines financial assistance on a sliding scale of family size and income. They also offer a self-pay discount of 15% to uninsured patients. Harness said the hospital’s financial services office initially told him he was ineligible for their assistance program as well as the Colorado Indigent Care Program. Harness had worked overtime the previous month and missed the qualification by around $200. The hospital would use only his past two pay stubs to verify his income, he said.

The hospital wouldn’t answer any questions about Harness’ care or bills, even though he gave it permission to do so.

Another quirk of the U.S. health care system that Harness encountered is that when surgeries don’t go as planned, and need revision with another operation, the patient (or his insurer) typically pays again. Medicare and some insurers have experimented with “bundled payments,” through which the hospital gets a set fee for the surgery and any follow-up care for 90 days thereafter.

Resolution: Harness filed a grievance with the hospital with the help of Novick-Smith, who is a lawyer, to push back on the bills for the two surgeries — $35,906 for the first and $44,326 more for the second —and express concerns with the quality of care.

Healthcare Bluebook, which estimates costs based on insurers’ claims data, says a fair price for an appendectomy in Salida is around $12,600. Dr. Gina Adrales, director of minimally invasive surgery at Johns Hopkins Medicine in Baltimore, said the complication Harness experienced is not common. The complication rate for an appendectomy is fairly low, she said.

In November, the hospital decided to give Harness a 30% discount for both surgeries, leaving him with a still hefty bill of $56,162.40.

The couple followed up repeatedly with the hospital for months, often finding representatives “hard to reach.” More than six months later, in March, the hospital told Harness he would have to pay for the second surgery because it was a risk he accepted by agreeing to the appendectomy.

Adam Fox, director of strategic engagement at Colorado Consumer Health Initiative, said it’s “especially important” to push back on bills resulting from surgical complications. “It usually indicates that something didn’t go right in the first surgery and at least that second surgery should be provided at a substantially reduced cost to the individual,” he said.

By May, the hospital gave in. Lesley Fagerberg, Heart of the Rockies’ vice president of financial services, wrote a response to Harness’ grievance, reducing the total bill by roughly the amount charged for the second surgery. But she didn’t explain how the hospital had come to that decision.

“Unfortunately, there was a complication in your appendectomy surgery,” Fagerberg wrote. “As explained in the consent to treat, a surgery/procedure has inherent risk. Your case has been reviewed and the total bill has been reduced by $31,218.60.”

Harness’ final bill from the hospital, Fagerberg wrote, stands at $22,304.17 after adjustments that included a self-pay discount.

Harness and Novick-Smith said that still seemed too high to them, and after some research, offered to pay the hospital $12,000 upfront. The hospital rejected this offer.

Now, Harness is working out a payment plan with the hospital. The hospital offers an interest-free payment plan if he can pay it off in two years, but for Harness, those monthly payments would be more than his rent.

“I would not be able to do it by myself, like, I wouldn’t have another choice other than taking out a loan,” Harness said. “Before the appendectomy, I was looking for property and homes to purchase, and that is pretty much completely off the table right now.”

Novick-Smith said she’s glad the hospital ultimately wrote off the bill for the second surgery. But she still feels angry with the hospital.

“What feels particularly hard is that the hospital markets itself in our community as this vital community resource and they provide a lot of jobs,” she said. “Their lack of transparency and lack of communication with us made this all a whole lot worse especially because there’s nowhere else to go.”

The Takeaway: The United States health care system is not forgiving to the uninsured, who, paradoxically, often face the highest bills of all patients. The benefit of having insurance is in part that your plan pays much of the bill, but also that you get the benefit of being charged the plan’s highly discounted rates. If your employer doesn’t provide health insurance, check whether you’re eligible for a public program, said Wright.

Harness now has VA Health Care. He initially avoided looking into VA Health Care because he felt “other vets needed it more.”

If you’re uninsured and stuck with a huge bill, Fox said, the first step is to ask for an itemized bill to ensure it reflects the actual service you received. The next step is to check the hospital’s charity care policy. Another resource uninsured patients can turn to are organizations like the Colorado Consumer Health Initiative.

“It’s by no means a perfect solution because there’s only so much that we can do to help consumers advocate for themselves in these cases, but we do our best,” Fox said.

If all else fails, Wright said, it’s best to put pressure on the hospital before they sell the bill to a collections agency. There’s less room for negotiation once a bill goes to collections, Wright said. And if all else really fails, you could try calling the press.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: How to Fight Bogus Medical Bills Like a Bulldog

Can’t see the audio player? Click here to listen.

After Izzy Benasso had knee surgery, she and her dad received a letter from a surgical assistant giving notice that he “had been present” at the procedure.

The surgical assistant was out-of-network and seemed to be laying the groundwork to get the Benassos to pay his fee.

Steve Benasso wrote a letter right back, basically telling the guy to buzz off: He had no intention of paying the surgical assistant. Because the bill was a surprise, Benasso suggested that the surgical assistant try to get the money from the insurance company, or negotiate for some part of the knee surgeon’s payment.

Benasso first shared his story with KHN and NPR for the Bill of the Month series.

There are two explanations for Benasso’s chutzpah.

One: “Steve is the kind of person to check every receipt twice and argue over any discrepancies he finds,” his daughter said.

Two: He had lots of experience haggling over medical bills in particular. As a human resources director, he specializes in defending his colleagues against bogus bills and unfair insurance denials.

“I am a bulldog on this stuff,” he said. “I do it every month.”

In this episode, learn how Steve became such a bulldog, and the tips he has for the rest of us.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This story can be republished for free (details).

Inside the Race to Build a Better $500 Emergency Ventilator

As the coronavirus crisis lit up this spring, headlines about how the U.S. could innovate its way out of a pending ventilator shortage landed almost as hard and fast as the pandemic itself.

The New Yorker featured “The MacGyvers Taking on the Ventilator Shortage,” an effort initiated not by a doctor or engineer but a blockchain activist. The University of Minnesota created a cheap ventilator called the Coventor; MIT had the MIT Emergency Ventilator; Rice University, the ApolloBVM. NASA created the VITAL, and a fitness monitor company got in the game with Fitbit Flow. The price tags varied from $150 for the Coventor to $10,000 for the Fitbit Flow — all significantly less than premium commercially available hospital ventilators, which can run $50,000 apiece.

Around the same time, C. Nataraj, a Villanova College of Engineering professor, was hearing from front-line doctors at Philadelphia hospitals fearful of running out of ventilators for COVID-19 patients. Compelled to help, Nataraj put together a volunteer SWAT team of engineering and medical talent to invent the ideal emergency ventilator. The goal: build something that could operate with at least 80% of the function of a typical hospital ventilator, but at 20% or less of the cost.

For decades, Nataraj has worked on medical projects — like finding a better way to diagnose a potentially deadly brain injury in premature infants — primarily with doctors at Children’s Hospital of Philadelphia and the Geisinger Health system in rural Pennsylvania, so key clinical players came together swiftly. By March 23, he had approached engineering faculty about collaborating on a monthslong effort to build the NovaVent, a basic, low-cost ventilator with parts that cost about $500. The schematics would be open-sourced, so others could use them free of charge to mass-manufacture the device.

The New Yorker wasn’t alone in referencing the ’80s TV series “MacGyver,” whose protagonist was a Swiss Army knife-carrying secret agent who got the job done with wits and whatever was at hand. The suggestion was that these ventilators were simple enough to throw together with parts from a medical supply closet or your neighborhood hardware store. “Everybody can make it,” one headline read, enticingly. These miracle machines, the thinking went, could be helpful in U.S. hospitals facing critical shortages, perhaps in cities surging with sick patients.

To understand the potential utility and true costs of these emergency ventilators, KHN followed Villanova’s team for three months as it developed, tested and prepared to submit the NovaVent for Food and Drug Administration approval.

The team tapped a maker of car parts, along with roboticists. It gathered input from anesthesiologists as well as electrical, mechanical, fluid systems and computer engineers. It tapped nurses to help ensure that users would immediately know how to operate the ventilator. Local manufacturers 3D-printed pieces of the machine.

Nataraj and his team realized that some of the other ultra-bare-bones machines wouldn’t meet the standards of the modern U.S. health care system. But they also believed there was a lot of room for Villanova’s team to innovate between those and the high-end, expensive devices from corporations like Philips or Medtronic.

One thing is clear: The $500 ventilator is something of a unicorn.

While the parts for the NovaVent cost about that much, the brainpower and people hours added uncounted value. In the early phases, the core group — all volunteers — worked 20 to 25 hours a week, Nataraj said, mainly via Zoom calls from home on top of their day jobs.

Teams of two or three were allowed into the lab to work — virtually the only people on campus. The effort, after all, was in line with the university’s Augustinian mission, which values the pursuit of knowledge, stewardship and community over the individual.

By the time they realized what they could achieve with the $500 model, the first wave of crisis had passed. Yet in those weeks, an alarm resounded across the land about the dismal state of America’s public health system.

So the NovaVent mission pivoted: build better low-cost vents for hospitals in poor and rural U.S. communities that have few, if any, ventilators.

One immediate legacy of the innovation happening at Villanova and elsewhere is the public-spirited nature of the effort, said Dr. Julian Goldman, an anesthesiologist at Massachusetts General Hospital who helps set standards for medical devices: “People from different walks of life in terms of their skills — engineers, clinicians, pure scientists — all thinking and working to try to figure out how to move very quickly to solve a national emergency with many dimensions: How do we make the patient safer? How do we make the caregiver safer? How do we deal with supply chain limitations?”

From other ventures, new designs have already been used as a jumping-off point to build emergency ventilators overseas. They’ve also bolstered New York City’s stockpile and could add to state and national reserves as well.

The early, urgent concerns about a looming ventilator shortage were well founded: On March 13, the U.S. had about 200,000 ventilators, according to the Society of Critical Care Medicine. But because of the surge of COVID patients, it was predicted the country could soon need as many as 960,000.

In early April, New York Gov. Andrew Cuomo said the state would run out of ventilators in six days, leaving doctors with the sort of grim calculation they’d heard about from hard-hit northern Italy: “If a person comes in and needs a ventilator and you don’t have a ventilator, the person dies.”

In Philadelphia, 12 miles east of Villanova, hospital administrators braced for shortages and reported short supplies of the drugs required to sedate patients on ventilators.

President Donald Trump invoked the Defense Production Act to get major manufacturers to make ventilators, though GM was already working on it. When GM signed a $500 million contract to deliver 30,000 ventilators to the U.S. government by August, the NovaVent team wondered whether its own efforts would be futile.

“We said, ‘Well, GM is making it. Why are we making it?’” Nataraj said. “But there was a lot of uncertainty with the epidemiological models. We didn’t know how bad it was going to get. Or [the curve] could completely collapse and there’d be no need at all.”

And for a few weeks, it did seem the worst was over. The rate of new cases began to slow in the nation’s early epicenters. Hot spots flared in nearly every pocket of the country, but those too were mostly contained.

People spilled back into normal life, gathering in backyards, beaches and bars. In June, news coverage moved on to the calls for racial justice and mass protests after the videotaped killing of George Floyd in the custody of Minneapolis police.

In the background, the highly contagious coronavirus tore across the South, through Florida, Georgia, Texas and Arizona, and surged in California. Some states reported ICU beds were quickly at or above capacity. This mercurial virus had proved uncontrollable, and the prospect of ventilator shortages had bubbled up once again.

***

Past pandemics have been mothers of innovation. Progress in mechanical ventilation began in earnest after a 1952 polio outbreak in Copenhagen, Denmark. According to the American Journal of Respiratory and Critical Care Medicine, 50 patients a day arrived at the Blegdams Infectious Disease Hospital. Many had paralyzed respiratory muscles; nearly 90% died.

An anesthesiologist at the hospital realized patients were dying from respiratory failure rather than renal failure, as was previously believed, and recommended forcing oxygen into the lungs of patients. This worked — mortality dropped to 40%. But one big problem remained: Patients had to be “hand-bagged,” with more than 1,500 medical students squeezing resuscitator bags for 165,000 total hours.

“They’d recruit nurses and medical students to stand there and squeeze a bag,” says Dr. S. Mark Poler, a Geisinger Health system anesthesiologist on the NovaVent team. “Sometimes they were just so exhausted that they would fall asleep and stop ventilating. It was obviously a catastrophe, so that was the motivation for creating mechanical ventilators.”

The first ones were simple machines, much like the basic emergency-use ventilators created during the COVID crisis. But those came with hazards such as damaging the lungs by forcing in too much air. More sophisticated machines would deliver better control. These engineering marvels — the monitors, the different modes of ventilation, the slick touch-screen controls designed to minimize the risk of injury or error — improved patient treatment but also drove costs sky-high.

The emergency ventilators of 2020 focused on models that, typically, used an Ambu bag and some sort of mechanical “arm” to squeeze it. Most people are familiar with Ambu bags from scenes in TV programs like “ER” where paramedics compress the manual resuscitator bags to help patients breathe as they’re rushed inside from an ambulance. The bags are already widely available in hospitals, cost $30 to $40 and are FDA-approved.

But making machines that are that simple could render them effectively useless (or, worse, dangerous). Medical experts watching university and hospital teams coalesce across the country this spring to develop low-cost emergency ventilators took notice — and worried.

***

Goldman, the Massachusetts General anesthesiologist, was among the medical experts nervous about all the slapped-together ventilators.

“We had the maker community being stood up very quickly, but they don’t know what they don’t know,” said Goldman, chair of the COVID-19 working group for the Association for the Advancement of Medical Instrumentation, the primary source of standards for the medical device industry. “There were videos of harebrained ideas for building ventilators online by people who don’t know any better, and we were very concerned about that.”

The general public doesn’t really understand the nuances required to build a safe medical device, Goldman said.

“They look at something and think, well, this can’t be that hard to build. It just blows air,” he said. “‘I’ll take a vacuum cleaner and turn it on reverse. … It’s a ventilator!’”

AAMI wanted to encourage innovation, but also safety. So Goldman assembled a meeting of 38 engineers, regulators and clinicians to quickly write boiled-down guidelines for emergency-use ventilators.

The simplest ventilators were based on the idea of a piston in a car engine, Poler said: Put a piston on a crankshaft, hook it up to a motor and use a paddle or “arm” to compress the Ambu bag.

“It’s better than no ventilator at all, but it goes at one speed. It doesn’t really have any controls,” Poler said — not ideal when patients need to be monitored for changes in how their lungs are responding, or not, to treatment.

Villanova’s team of engineers, doctors and nurses realized that the simplest ventilators, the ones that AAMI was concerned about, seemed to ignore some basic, practical considerations: What sort of hospitals would these be used in, and under what conditions? What sorts of patients would be put on these ventilators? For how long? Would they be used as backups for higher-end ventilators? What about error alarms?

All good questions, Poler said, but the answer to all of them essentially is “we hope to never use these.”

Their best use? “A surge situation where you simply don’t have enough of the sophisticated ventilators.”

***

Rather than go totally bare-bones, the Villanova team designed the devices as though they would one day be deployed in modern health care.

Flow sensors, which monitor patient ventilation, cost several hundred dollars, so the team designed its own in the lab and 3D-printed it at a cost of 50 cents, Nataraj said, enabled by strides in 3D-printing technology that have vastly cut the price of so many devices. Southco, a Pennsylvania-based global manufacturer that makes parts like the latch on your car’s glove box, was tapped to use its 3D printers to make airflow tubes and couplings for the ventilator.

Garrett Clayton, director of Villanova’s Center for Nonlinear Dynamics and Control, was the day-to-day keeper of the prototype. He was particularly excited about the addition of a handle, which made it easier for him, and eventually others, to lug the 20-pound device from the lab to home and back.

Clayton’s computerized control system measures the flow rate of air going into the patient and converts it into volume, much as commercial ventilators do. That controls how hard and fast the Ambu bag is squeezed; it’s made of a hobby-grade Arduino microcontroller board. A direct-current motor attached to a linear actuator with a fist-shaped piece of PVC on the end pushes the bag in and out. The operator of the ventilator can control the respiratory rate (the number of breaths per minute), as well as the ratio between inspiration and expiration and the volume of air going in.

While traditional ventilators have many control methods, Clayton’s team focused on just one: how much volume is forced into the airway. “We have a set point so we don’t damage the lung,” he said.

Polly Tremoulet, a research psychologist and human factors consultant for ECRI and Children’s Hospital of Philadelphia, was pulled in to focus on error messages and make sure the ventilators’ buttons and displays “spoke the user’s language,” whether that user was an anesthesiologist in New Jersey or a nurse in India pulled into an ICU COVID ward.

Graduate student Emily Hylton and other nursing students were brought in to provide feedback about using the NovaVent and ask questions such as: Would all the controls and monitors look familiar to nurses at the bedside?

The very prospect of these low-cost devices is relatively new, Nataraj said, because of the price of microcontrollers with any real capacity: “Twenty years ago, they cost, oh gosh, $20,000 — and now they’re $20.”

By May 30, the first NovaVent prototype was complete. It was successfully tested on an artificial lung at Children’s Hospital of Philadelphia on June 12. Villanova has applied for a patent for the NovaVent, to help ensure it won’t be commercialized by others.

“If you make it free without having a patent, other people can take it and charge for it,” Clayton said. “A patent protects the open-source nature of it.”

Once a provisional patent is received, the team will submit the ventilator for Emergency Use Authorization from the FDA — hewing to the guidelines set up by AAMI.

***

Within weeks of kicking off the NovaVent project, the curve in the East Coast had indeed flattened, and states had enough standard ventilators to treat every patient. The life-threatening ventilator shortage had not materialized. Some of the emergency-use ventilators based on designs by other teams, like the one at MIT, did go into production — but even those didn’t end up in hospitals, and instead went into city stockpiles meant to reduce potential future reliance on the federal government. So the Villanova team seized on a new, global mission.

“We thought if it wasn’t useful in the U.S. market,” Nataraj said, “we know the developing world, especially sub-Saharan Africa, Latin America and Central America, they don’t have the same kind of facilities that we do here.”

Where the ventilators might end up remains to be seen. Early on, Pennsylvania showed interest in helping Villanova find manufacturing partners. The team has spoken with engineers in India, Cambodia and Sudan (which reportedly has only 80 ventilators in the entire country) who are interested in possibly finding a way to manufacture the NovaVent.

Six thousand emergency ventilators based on the design by the University of Minnesota have been manufactured in the U.S., according to Dr. Stephen Richardson, a cardiac anesthesiologist who worked on that project. Three thousand were made by North Dakota aviation and agricultural manufacturer Appareo for state emergency stockpiles in North Dakota and South Dakota. UnitedHealth Group provided $3 million in funding to manufacture another 3,000 units made by Boston Scientific, which were donated to countries like Peru and Honduras through U.S. organizations; others were sent to the U.S. government.

Like the Villanova team, Richardson said he thinks the most promising potential for these ventilators is in developing countries.

“When we were arranging to get these donated to Honduras, we were speaking with a physician who was telling me that [at] his hospital right now, the med students are just hand-ventilating patients. For everything, and for COVID specifically,” Richardson said. “Right now, in Pakistan or in any low-resource country, a family member is hand-ventilating a toddler. Before COVID and after COVID, this is a problem.”

For Poler, the project was a reminder that the country needs to tend to its stockpiles. “People were thinking about [ventilator reserves] in the ’90s, and then they basically quit thinking about it,” he said. “COVID is a shocking reminder that we shouldn’t have stopped thinking about it.”

Goldman said the national efforts may not result in a flood of cheap ventilators in U.S. hospitals. International use could also be tricky. In countries with few resources, even very low-cost ventilators may not be feasible because of lack of electricity or compressed oxygen, though there is “potentially a sweet spot of need and capability where these things could be deployed.”

On the upside, he said, the pandemic kicked off a nearly unprecedented global engineering effort to share information and solve the problem.

“If there’s going to be a magic bullet to come out of this, it’s going to be the capability of our communities and our infrastructure,” he said. “People stood up, put in the appropriate processes and spirit, worked hard, made it happen. We’ve added resilience to the health care sector. That’s the outcome here.”

As for the NovaVent, team members were relieved they didn’t have to rush it into manufacturing as COVID-19 was ripping through the Northeast this spring, thanks to aggressive efforts to flatten the curve. “We ended up without a ventilator shortage, which is excellent,” Clayton said. “But with the increase in cases now, it’s very possible some of them may get used.”

To build on the project, Villanova is raising money for a laboratory for affordable medical technologies called NovaMed. The lab formalizes the process of making inexpensive medical equipment that follows the 80-20 function-to-cost rule. The university says the lab is “motivated by the belief that income should not determine who has access to lifesaving care.”

The effort to prevent a ventilator shortage, Nataraj said, made him think more critically about the American health care system overall.

“How come we haven’t built the technology, the economic and social systems that are able to handle a situation like this — especially when something like this was predicted?” he said. “It’s absolute nonsense. Why should a single person die because we weren’t prepared?”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Primary Care Doctors Look at Payment Overhaul After Pandemic Disruption

For Dr. Gabe Charbonneau, a primary care doctor in Stevensville, Montana, the coronavirus pandemic is an existential threat.

Charbonneau, 43, his two partners and 10 staff members are struggling to keep their rural practice alive. Patient volume is slowly returning to pre-COVID levels. But the large Seattle-area company that owns his practice is reassessing its operations as it adjusts to the new reality in health care.

Charbonneau has been given until September to demonstrate that his practice, Lifespan Family Medicine, is financially viable — or face possible sale or closure.

“We think we’re going to be OK,” said Charbonneau. “But it’s stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge.”

Like other businesses around the country, many doctors were forced to close their offices — or at least see only emergency cases — when the pandemic struck. That led to sharp revenue losses, layoffs and pay cuts.

Dr. Kevin Anderson’s primary care practice in Cadillac, Michigan, is also scrambling. The practice — like others — shifted in March to seeing many patients via telemedicine but still saw a dramatic drop in patients and revenue. Anderson, 49, and his five partners are back to about 80% of the volume of patients they had before the pandemic. But to enhance their chances of survival, they plan to overhaul the way the practice gets paid by Medicare.

Jodi Faustlin, CEO of the for-profit Center for Primary Care in Evans, Georgia, manages 37 doctors at eight family medicine practices in the state. She’s confident all eight will emerge from the pandemic intact. But that is more likely, she said, if the company shifts from getting paid piecemeal for every service to a per-patient, per-month reimbursement.

One of those 37 doctors is Jacqueline Fincher, the president of the American College of Physicians. Fincher said the pandemic “has laid bare the flaws in primary care” and the “misguided allocation of money and resources” in the U.S. health care system.

“It’s nuts how we get paid,” said Fincher, whose practice is in Thomson, Georgia. “It doesn’t serve patients well, and it doesn’t work for doctors either — ever, let alone in a pandemic.”

Physicians and health policy experts say the pandemic is accelerating efforts to restructure primary care — which accounts for about half the nation’s doctor visits every year — and put it on a firmer financial footing.

The efforts also aim to address long-festering problems: a predicted widespread shortage of primary care doctors in the next decade, a rising level of physician burnout and a long-recognized underinvestment in primary care overall.

No data yet exist on how many of the nation’s primary care doctors have closed up shop permanently, hastened retirement or planned other moves following the COVID-19 outbreak. An analysis by the American Academy of Family Physicians in late April forecast furloughs, layoffs and reduced hours that translated to 58,000 fewer primary care doctors, and as many as 725,000 fewer nurses and other staff in their offices, by July if the pandemic’s impact continued. In 2018, the U.S. had about 223,000 primary care doctors.

“We think we’re going to be OK,” says Dr. Gabe Charbonneau, a primary care doctor in Stevensville, Montana. “But it’s stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge.”(Tommy Martino for KHN)

“The majority [of primary care doctors] are hanging in there, so we haven’t yet seen the scope of closures we forecast,” said Jack Westfall, a researcher at the academy. “But the situation is still precarious, with many doctors struggling to make ends meet. We’re also hearing more anecdotal stories about older doctors retiring and others looking to sell their practices.”

Three-quarters of the more than 500 doctors contacted in an online survey by McKinsey & Co. said they expected their practices would not make a profit in 2020.

A study in the journal Health Affairs, published in June, put a hard number on that. It estimated that primary care practices would lose an average of $68,000, or 13%, in gross revenues per full-time physician in 2020. That works out to a loss of about $15 billion nationwide.

One main problem, said Westfall, is that payment for telehealth and virtual visits is still inadequate, and telehealth is not available to everyone.

Re-Engineering Primary Care Payments

The remedy being most widely promoted is to change the way doctors are reimbursed — away from the predominant system today, under which doctors are paid a fee for every service they provide (commonly called “fee-for-service”).

Health economists and patient advocates have long advocated such a transition — primarily to eliminate or at least greatly reduce the incentive to provide excessive and unneeded care and promote better management of people with chronic conditions. Stabilizing doctors’ incomes was previously a secondary goal.

Achieving this transition has been slow for many reasons, not the least of which is that some early experiments ended up paying doctors too little to sustain their businesses or improve patient care.

Instead, over the past decade doctors have sought safety in larger groups or ownership of their practices by large hospitals and health systems or other entities, including private equity firms.

A 2018 survey of 8,700 doctors by the Physicians Foundation, a nonprofit advocacy and research group, found, for example, that only 31% of doctors owned or co-owned their practice, down from 48.5% in 2012.

Fincher, the American College of Physicians president, predicts the pandemic will propel more primary care doctors to consolidate and be managed collectively. “More and more know they can’t make it on their own,” she said.

A 2018 survey by the American Medical Association found that, on average, 70% of doctor’s office revenue that year came from fee-for-service, with the rest from per-member, per-month payments and other methods.

The pandemic has renewed the push to get rid of fee-for-service — in large part because it has underscored that doctors don’t get paid at all when they can’t see patients and bill piecemeal for care.

“Primary care doctors now know how vulnerable they are, in ways they didn’t before,” said Rebecca Etz, a researcher at the Larry A. Green Center, a Richmond, Virginia, advocacy group for primary care doctors.

Charbonneau, in Montana, said he’s “absolutely ready” to leave fee-for-service behind.

However, he’s not sure the company that owns his practice, Providence Health System — which operates 1,100 clinics and doctors’ practices in the West — is committed to moving in that direction.

Anderson, in Michigan, is embracing a new payment model being launched next year under Medicare called Primary Care First. He’ll get a fixed monthly payment for each of his Medicare patients and be rewarded with extra revenue if he meets health goals for them and penalized if he doesn’t.

Medicare to Launch New Payment System

The Trump administration — following in the footsteps of the Obama administration — has been pushing for physician payment reform.

Medicare’s Primary Care First program is a main vehicle in that effort. It will launch in 26 areas in January. Doctors will get a fixed per-patient monthly fee along with flat fees for each patient visit. A performance-based adjustment will allow for bonuses up to 50% when doctors hit certain quality markers, such as blood pressure and blood sugar control and colorectal cancer screening, in a majority of patients.

But doctors also face penalties up to 10% if they don’t meet those and other standards.

Some private insurers are also leveraging the pandemic to enhance payment reform. Blue Cross and Blue Shield of North Carolina, for example, is offering financial incentives starting in September to primary care practices that commit to a shift away from fee-for-service. Independent Health, an insurer in New York state, is giving primary care practices per-patient fixed payments during the pandemic to bolster cash flow.

Meanwhile, two of the nation’s largest primary care practice companies continue to pull back from fee-for-service: Central Ohio Primary Care, with 75 practices serving 450,000 patients, and Oak Street Health, which owns 50 primary care practices in eight states.

“Primary care docs would have been better off during the pandemic if they had been getting fixed payments per month,” said Dr. T. Larry Blosser, the medical director for outpatient services for the Central Ohio firm.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Financial Self-Defense School Is Now in Session

Can’t see the audio player? Click here to listen.

When you need medical care, it can be a lot like entering a casino — playing for your financial life with the deck stacked against you.

But in this episode, reporter Celia Llopis-Jepsen offers insight and tips no dealer will divulge. She got a health care executive to talk honestly — maybe more honestly than he realized — about how his company and others are playing the game when they send patients huge bills.

When she investigated one man’s $80,000 bill, here’s what Llopis-Jepsen found:

Providers who took some of the $175 billion in pandemic-related bailout funds that Congress authorized in March had to promise not to ding patients with surprise bills for COVID-related care. But don’t expect your provider to merely tell you if that rule applies in your case. (That $80,000 bill did not include a footnote that said, “Once insurance pays us, you can forget all about this.”)

If you get a bill for COVID treatment, you can look up the provider yourself. Llopis-Jepsen found a government database where you can see if your provider took bailout funds.

She also has a tip sheet for pushing back against your medical bills.

And this story — which shows you don’t always owe what you are charged — is packed with insight, too.

Podcast Scheduling Announcement

From here on out, look for financial self-defense lessons from “An Arm and a Leg” every two weeks, instead of occasional seasons. Because it is always a good time to learn how to stand up against unfair medical bills.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Readers and Tweeters Defend Human — And Animal — Rights

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Standing Up for the Homeless

Many aspects of your story on homeless camps being “swept,” moved or cleared during this pandemic (“Sweeps of Homeless Camps Run Counter to COVID Guidance and Pile On Health Risks,” June 26) seemed tone-deaf or smacked of a skewed viewpoint by those who blame the homeless for poverty or other circumstances that lead them to camp on the street. Nancy Kuhn references 9,500 pounds of garbage after a sweep. Did that include tents, bicycles, clothing, shoes and other things people worked hard to acquire? If so, labeling it as “trash” falsely tars the owners as slovenly rather than hard-working and desperate. Colleen Echohawk’s comments about these people bringing “their COVID-19” and “their hepatitis A” with them after they’re kicked out of a site was another example of judgmental characterization and demonization from a position of privilege. I am so disappointed with the use of this forum to make things even worse for suffering individuals and families.

— Patricia Chritton, Stoughton, Wisconsin

It’s a lot cheaper to socially distance tents & put porta-potties & handwashing stations at camp sites, then it is to put people in hotel rooms. Some will refuse to go anyway. Clearing encampments is very traumatic for homeless individuals.

— Rosie Palfy (@RosiePalfy) July 6, 2020

— Rosie Palfy, Cleveland, Ohio

No Room for Rodeo

Be aware that every animal welfare organization in North America condemns the rodeo due to its inherent cruelty (“Montana Rodeo Goes On, Bucking Fears on Fort Peck Reservation,” July 17). For nearly all the abused animals involved, the rodeo arena is merely a detour en route to the slaughterhouse. Some “sport”! Rodeo — like those Confederate statues — has had its day, and now belongs in the Dustbin of History, R.I.P.

Lest we forget, COVID-19 was human-caused, a direct result of our gross mistreatment of animals, both wild and domestic. There are connections to be made here, folks.

How’s about a follow-up rodeo story from the animals’ point of view?

— Eric Mills, coordinator of Action for Animals, Oakland, California

Physical activity is the closest thing there is to a wonder drug. I REALLY miss the gym. Nice article: https://t.co/mHObNpWOqz

— Dr. Tom Frieden (@DrTomFrieden) June 30, 2020

— Dr. Tom Frieden, New York City

More Power to Him

Fantastic story (“‘More Than Physical Health’: Gym Helps 91-Year-Old Battle Isolation,” June 30). Very inspiring. My best wishes to Mr. Ballard. Please publish more such stories.

— Ramesh Gandhi, Sterling Heights, Michigan

1/2 Being a good #doctor has always required a mix of science & art. We are used to tradeoffs between “bad” & “worse.” But, this tradeoff between protection from #COVID19 & the adverse effect of isolation is a tough nut to crack. https://t.co/l3EFZJEbgb#seniorcare #patientcare

— Dr. Christopher Chen (@DrChrisChen) July 21, 2020

—— Dr. Christopher Chen, Miami

‘Skill’ of the Month?

I like your Bill of the Month stories. However, is there a technique or training of some sort that will help common folks decipher codes, understand charges so we know when these cross a red line? Perhaps you can write an article on best-known methods to decompose bills and understand what is fair and what is not. I know it varies per state, region, etc. But some guidance will be good. Sadly, I am starting to believe this is a “skill” everyone must have in the U.S.

I’m imagining a data “decoder ring” that one could use to quantify medical codes (ICD-9, ICD-10, etc.) and would give people a notion of “average” or “fair” charges in their area and in other parts of the country. This data would expose discrepancies among regions, perhaps among countries, making it very powerful to drive legislation. It is preposterous that we can get better info when buying/selling a car through Edmunds, the National Automobile Dealers Association and Kelley Blue Book than we can for medical procedures and services.

— Ramon Diaz, Phoenix

Editor’s note: We did publish training, of sorts, about a year ago. Please check out our go-to guide on decoding medical bills.

CMS has a list of surgeries for which an assistant is “always allowed,” “never allowed” or allowed with medical necessity. This isn’t a mystery. She needs to find out the CPT code, look it up. Her payer can tell her if it’s a surgery that typically uses an assistant or not. https://t.co/L3u9aGCeek

— Betsy Nicoletti (@BetsyNicoletti) July 28, 2020

The list is available in the physician fee schedule. Patients don’t normally meet the assistant surgery, and the assistant has no clinical responsibilities before or after the surgery.

— Betsy Nicoletti, Northampton, Massachusetts

‘Concierge’ Medicine Has Roots in the ACA?

National interest in “concierge” physician practices and services did not become widespread until the Affordable Care Act, when millions of patients and families were left “Holding the Bag” when they lost both their plan and their physician (“When a Doctor No Longer Accepts Medicare, Patients Left Holding the Bag,” June 9). This public interest “concierge” service was actually an effort to expand access to care for existing employer-health-plan patients who lost access under the ACA rather than reduce patient access, as this story suggests.

— Don Caton, San Diego

Sorry @khnews , but opting out of Medicare does NOT mean leaving Medicare patients behind. Quite the contrary, it means abandoning improper top-down interference in the patient-doctor relationship. https://t.co/KPp4yDIsxc

— AssocAmerPhys&Surg (@AAPSonline) June 9, 2020

The Association of American Physicians and Surgeons, Tucson

The Best Way to Honor Front-Line Heroes

We owe health care workers a sorry, not a thank you (“Lost on the Frontline”). We are sorry for what we have put you through. We messed up, big time.

When COVID-19 struck the U.S. and you were crying for PPE, we were too busy looking for someone to blame. When you were overworked and couldn’t go home to see your own children, we were too busy complaining about home-schooling.

When you had to see so much pain and suffering, every hour, every day, we said that this whole thing is just a conspiracy. When you were doing everything you could to save lives, we said that those are just numbers and — who knows? — maybe you are just trying to get some funding.

When you pleaded with us to stay home and be safe, we told you that freedom is our right. When you explained the science behind the testing and tracing, we asked you to slow it down and stop making us look bad.

When hundreds of you gave your own lives on the front line, we thanked you for being heroes, but we knew that had we done better, we could have saved many of you, too.

You are not superheroes and you shouldn’t be. There are things we can do and we must do to help you out and to take care of you. For so long, we were looking at others for answers but now we know the answer is in our hands and it has always been.

For so long we made this all about politics, but now we know it’s the people and lives that matter. This is not one person’s safety; it’s all of us. This is not one state’s problem; it’s all of us.

Whether we are in the middle of the first wave or the beginning of the second wave, let us take our social responsibilities, let us take this chance to do over. Health care Heroes, this time, let us make it right for you.

— Joyce Li Coffy, Los Angeles

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Don’t Count on Lower Premiums Despite Pandemic-Driven Boon for Insurers

When COVID-19 smacked the United States in March and April, health plans feared medical costs could skyrocket, jacking up premiums drastically in 2021, when millions of the newly unemployed might still be out of work.

But something else happened: Non-COVID care collapsed as hospitals emptied beds and shut down operating rooms to prepare for an expected onslaught of patients sickened by the coronavirus, while fear of contracting it kept people away from ERs, doctors’ offices and outpatient clinics. In many regions of the country, the onslaught did not come, and the billions of dollars lost by hospitals and physicians constituted huge savings for health plans, fattening their bottom lines.

But that doesn’t mean consumers will see lower premiums next year.

Numerous insurers across the country have announced plans to hike rates next year, though some have proposed cuts.

Peter Lee, executive director of Covered California, appeared skeptical about premium reductions in the state’s Affordable Care Act exchange, which is likely to announce 2021 health plan rates next week.

“Would we like zero increases? Absolutely. Would we like them negative? Yeah — but not if that means you’re going to increase premiums in a year by 20%,” Lee said in an interview with California Healthline this week. “We’ve been leaning on them to do what we always lean on them to do, and this is to have the lowest possible rates where you won’t be on a rate roller coaster. We want health plans to price right — not to price artificially low or artificially high.”

Covered California provides coverage for about 1.5 million residents who buy their own insurance.

If the insurance exchanges in other states offer any guidance for Covered California, it is in the direction of moderate premium increases for 2021, though there is wide variation.

A KFF analysis last week of proposed 2021 rates in the exchanges of 10 states and the District of Columbia showed a median increase of 2.4%, with changes ranging from a hike of 31.8% by a health plan in New Mexico to a cut of 12% in Maryland. (Kaiser Health News, which produces California Healthline, is an editorially independent program of KFF.)

Among the roughly one-third of filings that stated how much COVID-19 added to premiums, the median was 2%, with estimates ranging from minus 1.2% at a plan in Maine to 8.6% at one in Michigan.

The proposed premiums for ACA marketplace plans do not affect job-based coverage, but they may indicate how the pandemic is affecting premiums generally.

The consensus among industry experts is that COVID-19 has generated little pressure for rate rises, and health plans should err on the side of moderation. But some fear that many insurers will hold onto the reserves they’ve built up, citing the possibility of widespread vaccinations and concerns that the care forgone in 2020 could rebound with a vengeance next year.

“The tendency of health plans, when they are faced with any degree of uncertainty, is to be very conservative and price for the worst-case scenario,” said Michael Johnson, an industry observer and critic who worked as an executive at Blue Shield of California from 2003 to 2015. “Actuaries are less likely to get fired if the plan prices too high than if the plan prices too low. But I think regulators really need to push back hard on that.”

Lee said all 11 insurers participating in the exchange this year will remain in 2021, and no new ones will be added to the mix, though some of the current carriers will extend their coverage geographically. Ninety percent of consumers who buy their own health insurance get subsidies from the federal government or the state to help pay their premiums.

In January, California became the first state to offer subsidies to middle-income people who make too much money to qualify for federal subsidies. The lion’s share of the state subsidies is earmarked for those who earn between 400% and 600% of the federal poverty level, or $51,040 to $76,560 a year for an individual and $104,800 to $157,200 for a family of four.

The rate proposals expected to be unveiled next week will be subject to scrutiny by state regulators before they are finalized. Sign-ups for the plans start Nov. 1 and run through Jan. 31. This year, the average Covered California rate increase statewide was 0.8%, the lowest since the exchange started providing coverage in 2014.

The benefits reaped by health plans so far in the pandemic can be seen in strong second-quarter earnings and reduced spending on care. UnitedHealth Group, the nation’s largest health insurer, announced earlier this month that its net profit in the April-June quarter nearly doubled from the same period a year earlier. Its medical spending plummeted from 83.1% of premium revenue to 70.2% over that period.

Anthem, the parent company of Blue Cross of California, reported Wednesday that its net profit in the second quarter doubled from the same period in 2019, also on the back of plunging medical expenses.

Anthem said it offered one-month premium credits ranging from 10% to 50% to enrollees in individual, employer and group dental policies — including its Blue Cross plans in California.

UnitedHealth said it has provided $1.5 billion worth of financial support to consumers so far, including premium credits and cost-sharing waivers, and expects to pay out $1 billion in rebates.

But UnitedHealth, which does not participate in Covered California, is seeking a rate increase of 13.8% in the New York exchange. Anthem, which covers about 80,000 people in Covered California, is planning rate hikes of 16.6% in Kentucky and 9.9% in Connecticut.

On the other hand, Kaiser Permanente, which covers more than one-third of Covered California enrollees, plans rate cuts in other states, ranging from 1% in Hawaii to 11% in Maryland. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Lee downplayed the notion of a financial boon for California health plans, saying that, partly because of the use of telehealth, primary care has rebounded and the plans are paying for it. “So we don’t see this as being at this point a bonanza year for health plans,” he said. “Rather, it’s a year in which there are lessons learned for how we can deliver care in a pandemic.”

Still, the health plans are in a far stronger position than they had feared earlier this year.

In March, Covered California released a study showing that COVID-19’s impact on 2021 premiums for individuals and employers could range from an increase of 4% to more than 40%. But less than three months later, projections commissioned by the industry’s national advocacy group, America’s Health Insurance Plans, showed that even in the worst-case scenario of a 60% COVID infection rate — far above where it stands now — the pandemic would increase medical costs in 2020 and 2021 by 6% at most, and could even decrease them.

That moderate effect is largely attributable to what Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, called “a kind of yin and yang: If you have a lot of COVID, you don’t have a lot of other health care spending.”

Independent of the course the pandemic takes, emergency room and outpatient visits still lag behind pre-COVID levels and will probably continue to do so next year, to the continued benefit of insurers, predicted Glenn Melnick, a professor of health care finance at the University of Southern California’s Sol Price School of Public Policy. That could be good news for consumers, he said, potentially leading to lower premium increases or even reductions next year.

On the other hand, hospitals and doctors have lost money, and the ones whose contracts with health plans are up for renewal will be looking to make up those losses, Melnick said.

“Providers could be asking for 20-25% increases next year,” he said, “and if they’ve got market power, they can make it stick.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

KHN’s ‘What The Health?’: Republicans in COVID Disarray

Can’t see the audio player? Click here to listen on SoundCloud.

President Donald Trump’s pivot to a more serious view of the coronavirus pandemic didn’t last long. This week, he was again touting hydroxychloroquine, an antimalarial drug that has not been shown to work against the virus. Meanwhile, on Capitol Hill, Republicans continue to struggle to come up with a proposal for the next round of COVID-19 relief even as earlier bills expire. That’s leaving millions of Americans without the ability to pay rent or meet other necessary expenses, as the economy continues to sink.

Also on the agenda, at least briefly, is the subject of high drug prices. Once considered a leading health issue for the 2020 elections, it has been all but wiped from the headlines by the pandemic. Trump issued a series of executive orders he said would produce an immediate impact, but experts point out they are mostly wish lists of things the president has already said he supports.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Mary Ellen McIntire of CQ Roll Call and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Despite much disarray on Capitol Hill about which coronavirus relief economic provisions Republican senators will agree on, there is largely agreement within the party and among Democrats on the health provisions, such as the need for more money for testing and for health care providers.
  • Senate Majority Leader Mitch McConnell insists the stimulus package must include liability protection for employers to protect businesses struck by a COVID-19 outbreak through no fault of their own. But Democrats are opposed and argue that the promise of liability waivers may keep employers from taking adequate safety precautions.
  • The Atlantic magazine recently explored the issue of “hygiene theater” in which people take measures they hope will keep the coronavirus at bay — such as excessive scrubbing, temperature checks, etc. — that science suggests have limited or no effect. These measures may give people comfort, but the efforts can also be dangerous in that they give a false sense of security and divert attention and resources from other, more complicated methods to stop the disease.
  • Much attention in recent weeks has been given to the development of a vaccine. Several options are in advanced stages of testing. But public health advocates fear that the speed of the testing and the administration’s past erroneous statements about the disease may raise fears among consumers about taking the vaccine. Nonetheless, Democrats looking ahead to the election worry that the administration will make a major announcement about vaccine availability as an October surprise.
  • COVID-19 has basically eclipsed efforts to make progress on several other key health issues that were expected before the election, including drug pricing and surprise medical bills.
  • With great fanfare this week, Trump announced orders for the administration to move toward new drug pricing policies. But the orders have little or no effect and haven’t created any momentum for advancing legislation in Congress.
  • The president surprised many people this week when he announced he was loaning Kodak millions of dollars to produce ingredients needed for the generic drug industry. Many of those chemicals have been made overseas, so the effort does follow the administration’s quest to establish more manufacturing in the U.S. But one reason few companies do the work here is that there is not a big profit margin on the drugs.

Also this week, Rovner interviews KHN’s Markian Hawryluk, who reported the July NPR-KHN “Bill of the Month” installment, about a surprise bill from a surprise participant in the operating room: a surgical assistant. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “Disability Pride: The High Expectations of a New Generation,” by Joseph Shapiro

Alice Miranda Ollstein: Politico’s “Pelosi Mandates Wearing Masks on the House Floor After Gohmert Case,” by Heather Caygle and Sarah Ferris

Mary Ellen McIntire: The Atlantic’s “Why Can’t We Just Have Class Outside?” by Olga Khazan

Anna Edney: ProPublica’s “How to Understand COVID-19 Numbers,” by Caroline Chen

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Missourians to Vote on Medicaid Expansion as Crisis Leaves Millions Without Insurance

ST. LOUIS — Haley Organ thought she had everything figured out. After graduating from a small private college just outside Boston, she earned her master’s degree, entered the workforce and eventually landed a corporate job here as a data analyst.

Life seemed to be going as planned until the national retailer that Organ worked for announced furloughs during the coronavirus pandemic. After nine weeks of mandatory leave, the 35-year-old was laid off. The company gave her a severance package and put an expiration date on her health insurance plan.

“I haven’t slept the whole night since about March,” Organ said earlier this summer. “I can’t turn my brain off, just worrying about everything.”

Organ filed for unemployment, adding her claim to more than 40 million others nationwide since the pandemic took hold in mid-March, according to the Department of Labor. That’s about 1 in 4 U.S. workers. As a result of the unemployment crisis, millions of people lost access to their private health insurance plans at a time when they might need it most.

Medicaid, the federal and state health insurance program for people with low incomes or disabilities, could have served as a safety net for Organ if she lived in one of the 38 states that have opted to expand under provisions of the Affordable Care Act. But in Missouri, Republicans who control both the governor’s office and the legislature have said the state cannot afford its share of the cost of expansion and have been adamant foes of the ACA, helping lead a lawsuit now before the U.S. Supreme Court that may nullify the law.

That opposition by state leaders has meant adults like Organ who don’t have dependent children or specific disabilities cannot qualify for Missouri’s Medicaid program — even if their incomes are well below the poverty line.

“This is literally the first time in my life I’ve had to worry about health care coverage,” Organ said. “It’s kind of been a rude awakening for me.”

Voters in Missouri will decide Tuesday whether to expand eligibility for MO HealthNet program (Missouri’s Medicaid program) to provide insurance to more than 230,000 additional people in the state, including many who find themselves newly struggling for health coverage amid a national health crisis. More than 700,000 initial unemployment claims were reported in Missouri from mid-March through the first week of July.

If Medicaid expansion passes in Missouri, coverage for those newly eligible people would begin in 2021. Advocates for the measure say Medicaid expansion would also create jobs, protect hospitals from budget cuts and bring billions of federal taxpayer dollars back to the state.

Missouri is the latest red state to try expanding Medicaid with a ballot measure to circumvent recalcitrant legislatures. Oklahoma approved a measure June 30.

But Missouri’s Republican Gov. Mike Parson, who has said he opposes expanding Medicaid, moved the ballot measure from the general election in November to the primary election on Tuesday. Democrats criticized the shift, noting that fewer voters traditionally turn out for the primary and suggesting it could be easier to defeat in August. The ongoing threat of COVID-19 could also keep some voters away from the polls.

In a statement, Parson said changing the election date will allow the state to prepare for the potential cost of expansion. But an analysis from Washington University in St. Louis suggests that expanding the program could save the state money by lowering the amount it must pay for uncompensated care and bolstering efforts to prevent certain diseases, thereby reducing treatment costs to the state. Under the terms of the Affordable Care Act, the federal government picks up 90% of the coverage costs for newly eligible enrollees, as compared with the 65% it pays for people who qualify under regular Medicaid rules.

Backers of expansion are cautiously optimistic that Missouri voters will approve the measure Tuesday, heartened by Oklahoma’s win last month and positive polling.

For people who qualify for the current Medicaid program, enrollment is open year-round, which means people can apply when needed.

“That’s why we call them safety-net programs,” said Jen Bersdale, executive director of Missouri Health Care for All, a group that has advocated for Medicaid expansion since 2012. “When you get dropped from a job, dropped from insurance, they are there to catch you until you’re back on your feet.”

Amid the pandemic, Medicaid already appears to be helping people newly out of work. In 22 states, Medicaid enrollment increased by an average 5% from February to May, according to Georgetown University Health Policy Institute data. Newer data for May in those same states suggests enrollment growth is accelerating.

Even without expanding the program, Missouri leads the group with an 8.8% increase since February in total Medicaid enrollment. While economic recessions often contribute to increasing Medicaid enrollment, the early spike in Missouri could signify reenrollment of a large number of people, mostly children, who had been dropped from the program two years in a row. A federal rule blocks disenrollment during the pandemic.

Even some Missourians already on Medicaid are worried about the ballot measure not passing. Without expansion of the program, Sally Terranova fears that her 16-year-old son, Colin, will be ineligible for Medicaid when he ages out of the kids’ coverage at age 19. He was diagnosed with Type 1 diabetes in 2016.

Terranova is concerned that her son wouldn’t be able to afford the insulin he needs without insurance. She worries even more when she hears stories about diabetics rationing their insulin.

“It’s bad enough he has this illness hanging over him,” Terranova said. “But he can live a good life and be healthy if he has access to health care.”

That’s one reason Terranova, 39, hopes to land a job with good benefits when she finishes graduate school in a year and half. She has studied social work for the past four years, so she understands the challenges low-income families face.

Terranova had moved from New York to Missouri to give her son a better life. They’ve called St. Louis home for 10 years, but the single mom is contemplating another big move for her son’s health. She’s thinking of going this time to a state that has already expanded the program.

Organ, whose health insurance expired in July, is now one of the lucky ones. She just got a new job and will get new health insurance when she starts next week. Still, she’s hoping the Medicaid measure will pass, as she now appreciates more than ever how much it could mean for others who have lost their jobs and lack coverage amid the COVID-19 pandemic. Instead of heading to a polling place Tuesday, though, Organ is planning to vote by mail.

“I’m trying to do everything I can to keep me and others safe,” Organ said. “But I want to make sure my voice is still heard.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Last Thing Patients Need During Pandemic: Being Last to Know a Doctor Left Network

NEW YORK — As the coronavirus spread silently through New York City early this year, Deborah Koeppel had an appointment with her cardiologist and two visits with her primary care doctor. Both physicians are members of Concorde Medical Group, a practice in Manhattan with an office conveniently located a few blocks from where Koeppel works.

She soon received notices telling her — after the fact — that those doctors were not in her health plan’s network of providers. According to the notices, she was on the hook for $849 in out-of-network cost sharing for three visits, which typically would cost her nothing from in-network providers.

Changes to health plan networks occur all the time as doctors retire, relocate or leave networks. And patients may be the last to find out about such changes because providers or insurers are not always required to inform them.

Koeppel also faced the loss of low-cost access to her in-network gynecologist and dermatologist.

“I felt sickened,” said Koeppel, 62, a senior social worker who kept working even as New York was hit by a brutal COVID-19 outbreak, with more than 1,000 deaths a day at its peak. “To me, it feels like physician abandonment. In the middle of something like this, you’re left without your doctors.”

Legislators, regulators and insurers have enacted special policies during the coronavirus pandemic, including paying for more virtual visits and eliminating copays for COVID-related testing and care. But long-standing issues, such as ever-shifting networks — often unbeknownst to patients — persist unchanged. And blindsiding patients with such changes is particularly hazardous at a time when many offices are partly closed, and patients are vulnerable and more likely than usual to need medical advice or attention.

That’s not how it should work, experts say. “Both parties should have responsibility for notifying their members,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms who co-authored a recent report examining state protections for patients who lose access to their doctors and other providers during contract disputes between providers and health plans.

The paper highlighted published examples of contract disputes that potentially affected hundreds of thousands of members, including 100,000 UnitedHealthcare members who lost access to eight Houston hospitals because of a contract dispute last year and the long-running feud in Pennsylvania between Highmark Health and the University of Pittsburgh Medical Center over in-network access to at least 11 hospitals.

Network changes that affect only a small number of patients or are the result of amicable negotiations between providers and insurers happen too, but they rarely make the news.

Health care experts agree that maintaining regular relationships with providers over time can help people manage chronic conditions and stay healthy. But patient protections from disruptions caused by network changes are scant. Most states have laws that permit health plan members to continue to see their doctors for a time after they leave the network, but only under certain limited circumstances, such as if they are pregnant or have a terminal illness. And some states require insurers to notify members in advance of network changes, Corlette said.

Deborah Koeppel learned her cardiologist and primary care doctor had been dropped from her insurance network ― shortly after her most recent appointments with both. “I felt sickened,” says Koeppel. “To me it feels like physician abandonment.” (Courtesy of David Koeppel)

But state laws don’t protect the majority of people who have coverage through health plans that are self-insured, meaning they pay members’ claims directly rather than buy insurance for that purpose. Those plans operate under federal guidelines and generally aren’t subject to state insurance regulation.

Koeppel is a member of 1199SEIU, the Service Employees International Union’s largest local, representing nearly 450,000 health care workers on the East Coast. She receives health care through the National Benefit Fund, a self-insured plan funded by contributions from the union members’ employers.

Koeppel has gone to doctors at Concorde for eight years. Until January, Concorde doctors participated in plans offered through the Independent Practice Association at NYU Langone Health, a large private health system. Eleven Concorde doctors treated members of the National Benefit Fund for 1199SEIU. In January, the physicians group joined Northwell Health, another large private health system in New York. Koeppel and 162 other 1199SEIU patients lost in-network access to their Concorde doctors as a result, said Terry Lynam, a Northwell spokesperson.

Northwell put out a press release in October announcing that Concorde Medical Group was joining the health system. In December, the Concorde Medical Group posted the upcoming change on its website.

But no one told the patients about the change.

The National Benefit Fund wasn’t notified of the change either, according to a statement from the fund. A staff member for the fund brought it to their attention.

Koeppel said she knows there are other doctors she can see — there are tens of thousands in network in the New York City area. But she was distraught to lose those with whom she’s developed a trusting relationship.

Her primary care physician “has been incredibly available by phone, just a really committed person who’s caring, warm and very reassuring,” she said.

After Koeppel complained to Northwell, administrators offered to write off any charges for her visits to Concorde physicians during the pandemic, she said.

And after a reporter contacted Northwell and the union’s National Benefit Fund about the network changes, the health system and the union agreed to a temporary contract extension from January 2020 through the end of August that allows 1199SEIU members to continue to see their Concorde doctors without cost sharing. The two parties are in negotiations for a new agreement that would give National Benefit Fund members in-network access to Concorde and other Northwell physicians after that date.

Northwell’s Lynam said that since there was no interruption in patient care, the timing of patients’ discovering the change is immaterial.

“Whether they found out in December that they had to find a new provider or they found out in June that they had to do so, the end result would be the same,” he said. “No patient was abandoned or harmed because they didn’t know earlier, and they would have been equally upset by the news whether they found out now or in December.”

Koeppel disagreed. If she had been informed of the upcoming change in October when Northwell put out its press release, Koeppel said, she would still have been upset. But she would have been better positioned to switch providers before January and would have had new physicians in place before the pandemic hit.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Medicaid Mystery: Millions of Enrollees Haven’t Materialized in California

The predictions were dire: Coronavirus lockdowns would put millions of Americans out of work, stripping them of their health insurance and pushing them into Medicaid, the health insurance program for low-income people.

In California, Gov. Gavin Newsom’s administration projected that the pandemic would force about 2 million additional people to sign up for the state’s Medicaid program, called Medi-Cal, by July, raising enrollment to an all-time high of 14.5 million Californians — more than one-third of the state’s population.

But July is almost over, and Medi-Cal enrollment has hovered around 12.5 million since March, when the pandemic shut down much of the economy — though enrollment ticked up in May and June, according to the latest data from the state Department of Health Care Services, which administers the program.

Essentially, enrollment hasn’t budged even though nearly 3 million Californians are newly unemployed.

“It’s a mystery,” said Anthony Wright, executive director of Health Access California, an advocacy group for health consumers. “We have lots of plausible explanations, but they don’t seem to add up.”

Even the state is stumped. The enrollment data is preliminary, and Medi-Cal officials expect the numbers to grow as eligibility appeals and other “unusual cases” are resolved, but not by 2 million people, said Norman Williams, spokesperson for the Department of Health Care Services.

The department based its projections on the state’s experience with the Great Recession a decade ago, a comparison that it now acknowledges was misguided because the pandemic did not spur a purely economic crisis. The state failed to predict people would avoid care at clinics and hospitals during this public health crisis, and thus be less likely to need coverage immediately.

“The current situation is far more complex because it involves both economic and health decisions, creating a more complicated picture more closely related to that seen during the 1918 influenza pandemic,” Williams said in a prepared statement.

Even with the faulty comparison, it’s not clear why more Californians haven’t enrolled, he said.

“The state prepared an estimate based on the best data available, during an unprecedented and rapidly evolving situation,” he said.

The miscalculation meant the state likely allocated more money to Medi-Cal than the program now needs, even as lawmakers struggled to find ways to prevent deep health care cuts and close a massive $54 billion budget deficit as they negotiated the 2020-21 state budget in May and June.

And a more accurate estimate could have potentially funded new programs, such as expanding Medi-Cal to unauthorized immigrants age 65 and up, some state lawmakers and advocacy groups said.

Newsom backed that expansion of Medi-Cal, estimated to cost $80.5 million in the first year, in his January budget proposal but abandoned it in May, citing California’s financial crisis spurred by the pandemic.

“We are talking about life-or-death services, so to say I’m frustrated is putting it mildly,” said state Sen. Holly Mitchell (D-Los Angeles), who chairs the Senate budget committee and leads budget negotiations in the upper house. “It’s irritating to me that they can be so off.”

The new state budget puts Medi-Cal’s overall cost at $115 billion, of which $2.4 billion in state money has been earmarked for caseload growth. Yet it’s unclear how much of that could have been available to fund other programs or stave off cuts had the caseload projection been more accurate, department officials acknowledged.

Most states predicted their Medicaid enrollment would rise due to the pandemic, though many are seeing similar delays in Medicaid sign-ups, said Cindy Mann, a partner at the legal and consulting firm Manatt Health who served as federal Medicaid director for the Centers for Medicare & Medicaid Services during the Obama administration.

Washington state, like California, hasn’t seen its Medicaid caseload grow as expected, said MaryAnne Lindeblad, its Medicaid director. It projected up to 95,000 people would join the program by now, yet it has seen 80,000 new enrollees since March.

“It’s been a little bit surprising,” she said. “There’s so much going on in people’s lives right now and signing up for Medicaid doesn’t seem to be one of them.”

Yet a record number of Americans have lost health insurance as a result of the COVID-19 pandemic and corresponding economic crash, according to a new report from Families USA, a national health advocacy group. California experienced the largest increase in newly uninsured residents of any state so far when an estimated 689,000 people lost coverage between February and May this year, the study shows.

“It’s a different kind of downturn and that might explain some of the reason we’re seeing lags across the country,” Mann said. “But unless unemployment numbers turn around dramatically, which is not the prediction, I think we will see the number of uninsured people continuing to grow and turn to the program.”

There are several theories about why Californians who have lost their jobs during the pandemic have not yet enrolled in Medi-Cal.

For one, signing up for food and housing assistance appears “more urgent” than signing up for Medi-Cal, Williams said.

The pandemic has also created new sign-up hurdles. With libraries, schools, community centers and county health care offices largely closed during lockdowns, uninsured residents have had fewer places to enroll. Hospitals and clinics also frequently enroll uninsured people into the program, but many healthy people are avoiding treatment for fear of being infected with COVID-19.

And those who have lost jobs may still have work-based coverage because employers planned to rehire them and kept them on job-based insurance plans, or because they’ve signed up for COBRA insurance temporarily.

Enrollment could also be lagging because the service industry has been hit hard, and many low-income workers in restaurants, bars or salons were already enrolled in Medi-Cal.

“About a quarter who were at risk of losing jobs were already enrolled when the crisis started,” said Laurel Lucia, director of health care programs at the Center for Labor Research and Education at the University of California-Berkeley.

Vanessa Poveda lost her health insurance after losing her job as a server at a San Francisco gastropub. She thinks she probably qualifies for Medi-Cal but hasn’t signed up yet, in part because the task feels daunting. (Courtesy of Lindsay Thomas)

Vanessa Poveda, 28, wasn’t among the service workers already enrolled in Medi-Cal when the crisis hit. Instead, she had health insurance through her job as a server at Bartlett Hall, an upscale gastropub near San Francisco’s Union Square.

When Poveda was laid off during the first round of coronavirus closures in March, the restaurant extended her health coverage for 30 days before it expired, she said. Now unemployed and uninsured, she thinks she probably qualifies for Medi-Cal but hasn’t signed up.

“I haven’t really gotten around to it,” she said.

Because Poveda is relatively healthy, she said, enrolling in coverage isn’t as urgent as some of her other needs.

“Medical insurance is definitely a top priority for me,” she said, “but I also need a roof over my head.”

In California, another factor may be at play. The Trump administration’s “public charge” policy may be having an outsize impact on Medi-Cal enrollment because of the state’s large immigrant population, said Hamutal Bernstein, a researcher at the Urban Institute. The rule allows federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

“A lot of immigrant families are being disproportionately impacted by economic and health hardship and are increasingly needing some of this assistance,” Bernstein said. But “a lot of people are afraid of getting any kind of help.”

Federal rules also prevent the state from kicking anyone off Medicaid during the pandemic, which means people who normally would have fallen off the program will stay enrolled, contributing to the state’s inflated projections, Williams said.

The department said it is working to get out the word that Medi-Cal is available, but Mitchell is urging the state to do more.

“I’m concerned not enough outreach is being done,” she said. “We expect people to magically know they may qualify for Medi-Cal and they should go online and apply.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Another Problem on the Health Horizon: Medicare Is Running Out of Money

Everyone involved even tangentially in health care today is completely consumed by the coronavirus pandemic, as they should be. But the pandemic is accelerating a problem that used to be front and center in health circles: the impending insolvency of Medicare.

With record numbers of Americans out of work, fewer payroll taxes are rolling in to fund Medicare spending, the numbers of beneficiaries are rising, and Congress dipped into Medicare’s reserves to help fund the COVID-19 relief efforts this spring.

“I think we have a real, impending health care crisis,” said Dr. David Shulkin, who was undersecretary for health at the Department of Veterans Affairs under President Barack Obama for two years and led the VA for a year under Donald Trump.

In April, Medicare’s trustees reported that the Part A Trust Fund, which pays for hospital and other inpatient care, would start to run out of money in 2026. That is the same as the projection in 2019. But the trustees cautioned at the time that their projections did not include the impact of COVID-19 on the trust fund.

“Given the uncertainty associated with these impacts, the Trustees believe that it is not possible to adjust the estimates accurately at this time,” said the report.

So Shulkin, now a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, did his own projections. Given even a conservative estimate of how many workers and businesses would not be contributing payroll taxes that finance Part A spending, he said, the trust fund could become insolvent as early as 2022 or 2023.

“I think this is something that needs more immediate attention,” he said.

Others who make projections agree the insolvency date is getting closer, maybe not as close as 2022.

The Committee for a Responsible Federal Budget, a nonpartisan group of budget experts focused on fiscal policy, estimates that the pandemic will cause the Part A Trust Fund to be unable to pay all of its bills starting in late 2023 or early 2024. “But we’re still very close,” said Marc Goldwein, the group’s senior vice president.

There are two ways the Trust Fund can get into trouble: Either the money flowing in is too little, or the payments going out for care are too much.

Most of those who watch Medicare finances agree that the larger problem right now is how much money is being collected for the Trust Fund. That money largely comes from the 1.45% payroll tax paid by employees and employers. With so many people out of work due to pandemic-related shutdowns, cash flowing in has dropped dramatically.

It’s far less clear what is happening on the spending side of Medicare Part A. (Medicare Part B, which pays physicians and other outpatient costs, is funded by beneficiary premiums and general tax funding, so it cannot technically become insolvent.)

While COVID-related hospital expenses for those on Medicare are expected to be substantial, Medicare hasn’t been reimbursing as much care of other sorts. In some cases, that’s because hospitals in COVID hot spots temporarily stopped doing elective procedures like joint replacements. In other cases, patients with non-COVID ailments have been afraid to go to hospitals for fear of catching the virus.

Also, said Goldwein, health care use tends to fall in recessions, even for Medicare, whose beneficiaries are largely retired.

In the end, he said, “we basically threw our hands up and said we don’t have the information” to estimate how health costs will affect the Trust Fund’s financing.

There is one other COVID-related policy that could hasten the depletion of the Trust Fund. At least $60 billion of the funding provided as part of the CARES Act to help hospitals weather the pandemic came not from the general treasury, but from the Trust Fund itself.

That money in “accelerated and advance payments” is supposed to be paid back, via a reduction in future payments. But there is a push in some quarters for that funding to be forgiven, which would make the Trust Fund’s hole even bigger.

It is not exactly clear what would happen if the Trust Fund were to become insolvent because it has never happened before. As the Congressional Research Service pointed out, “There are no provisions in the Social Security Act that govern what would happen if insolvency were to occur.”

It is important to remember that the fund becoming insolvent is not the same as being bankrupt. Insolvent means the Trust Fund would still have money flowing in, but not enough to pay for all the care Medicare patients will consume.

Most budget experts think that Medicare would reimburse hospitals and other Part A providers 100% of their claims until the fund truly runs out of money. Then it would pay claims only as more money flows in. Others think Medicare might reimburse only a percentage of those claims, but that might require congressional action.

Meanwhile, one would expect the hospital industry to be ringing the alarm bells as potential insolvency approaches. But that’s not happening.

“They’re more concerned with next month than with 2023 at this point,” said Goldwein.

Chip Kahn, president and CEO of the Federation of American Hospitals, agreed. “I’m not going to worry about this right this minute,” he said. “At this point, my focus is completely on COVID.”

Administration Eases Rules to Give Laid-Off Workers More Time to Sign Up for COBRA

People who’ve been laid off or furloughed from their jobs now have significantly more time to decide whether to hang on to their employer-sponsored health insurance, according to a recent federal rule.

Under the federal law known as COBRA, people who lose their job-based coverage because of a layoff or a reduction in their hours generally have 60 days to decide whether to continue their health insurance. But under the new rule, that clock doesn’t start ticking until the end of the COVID-19 “outbreak period,” which started March 1 and continues for 60 days after the COVID-19 national emergency ends. That end date hasn’t been determined yet.

By extending the time frame to sign up for COBRA coverage, people have at least 120 days to decide whether they want to elect COBRA, and possibly longer depending on when they lost their jobs.

Take the example of someone who was laid off in April, and imagine that the national emergency ends Aug. 31. Sixty days after that date takes the person to the end of October. Then the regular 60-day COBRA election period would start after that. So, under this example, someone whose employer coverage ended at the beginning of May could have until the end of December to make a decision about whether to sign up for COBRA, with coverage retroactive to the beginning of May.

Some health policy experts question the usefulness of the change, given how expensive COBRA coverage can be for consumers, and how limited its reach: It isn’t an option for people who are uninsured or self-employed or who work for small companies.

“For ideological reasons, this administration can’t do anything to expand on the Affordable Care Act’s safety net,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “So they’re using these other vehicles. But it’s really a fig leaf. It doesn’t do much to actually help people.”

What does this rule change mean for workers? If you have lost your job, here are some things to consider.

Playing a Waiting Game

Under the new rule, workers can keep their COBRA options open far longer than before. It’s always been the case that people could take a wait-and-see approach to signing up for COBRA during the first 60 days after losing their coverage. If they needed care during that time, they could elect COBRA, pay the back premiums and continue their coverage. But if they didn’t need care during that time, they could save a chunk of money on premiums before opting for other coverage to kick in after the 60-day period.

Now, people have even more time to wait and see. Under the rule, once the administration declares the national emergency over, laid-off workers would get 120 days to decide whether to purchase their job-based insurance — 60 days under the new rule and the regular 60 days allowed as part of the COBRA law.

“It becomes a long-term unpaid insurance policy,” said Jason Levitis, a fellow at the Center for Health Policy at the Brookings Institution. “There’s no reason to enroll until something bad happens.”

This is not without risk, consumer advocates point out. Someone who has a serious medical emergency — a car accident or a stroke — might not be able to process their COBRA paperwork before they need medical care.

Waiting too long could also affect people’s ability to sign up for other coverage. When people lose job-based coverage, it triggers a special enrollment period that allows them to sign up for new coverage on their state health insurance marketplace for up to 60 days afterward.

“You could miss your opportunity to enroll in the [insurance] exchange” created under the Affordable Care Act, said Katy Johnson, senior counsel for health policy at the American Benefits Council, an employer advocacy group.

Don’t Count on the Boss to Clue You In

Employers are not mandated to tell people promptly about their eligibility for COBRA. The same federal rule that gives workers more time to sign up for COBRA also pushes back the notification requirements for employers.

“Once an employer lays you off, they don’t have to notify you that you’re eligible for COBRA until after the emergency period,” said Karen Pollitz, a senior fellow at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

For many employers, especially large ones that outsource their benefits administration, notifications are routine and are continuing despite the federal change, said Alan Silver, a senior director at benefits consultant Willis Towers Watson. However, for smaller companies with fewer than 200 workers, getting the information out might be an issue, Silver said.

Costs Can Be Jaw-Dropping

Opting for COBRA is expensive because workers have to pay both their portion of the premium and their employer’s share, plus a 2% administrative fee. A 48-year-old paid $599 a month on average for individual COBRA coverage last year, according to a KFF analysis.

In addition, if people elect COBRA several months after losing their coverage, they could be on the hook for thousands of dollars in back premiums.

The upside for former employees is that sticking with their previous employer’s plan means they don’t have to start from scratch paying down a new deductible on a new plan. Nor do they have to find new doctors, as often happens when people switch health plans and provider networks change.

Ten percent of workers laid off or furloughed because of the coronavirus pandemic reported they had COBRA coverage, according to a survey conducted last spring by the Commonwealth Fund.

The COBRA extension is available only to people who worked at firms with 20 or more employees and had job-sponsored coverage before being laid off or furloughed. If the company goes out of business, there’s no health insurance to continue to buy.

Might Hospitals Step In to Pay Premiums?

Employers are typically not big fans of the program. Workers who elect COBRA are typically older and sicker than others with employer coverage, the KFF analysis found. They may have serious medical conditions that make them expensive to cover and raise employer costs.

Some policy experts are concerned that giving people more time to sign up for COBRA leaves the door open for hospitals or other providers to offer to pay sick patients’ back premiums in order to increase their own payment above what they’d receive if someone were on Medicaid or uninsured. Doing so could be a boon for some patients but raise health care costs for employers, said Christopher Condeluci, a health care lawyer who does legal and policy work around the Affordable Care Act and ERISA issues.

“Employers are worried,” said Pollitz. After getting laid off, “what if you’re uninsured and you wind up in the hospital six months in, and then the hospital social worker learns you’re eligible for COBRA and offers to pay your premium?”

For COVID Tests, the Question of Who Pays Comes Down to Interpretation

In advance of an upcoming road trip with her elderly parents, Wendy Epstein’s physician agreed it would be “prudent” for her and her kids to get tested for COVID-19.

Seeing the tests as a “medical need,” the doctor said insurance would likely pay for them, with no out-of-pocket cost to Epstein. But her children’s pediatrician said the test would count as a screening test — since the children were not showing symptoms — and she would probably have to foot the bill herself.

It made no sense. “That’s two different responses for the exact same scenario,” said Epstein, a health law professor at DePaul University in Chicago, who deferred the tests as she clarified the options.

Early on in the coronavirus pandemic — when scarce COVID testing was limited to those with serious symptoms or serious exposure — the government and insurers vowed that tests would be dispensed for free (with no copays, deductibles or other out-of-pocket expense) to ensure that those in need had ready access.

Now, those promises are being rolled back in ways that are creating turmoil for consumers, even as testing has become more plentiful and more people — like Epstein — are being advised to get them.

Late last month, the Trump administration issued guidance saying insurers had to waive patient costs only for “medically appropriate” tests “primarily intended for individualized diagnosis or treatment of COVID-19.” It made clear that insurers do not have to fully waive cost sharing for screening tests, even when required for employees returning to work or for assisting in public health surveillance efforts.

Left unclear are situations like that faced by Epstein — and others who seek a test to clear a child for summer camp or day care. Public health officials have been unanimous in the opinion that widespread, readily available testing is crucial for getting businesses and schools open again, and society back on its feet.

But who should bear the costs of that testing — or a share of them — is an unresolved question.

Who pays when all employees are required to have a negative COVID test in order to return to work? Or if a factory tests workers every two weeks? Or just because someone wants to know for their own peace of mind?

The questions may be compounded in some cities and states where tests are widely available at clinics or drive-thru centers. In New York, CityMD clinics bill insurers $300 for the service, according to an explanation-of-benefits document given to KHN by a patient. The related charge from the lab that processed the test, according to the same patient’s insurance statement, was $55. Most patients don’t have to pay a share of those amounts.

The clinic has a partnership with the city allowing anyone who wants a test for the virus to get one. Still, no test is truly free, as labs bill insurers or submit for reimbursement from government programs.

Until a recent spike in virus cases created long delays in many areas, some other regions also took a test-everyone-who-wants-a-test approach. While that is one way to get a picture of where the virus is spreading, it can also become a cash cow providing income to clinics and labs, as residents seek multiple “free” tests after each potential exposure.

In an email, a spokesperson for CityMD would not say how much the clinic is reimbursed for testing. The clinics do not bill for lab testing, she wrote, referring questions about those costs to the laboratories that process them.

Insurers will be making judgment calls — likely on a case-by-case basis — about how they will handle cost sharing for screening tests under the new Trump administration guidance.

What is clear: Insurers have argued against requirements that they waive all cost sharing for workplace COVID testing, noting they don’t do that for other screening efforts, such as drug-testing programs. For now, insurers will “continue to pay for tests recommended by a doctor,” Kristine Grow, spokesperson for AHIP, an industry group, wrote in an email to KHN.

But AHIP also sent a clear signal that it would not embrace cost sharing waivers for workplace or public health screening efforts. Earlier this month, the organization lobbied federal lawmakers to include funding in the next stimulus package for public health surveillance and workplace testing programs — a cost estimated between $6 billion and $25 billion annually in an earlier study commissioned by the group.

The Evolving Rules for Free Testing

The coronavirus relief legislation passed by Congress in March, and April guidance from the Trump administration implementing it, agreed that patients should not be burdened with payments for COVID testing and treatment that is “medically appropriate.”

But as the pandemic has evolved and grown, the definition of that term has both broadened and become fuzzier.

The Centers for Disease Control and Prevention says testing is appropriate for people who fall into five broad categories, including those with suspected exposure and those required to be tested for “purposes of public health surveillance,” which it defines as checking for disease hot spots or trends.

“There’s definitely a disconnect between what public health experts are recommending for testing and how it’s going to be paid for,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

And tension is mounting among insurers, employers and consumers over who should pay. While insurers say employers should cover the cost for back-to-work testing, many employers are struggling financially and may not be able to do so. At the same time, workers, especially those in lower-wage jobs, also cannot afford out-of-pocket costs for testing, particularly if it is required regularly.

Among those waiting to hear if their insurance will cover the test is Enna Allen of Glencoe, Illinois, who urged her au pair to get a test after the young woman traveled to New Orleans. She had been on a plane, after all, and New Orleans has its share of COVID cases.

“I wanted her to have a test before she returned to work with my kids,” said Allen.

As Allen called around to find a testing site, she explained the test was needed for employment — for someone with no symptoms. After some effort, she found a clinic that, for $275, offered a 15-minute rapid test and said it would accept her au pair’s insurance.

“I’m assuming they [the insurer] will cover it unless I get a bill weeks from now,” said Allen, who said she would pay the bill for her employee if that happens.

There is also a great gray area in deciding who should qualify for free testing after “suspected” exposure. What is suspected exposure? Sharing a small office with an infected co-worker? Participating in a protest? Or simply living in or visiting the Sun Belt, where community spread is accelerating?

“If the au pair went to a clinic and said she was just in New Orleans, and the doctor said that’s enough of a risk to order a test, even though she doesn’t have symptoms, my read of the guidance is the health plan has to cover it 100%,” said Corlette.

Yet a child who’s mainly been sheltering at home who needs a test before being admitted to summer camp probably would not meet the definition.

“That’s a different story because it’s harder to argue there’s been exposure or potential exposure,” said Corlette. “At the end of the day, there’s many ways to interpret the guidance.”

Congressional Democrats have accused the Trump administration in its new guidance of “giving insurance companies loopholes instead of getting people the free testing they need.”

Insurers, patients and politicians have locked horns before when screening tests were billed differently than those same tests for diagnostic purposes, since the boundary is often unclear. Under the Affordable Care Act, for example, colonoscopy screening for cancer is “free,” meaning no patient copayment. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to hundreds or even thousands of dollars in copayments.

While vital, testing is costly — or can be. Medicare reimburses up to $100 for the COVID test. On top of that, there may also be costs associated with the office or clinic visit. And the price is widely variable in the private market, according to a report out last week by KFF, the Kaiser Family Foundation. Prices ranged from $20 to $850 for a single test. (KHN is an editorially independent program of the foundation.)

Media reports have shown tests average $100, but some labs bill insurers for thousands of dollars for each one.

Without a copay, many patients never learn how much their tests actually cost their insurers, which could lead to overuse.

Also, when patients are entirely shielded from the cost, test makers, labs and medical providers are more likely to seek price increases, said Heather Meade, a principal at Washington Council Ernst & Young.

In the end, consumers may still feel a resulting pinch in the form of higher premiums.

Wondering about the sharply different views of her doctors on whether her insurance would fully cover the cost, law professor Epstein called her insurer, which assured her the tests would be covered 100% at in-network providers with no copay or deductible, as long as they were coded correctly. The family will be tested soon, and it appears she’s dodged a financial bullet. But Epstein cautioned in an email: “It’s unclear to me how many insurers will maintain this policy.”

Listen: Colorado Cuts Back Health Care Programs Amid Dual Crises

KHN senior correspondent Markian Hawryluk joined KUNC’s Erin O’Toole on “Colorado Edition” to discuss his recent story on how Colorado is one of the many states having to cut back on health care programs and new policy initiatives as part of the economic fallout of the pandemic.

These cuts, which in Colorado include slashing $1 million from a program designed to keep people with mental illness out of the hospital and $5 million for addiction treatment programs in underserved communities, come amid the century’s largest health crisis when people may need those services most.

You can hear the conversation here.

Azar Says Federal Law Had Preexisting Conditions Covered Before ACA. Not So Much.

One of the most popular features of the Affordable Care Act is its guarantee of insurance coverage — at no greater cost — for people with preexisting health conditions.

Thus, even as the Trump administration argues before the Supreme Court that the entire Affordable Care Act should be declared invalid, the president and his administration officials maintain that regardless of what happens to the ACA, they will protect people who have had health problems in the past.

Speaking to a “virtual health summit” sponsored by the political newspaper The Hill, Health and Human Services Secretary Alex Azar answered a question about the case, Texas v. Azar, by pointing out “it’s in statute already in HIPAA that preexisting conditions are covered,” implying that if the ACA were declared unconstitutional, those protections would remain in place for everyone.

Umm … not so much.

When we checked with HHS for more information about Azar’s comment, a spokesperson reiterated the secretary’s statement, adding that Azar was “clear that the story on preexisting conditions doesn’t end with HIPAA” and that affordability is a critical component.

So we investigated.

A Little About HIPAA

The Health Insurance Portability and Accountability Act, a law we have examined before, was passed by a Republican-led Congress and signed by Democratic President Bill Clinton in 1996. It is best known for safeguarding medical privacy and patient access to medical records, even though the privacy provisions were added toward the end of congressional deliberations.

HIPAA’s original purpose was to end what was known as “job lock,” a situation in which people with preexisting conditions were reluctant to leave jobs with health insurance even for other positions with health insurance for fear their conditions would not be covered or they would be subject to long waiting periods for coverage. Both scenarios were common at the time.

HIPAA addressed that problem — as long as people maintained “continuous” coverage, defined as having health insurance for at least 12 months without a break of more than 63 days. People who met that requirement could not have waiting periods or denials of coverage imposed upon their own or a family member’s preexisting condition. HIPAA included protections for people with coverage in the small-group insurance market, which primarily comprises small businesses, by requiring insurers who sold policies in that market to sell to all small groups, regardless of health status, and to cover every eligible member of the groups — again, regardless of health status.

But HIPAA was not designed to comprehensively address the problem of people with preexisting conditions getting and keeping affordable health insurance.

For starters, the protections were only for people who already had job-based insurance, to make it easier for them to move to other job-based insurance. It did nothing for those in the individual insurance market who needed to purchase their own coverage — such as self-employed people and those working for companies that did not offer health insurance.

HIPAA attempted to create a pathway for people transitioning from employer-sponsored to individual coverage. It ensured that, after leaving a job, people who secured insurance through another law, the 1986 Consolidated Omnibus Budget Reconciliation Act, or COBRA, would be eligible to buy a “conversion” plan from their insurer once their previous job-based benefits were exhausted.

However, two giant problems arose. First, COBRA, which allows individuals to continue their employer-provided coverage for up to 18 months if they pay the entire premium themselves (plus a small administrative fee), is prohibitively expensive for most people. In 2019, the average premium for a single worker was $599 per month.

The other problem was that even if a former worker did manage to pay for COBRA coverage until that 18-month period ended, there was no limit on how much insurers could charge for the conversion policies. So, even if they were technically available, they were frequently unaffordable.

There were other problems. COBRA coverage was not available to people who worked for small businesses, or for those who became unemployed because the business they worked for failed and no longer offered insurance to anyone. HIPAA also did not stipulate which benefits had to be offered.

Next, the ACA

The ACA sought to deal with HIPAA’s shortcomings. It required most employers to offer coverage and, for those purchasing their own, it required insurers to provide a comprehensive package of benefits at the same price to all purchasers, regardless of health status.

However, the ACA rewrote the HIPAA provisions regarding preexisting conditions, so if the ACA is struck down by the Supreme Court, it’s not clear whether even HIPAA’s lesser provisions would remain. Experts disagree about this, but there is a possibility that HIPAA’s protections could be swept away along with the ACA.

Later in his answer to the question posed at The Hill’s summit, Azar pointed out that there are significant affordability problems with coverage under the ACA, as well. “So we will work with Congress if the time ever comes, to get real affordable solutions,” he said. That’s true. ACA plans, even with subsidies, can be too expensive for some people, and prohibitive for those who earn just slightly too much to qualify for government help. Earlier this month, Democrats in the House passed a bill to make ACA plans more affordable.

Our Ruling

Azar’s statement suggested that if the Supreme Court rules against the ACA and that sweeping law is nullified, Americans with preexisting conditions would continue to have the protections originally offered under HIPAA.

Though it contains an element of truth, it leaves out critical pieces of information. For instance, the HIPAA protections are not equivalent to those provided by the ACA. First, they are geared toward people who have work-based insurance coverage — as long as that coverage is continuous for at least 12 months with lapses no longer than 63 days. One expert we consulted pointed out that this window could be especially problematic now, during a time of “enormous economic dislocation.”

Additionally, the ACA rewrote the HIPAA provisions regarding preexisting conditions — bringing into question what might become of them, too.

We rate Azar’s claim Mostly False.

KHN’s ‘What The Health?’: ‘Open The Schools, Close The Bars’


Can’t see the audio player? Click here to listen on SoundCloud.


How to safely open the nation’s schools this fall has become the latest spat in attempting to deal with the COVID-19 pandemic. President Donald Trump and Vice President Mike Pence have decried the guidelines issued by the Centers for Disease Control and Prevention as too complicated and expensive and ordered a new set. Meanwhile, tests for the virus remain difficult to get, particularly in states experiencing spikes, and getting results to patients is taking increasingly longer, making contact tracing effectively impossible.

Also this week, the Supreme Court handed the Trump administration a victory, upholding a set of regulations aimed at making it easier for employers to decline to offer birth control as part of their health insurance — even though it is generally required under the Affordable Care Act.

And Oklahoma voters narrowly approved a ballot measure to expand the Medicaid program, becoming the latest Republican-dominated state where voters opted for something that had been rejected by their elected officials.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s podcast:

–Although the Supreme Court upheld — at least for now — the changes made to ACA contraception coverage, Congress could rescind the policy, which might happen if Democrats gain control of the Senate next year. The rule could also be struck down by a lower court on grounds that were not reached in the current lawsuit.

–Much attention has been paid to the Trump administration’s rule on contraception coverage. But at the same time, the administration has been chipping away at other programs that provide birth control to many low-income women.

–With Trump doubling down on his support of Republican state officials’ legal challenge to the ACA, the federal health law could play a role again in the fall election. But it will likely also be linked to other health issues, including the government’s response to the coronavirus pandemic.

–The Medicaid vote in Oklahoma comes as the pandemic has created economic havoc, and it’s not clear where the state will get its share of the costs for the federal-state program that provides health coverage to low-income residents.

–Even after four months of battling COVID-19 in the U.S., people are still waiting in long lines to get a test, and results are slow because of the huge demand. Some consumer advocates hope a new stimulus package will provide more funding, but what’s really needed to help the economy and the schools is a rapid, inexpensive test that can be self-administered.

Also this week, Rovner interviews KHN’s Sarah Varney, who reported the latest KHN-NPR “Bill of the Month” installment, about an essential health worker with suspected COVID-19 who was sent to the emergency room, where she did not get a COVID test — but did get a large bill. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “Sweden Has Become the World’s Cautionary Tale,” by Peter S. Goodman.

Kimberly Leonard: The Atlantic’s “The Pandemic Experts Are Not Okay,” by Ed Yong.

Joanne Kenen: The New Yorker’s “The Emotional Evolution of Coronavirus Doctors and Patients,” by Dhruv Khullar.

Mary Ellen McIntire: Science News’ “How Making a COVID-19 Vaccine Confronts Thorny Ethical Issues,” by Bethany Brookshire.


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